Impact of the revised VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder for couples and families: Commentary on Lang et al. (2024)

As a multinational group of clinicians and researchers focused on including family in veterans’ and military members’ care for posttraumatic stress disorder (PTSD), we wrote this commentary to raise specific considerations related to the revised Department of Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline (CPG) for PTSD and Acute Stress Disorder (VA/DoD, 2023) regarding couple- and family-based treatment. We discuss concerns regarding: (a) insufficient guidance about the role of intimate partners and families, (b) issues with using and defining specific treatments in the CPG evidence rubric, and (c) algorithm and recommendations for guiding patient preference toward individual interventions. Interpersonal relationship factors are among the most potent predictors of who goes on to have PTSD, initiates treatment, completes treatment, and responds to frontline evidence-based PTSD treatment (e.g., Monson et al., 2022), yet the CPG offers little guidance about their role in the treatment and assessment of PTSD. Aside from the determination that there was evidence “neither for nor against” couple-based therapies for PTSD, there are only two references to couples and families: (a) their possible inclusion in shared decision-making and (b) the need to educate them about PTSD. This was surprising given public policies aimed at including family members in veterans’ and service members’ mental health care. Some examples include Veterans Health Administration (VHA) Directive of Family Services in Mental Health 1163.04, which requires family services to be available to veterans with a mental health diagnosis and providers to hold regular conversations with veterans about family involvement; the creation of the VA Caregiver Support Program; and DoD Instruction 6490.06, which establishes the DoD's attention to the family unit among active duty personnel to increase force readiness and health. The CPG refers to facilitating social support as part of addressing additional treatment needs, but there is no guidance provided on how to do it. We argue that partners and family members should figure more prominently in guidelines for PTSD assessment and treatment. To parallel data on medications, it was decided with this revision to consider all psychotherapy packages (e.g., prolonged exposure [PE; Foa et al., 2019]) separately versus combining them in classes of psychotherapies (e.g., trauma-focused psychotherapies). Defining what constitutes a specific therapy is a nuanced task and has implications for evidence classification in the CPG rubric. For example, specific to couple therapy for PTSD, the independent reviewers considered three randomized controlled trials (RCTs), including trials of the full protocol of cognitive behavioral conjoint therapy for PTSD (CBCT for PTSD; Monson et al., 2012), a brief version of CBCT for PTSD (Morland et al., 2022), and a trial of structured approach therapy (SAT; Sautter et al., 2015). Illustrating the point of defining specific treatments, the narrative is unclear whether the brief and full versions of CBCT for PTSD are considered the same treatment. We are aware of an additional RCT by Davis et al. (2021) that examined couple treatments in a veteran sample but was not included in the independent review for the CPG. The authors tested adaptations of CBCT for PTSD (i.e., with mindfulness exercises) versus general cognitive behavioral therapy for couples delivered in a multicouple retreat format that used clinician ratings of PTSD. Both couple therapies in this RCT yielded significant improvements in PTSD and both veterans’ and partners’ ratings of relationship satisfaction; there were no differences between the couple-based treatments on these primary outcomes. We wonder whether these adaptations (i.e., mindfulness and massed dosing) would have led these CBCT treatment protocols to be considered distinct treatments from others included in the review. Although the lines of what is and is not considered a treatment package are unclear, separating them may run the risk of diluting the strength of evidence for evidence-based practices that are more similar than distinct. Indeed, guidelines are and have been organized in different ways, and the guidance for clinicians and patients differ when classes of therapies (e.g., cognitive behavioral couple therapy, trauma-focused couple therapies for PTSD) are employed. It is important to note that the many treatments in Recommendation 10, for which the CPG states there is “insufficient evidence to recommend for or against,” are highly heterogeneous in the strength of their evidence base. Many more interventions are included in this category than in the 2017 CPG, in part because of the choice to review specific treatments. A perhaps unintended consequence of the CPG methodology is that frontline providers working with veterans and service members who are entitled to general or PTSD-specific couple and/or family therapy are left without guidance regarding interventions in this category that have varying degrees of empirical support. They are guided to encourage patients toward the specific recommended therapies—all of which are delivered to patients individually. Notwithstanding these concerns, we agree with the Work Group that more research is needed on couple and family interventions for PTSD. The CPG rightly emphasizes the importance of honoring patient preferences to improve engagement, adherence, and outcomes, and patient preferences and values were identified as one of the four domains used to inform the strength of each recommendation. In the CPG treatment algorithm, specific trauma-focused individual psychotherapies are recommended first, then pharmacologic interventions (i.e., paroxetine, sertraline, venlafaxine), followed by suggested (weak “recommendation for”) individual psychotherapies. If patients prefer any intervention outside of these parameters, Lang and colleagues (2024) recommend guiding clients back to these individual treatments, which limits the ability to elicit and honor patient preference for family-inclusive treatment. This is problematic on several fronts. First, an overwhelming number of veterans are interested in partner involvement in their PTSD care (e.g., 78%; Meis et al., 2013), and at least one study has shown that when given the choice between various treatments for PTSD, approximately the same number of participants said they preferred CBCT for PTSD as their first-choice treatment (20%) as those who preferred PE (18%); for comparison, 51% preferred cognitive processing therapy [CPT; Resick et al., 2017]; Schumm et al., 2015). The pattern of dropout rates postrandomization in a recently published RCT comparing CBCT for PTSD and PE (Monson et al., in press) suggests that matching patient preference with desired therapy package is associated with treatment engagement and outcomes. Second, trauma-focused couple therapies for PTSD not recommended by the CPG (e.g., CBCT for PTSD, SAT) have efficacy and effect sizes on par with those recommended, whereas other treatments in the same “neither for nor against” category are less rigorously studied and theoretically grounded (e.g., equine-assisted therapy, thought field therapy). Third, dropout from the recommended therapies is high in routine care, and some patients do not adequately respond to these treatments. Little is known about how to ensure a patient achieves their optimal dosage of, or experiences gains from, PTSD treatment. Aligning treatments with some demonstrated efficacy with patient preferences is a promising pathway to this end, as many patients want family members involved in their care, and family functioning impacts treatment engagement and outcomes. We propose that when there are quality data for an individual's preferred treatment, honoring their preference is actually more important than insisting they try one of the limited number of CPG-recommended treatments first. We recommend that patients be routinely asked whether they want their loved ones involved in their care. If so, a family-inclusive therapy might be the optimal choice if that therapy has demonstrated evidence of safety and efficacy in at least one RCT as well as effects on par with CPG-recommended frontline individual treatments for PTSD. Candice M. Monson and Steffany J. Fredman receive royalties from Guilford Press for their published treatment manual on cognitive behavioral conjoint therapy for posttraumatic stress disorder (PTSD) and payment for providing psychotherapy workshops on PTSD and/or conjoint interventions for psychopathology. Candice M. Monson also receives royalties from Guilford Press and the American Psychological Association Press for books related to the treatment of PTSD (i.e., cognitive processing therapy, cognitive-behavioral therapy for PTSD) and couples/families and trauma, and she owns equity in Nellie Health, a digital mental health intervention company. Skye Fitzpatrick receives payment for providing psychotherapy workshops, including conjoint interventions for psychopathology, and owns equity in Nellie Health. No other authors have conflicts of interest to declare.

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