adapting the multifamily group model for treating veterans with posttraumatic stress disorder

Adapting the Multifamily Group Model for Treating Veterans WithPosttraumatic Stress Disorder

Michelle D. ShermanOklahoma City VA Medical Center, Oklahoma

City, OK, and South Central Mental IllnessResearch, Education, and Clinical Center

(MIRECC)

Deborah A. PerlickVISN 3 Mental Illness, Research, Education and

Clinical Center, Bronx, NY, and Mount SinaiSchool of Medicine

Kristy Straits-TrosterVA Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center (MIRECC) and

Duke University School of Medicine

The Department of Veterans Affairs (VA) health care system’s leadership has endorsedfamily involvement in veterans’ mental health care as an important component oftreatment. Both veterans and families describe family participation as highly desirable,and research has documented that having healthy social support is a strong protectivefactor for posttraumatic stress disorder (PTSD). Family psychoeducation has beenshown to be effective in preventing relapse among severely mentally ill, and prelimi-nary evidence suggests that family interventions for PTSD may improve veteran andfamily outcomes. The multifamily group (MFG) treatment model incorporates psy-choeducation, communication training, and problem-solving skill building, and itincreases social support through its group format. This article describes the rationale forfurther adaptation of the MFG model for PTSD, and it reviews issues related to itsimplementation as a promising adjunctive treatment as part of the continuum of PTSDservices available in VA.

Keywords: multifamily groups, family psychoeducation, PTSD, veterans, traumatic brain injury

The toll of combat deployments and relatedposttraumatic stress disorder (PTSD) impactsservice members, veterans and their respectivefamilies, and social support systems (Monson,Taft, & Fredman, 2009). Interviews with family

members of Vietnam veterans have indicatedthat male veterans with PTSD had problems inmarital and family adjustment, deficits in par-enting skills, and more frequent violent behav-ior compared with Vietnam veterans withoutPTSD (Jordan et al., 1992). Approximately 20%of veterans of the prolonged conflicts in Iraqand Afghanistan experience symptoms of PTSD(Seal et al., 2009); many also struggle withdepression, substance abuse, traumatic brain in-jury (TBI), marital conflict, and domestic vio-lence (Milliken, Auchterlonie, & Hoge, 2007;Okie, 2005). Among a cohort of recent veteransreferred for a mental health evaluation, threequarters of the married or cohabiting veteransreported family problems, such as feeling like aguest in their household (40.7%), reporting theirchildren acted afraid or not warm toward them(25%), or being unsure about their family role(37.2%;Sayers, Farrow, Ross, & Oslin, 2009).

The Department of Veterans Affairs (VA)healthcare system offers an array of evidence-

This article was published Online First June 25, 2012.Michelle D. Sherman, Oklahoma City VA Medical Cen-

ter, Oklahoma City, OK, and South Central Mental IllnessResearch, Education, and Clinical Center (MIRECC); Deb-orah A. Perlick, VISN 3 Mental Illness, Research, Educa-tion and Clinical Center, Bronx, NY, and Department ofPsychiatry, Mount Sinai School of Medicine; Kristy Straits-Troster, VA Mid Atlantic Region Mental Illness Research,Education, and Clinical Center (MIRECC) and Departmentof Psychiatry and Behavioral Sciences, Duke UniversitySchool of Medicine.

The views expressed in this article are those of theauthors and do not necessarily represent the views of theDepartment of Veterans Affairs.

Correspondence concerning this article should be ad-dressed to Michelle D. Sherman, Oklahoma City VA Med-ical Center, 921 NE 13th Street (116A), Oklahoma City, OK73104. E-mail: [email protected]

Psychological Services In the public domain2012, Vol. 9, No. 4, 349–360 DOI: 10.1037/a0028963

349

based therapies and best practices for PTSD,and the individual veteran is usually the targetof such services. Partners and family memberssometimes facilitate the veteran’s accessingpsychiatric treatment; however, despite manyfamily members’ documented strong interest inparticipation in their veterans’ PTSD care (Bat-ten et al., 2009; Sherman, Sautter, et al., 2005),they are not routinely included in treatment atmost facilities at this time.

Although families exhibit remarkable strengthand resilience in dealing with operational stressand combat-related issues, the severity of PTSDsymptoms in veterans has been found to be relatedto increased family stress/burden, poorer psycho-logical adjustment in veterans’ partners, and wors-ened couples’ functioning postdeployment (Bat-ten et al., 2009; Gewirtz, Erbes, Polusny, For-gatch, & DeGarmo, 2011; Sherman, Sautter, et al.,2005). Further, there is considerable evidence thatPTSD is associated with intimate relationship dis-cord and both physical and psychological aggres-sion (Taft, Watkins, Stafford, Street, & Monson,2011); these findings highlight the importance ofaddressing the needs of family members as well asveterans in treatment programs for PTSD. In astudy comparing couples’ functioning among vet-erans with and without PTSD, over 70% of thecouples in which the veteran had PTSD reportedhigh levels of relationship distress, compared with30% of the nonPTSD couples. Distress was man-ifested in problems with intimacy and consider-ation of divorce/separation, and the degree of dis-tress was related to PTSD symptom severity, par-ticularly emotional numbing (Riggs, Byrne,Weathers, & Litz, 2005). Beyond the couple andimmediate family, persistent PTSD symptomsmay erode social support over time, potentiallyreducing a strong protective factor for trauma-exposed veterans (Kaniasty & Norris, 2008).

Preliminary evidence that structured family in-volvement in PTSD treatment can help reducePTSD symptoms, relationship distress, and care-giver burden has been demonstrated in pilot clin-ical trials of Cognitive Behavioral Conjoint Ther-apy (CBCT) for PTSD (Monson, Fredman, &Adair, 2008). CBCT is focused on cohabitingpartner dyads, and recent adaptation of the multi-family group model for PTSD through theREACH program—Reaching out to Educate andAssist Caring, Healthy Families (Sherman, Fi-scher, Sorocco, & McFarlane, 2009). Additionalfamily targeted efforts have been implemented to

successfully promote family resilience in order toprevent PTSD and related family and servicemember distress, including the FOCUS pro-gram—Families Overcoming Under Stress (Les-ter et al., 2011). The FOCUS program utilizespsychoeducation and skill building for emotionalregulation, goal setting, problem solving, and fam-ily communication for active duty service mem-bers and their military families with particularemphasis on parenting issues.

National Efforts to Increase FamilyEngagement in Care of Service Members

and Veterans

Over the past five years, several significant na-tional initiatives have been launched to support theneeds of military families. In a hallmark statementsigned by every member of President Obama’sCabinet, “Strengthening our Military Families:Meeting America’s Commitment (1–14-11)” con-stitutes an unparalleled commitment to servingand supporting military families (http://www.de-fense.gov/home/features/2011/0111 initiative/strengthening our_military_january_2011.pdf). First lady, Michelle Obama,and Dr. Jill Biden subsequently announced aninitiative called “Joining Forces: Taking Action toServe America’s Military Families” on August 2,2011 (http://www.whitehouse.gov/joiningforces),which calls upon all sectors of society to providesupport and opportunities to service members andtheir families. Ranging from increased awarenessof the sacrifices made by veterans and their fam-ilies, to calls for priority hiring and education ofreturning veterans, the Joining Forces initiativehas incorporated efforts from the faith-based com-munity, educational systems, and a broad varietyof service organizations.

President Obama’s recent Caregivers andVeterans Omnibus Health Services Act of 2010(Public Law 111–163) significantly increasedservices to caregivers, especially of veteranswith significant physical and/or psychologicalinjury. This act provides family caregivers theopportunity to be partly compensated for theirprovision of care for the injured veteran. For thefirst time, family members who provide caregiving for injured service members who requirea high level of care with activities of daily livingmay be compensated for their efforts and sacri-fice—which often has included leaving paidemployment outside the home.

350 SHERMAN, PERLICK, AND STRAITS-TROSTER

The Department of Veterans Affairs has re-cently designated serving veterans’ families asone of VA’s core values (http://www.va.gov/landing2_about.htm); family counseling islisted as one of the services that may be pro-vided if considered appropriate for the effectivetreatment and rehabilitation of a veteran (Ti-tle 38 U.S.C. § 1701). Inclusion of family mem-bers in veterans’ mental health care is furthersupported by Public Law 110–387: Veterans’Mental Health and Other Care ImprovementsAct of 2008 (http://va.gov/vhapublications/ViewPublication.asp?pub_ID � 2285). Thislaw gives authority to mental health cliniciansto provide marriage and family counseling andother mental health services to veterans andeligible individuals, while reminding providersthat the primary focus for VA care is always onthe veteran. Further, in 2008 the Uniform Men-tal Health Services Handbook for VA was is-sued to ensure that all veterans have access toneeded mental health services, and to establishstandards for access to care. Important elementsof this handbook include incorporation of inputfrom family members for the veteran’s treatmentplan, education for family members when it isassociated with benefits for veterans, and familytherapy when it is indicated as an evidence-basedpsychotherapy (VHA Handbook 1160.01). All ofthese recent efforts are consistent with the 2008President’s New Freedom Commission on MentalHealth: Transforming the Vision—which seeks toensure that all “. . . mental health care is consum-er- and family driven” (Carter Center, 2003, p. 5).

Another example of national commitment tomilitary families is evident in the SubstanceAbuse and Mental Health Services Administra-tion (SAMHSA; 2011) list of priorities in“Leading Change: A plan for SAMHSA’s Rolesand Actions, 2011–2014” (http://store.samhsa.gov/product/SMA11-4629). To address thegaps in trauma and military culture-informedcare available in the community for militaryfamilies, SAMHSA plans to help improve co-ordination between military and civilian behav-ioral health care systems, improve access toquality support services available to militaryfamilies where they live, and to promote evi-dence-based care for prevention, treatment, andrecovery support services for military servicemembers and their families. These efforts in-clude several specific educational strategies cur-rently underway to increase clinician and ad-

ministrator awareness about the problems andneeds confronting military families.

The History of Family Services in the VAHealth Care System

The recent focus and legislation supportingmental health care/marital counseling for veter-ans’ families described above represents amarked shift in the interface between VA pro-viders and veterans’ families. Historically, fam-ilies have had infrequent and inconsistent in-volvement in veterans’ care for mental illnessand PTSD. In the late 1970s, some VA facilitiesreceived funding to hire staff to create FamilyMental Health Programs; however, almost all ofthese positions dissolved, or they were sub-sumed into other programs over time. Notableexceptions included VA medical centers in PaloAlto, CA, Oklahoma City, OK, and Portland,OR, which have had long-standing family pro-grams. These programs have primarily providedcouples therapy to veterans and their families. Afew other facilities have provided family ser-vices on an as-needed basis, but this has usuallybeen an adjunct responsibility for clinicians,many of whom lacked formal training in familywork. As part of this historical dearth of for-malized services, there have been very few sitesproviding formalized training to psychology in-terns, postdoctoral fellows, or psychiatry resi-dents in working with families.

As described above, the past decade has in-volved a significant shift in the law and VAdirectives about family services, creating manyopportunities for broadening our care for vet-eran families. However, this exciting time hasbeen fraught with some challenges, includinglack of clarity about eligibility and appropriateservices, mental health staff that lack training inevidence-based family services, some familymembers’ negative attitudes toward the VA,veterans’ ambivalence and fears about familyparticipation, providers’ mindset about theappropriate role of families, and logisticalchallenges in establishing family work in afacility (e.g., issues of documentation, collat-eral charts, etc.; Sherman, Blevins, Kirchner,Ridener, & Jackson, 2008; Sherman &Carothers, 2005). In spite of these challenges,great progress has been made in a short periodof time, and many more families are receivingservices (S. McCutcheon, personal communi-

351MULTIFAMILY GROUPS WITH PTSD

cation, January 3, 2012). All VA family ser-vices are provided in the context of support-ing the veteran’s treatment plan.

The VA has rolled out several evidence-basedfamily treatments to VA clinicians for a variety ofmental illnesses, consisting of in-person trainingfollowed by phone consultation (Makin-Byrd,Gifford, McCutcheon, & Glynn, 2011). Since2007, four national trainings have been providedon Behavioral Family Therapy (BFT; Mueser &Glynn, 1999)—a treatment provided to a singleveteran and his or her support person to enhancecoping with serious mental illness. One study ex-amined the effectiveness of BFT with PTSD(Glynn et al., 1999), and it found that it did notprovide any additional reduction in PTSD symp-toms beyond that associated with exposure treat-ment. More recently, national training on a cou-ples therapy model, Integrative Behavioral Cou-ples Therapy (IBCT; Christianson & Jacobson,2000), has begun; notably, this model is focusedon intimate dyads, and it has no research on its usewith PTSD.

Another family based service identified as abest practice in the VA system is the Support AndFamily Education (SAFE) Program (Sherman,2008), an 18-session family education programfor adults who care about someone living withmental illness or PTSD. Numerous national train-ings and ongoing consultation have been providedfor VA clinicians, and the program is being pro-vided in approximately 50 medical centers to date.This program is provided solely to the familymember/support person, not the veteran, and itprovides education and an opportunity for mutualsupport in understanding and coping with a vet-eran living with PTSD. Participation in SAFE iscorrelated with increased understanding of mentalillness and enhanced awareness of VA resources.Workshop attendance is also positively correlatedwith improvements in participants’ self-care andinversely correlated with caregiver distress (Sher-man, 2003, 2006).

A new family based program in VA is the“Coaching Into Care” call center (www.mirecc.va.gov/coaching/). The purpose of this nationaltelephone-based support service for familymembers is to help family members and theirloved ones encourage distressed veterans to ac-cess their VA health care benefits, especially formental health issues. Information about how toaccess VA health care and to problem-solvebarriers to care is provided through the call

center Monday through Friday, 8 a.m. to 8 p.m.EST, with evening and weekend coverage pro-vided by the Veterans Crisis Center, which op-erates 24/7. Coaching Into Care call respondersrefer to licensed mental health clinicians onstaff for multisession coaching as needed toprovide support. Coaches help the family mem-ber plan and implement an informed, noncoer-cive approach when talking with a troubledveteran about seeking or resuming VA mentalhealth care. Call centers in Philadelphia, PA,Durham, NC, and Los Angeles, CA support thenational VA Coaching Into Care effort.

All four of these programs (BFT, IBCT,SAFE, and Coaching Into Care) meet importantclinical needs. The Multifamily Group model(MFG; McFarlane, 2002) helps fill other signif-icant gaps in our continuum of services, and ithas potential for broader distribution in the VAhealth care system. The MFG model was orig-inally developed to treat individuals living withschizophrenia and their families; it has sincebeen applied to a range of other serious mentalillnesses. In this model, the “family member”can be anyone that the veteran trusts and wantsinvolved in his or her health care. The interven-tion is a 3-phase, 9-month program beginningwith 2–4 single-family “joining” sessions fo-cused on assessment, eliciting a thorough his-tory and rapport building. Phase two involvesprovision of psychoeducational information (aday-long workshop), and phase three consists ofregularly scheduled multifamily group meetingsover the span of 6–9 months. The psychoedu-cational approach employed by the MFG modelfocuses on helping the family manage stresseffectively, improving communication skills,and teaching a structured problem-solving pro-cess. Many randomized clinical trials fromaround the world have consistently found posi-tive results for the MFG intervention, includingreduced relapse rates, improved recovery of pa-tients, and improved family well-being (McFar-lane, Dixon, Lukens, & Lucksted, 2003). TheVA has provided two national trainings for VAclinicians in the MFG model, and most facilitieshave focused on veterans living with schizo-phrenia. Notably, the model has not been usedwith PTSD until recently. In the next sections,we will review the ways in which MFGs canbroaden the trauma-informed continuum of carefor veterans living with PTSD, followed by a


brief overview of two MFG programs currentlybeing piloted in the VA system.

The Multifamily Group Model as a UsefulAddition to the Continuum of Care for

Veterans Living With PTSD

MFGs have numerous advantages in ap-proach, format, and modality—making themodel an excellent treatment option for the VAsystem. Benefits of the model can be conceptu-alized as addressing four domains, includingsystemic issues, enhanced care for veterans,support for veterans’ relationships, and rewardsfor clinicians.

First, systemically, the model conceptualizesfamilies as partners in the veteran’s treatmentplan, which is consistent with the VA’s visionof the role of family members in care. Ratherthan couples therapy, which often addresses re-lationship issues, the MFG model specificallyworks with the dyad to enhance coping with theillness. Also, this model can target some gaps inexisting services. As MFGs include any adultwho the veteran trusts and wants involved in hisor her care, this model provides a venue forincluding previously relatively neglected (yetimportant) people such as veterans’ parents ortheir adult children, and husbands of femaleveterans with PTSD. Further, MFGs can pro-vide a cost savings for the institution, as multi-ple veterans/families are served simultaneouslyin the group sessions. Some research has docu-mented that MFGs for schizophrenia (Breit-borde, Woods, & Srihari, 2009) may not only bea cost-effective intervention, but they may re-duce overall health care costs for the consumer.

Second, MFGs can broaden our range oftreatment options for veterans. It can serve as anancillary treatment to the evidence-based indi-vidual treatments for PTSD being disseminatedin the VA system (prolonged exposure and cog-nitive processing therapy). Although both ofthese approaches are well established and havestrong data attesting to their efficacy, high drop-out rates are problematic (Garcia, Kelley,Rentz, & Lee, 2011), and not all veterans desirethis exposure-based form of treatment. Partici-pation in a MFG could precede or follow suchindividual therapy. The psychoeducationalMFG could serve as an introduction to therapy,preparing the veteran for the more intensivetrauma-focused work. Or, the veteran could in-

clude his or her family in care after completingindividual trauma work as a way of educatinghis or her family about PTSD and promotinghealthy family coping.

In contrast to the intensive psychotherapyapproach of many treatments for PTSD, theMFG approach is provided as a “class” thatteaches “skills.” While the group format facili-tated by skilled clinicians retains many essentialtherapeutic factors (Yalom & Leszcz, 2005),participation in the program may feel less stig-matizing for veterans and family members.MFGs are presented as a way to offer educationand skills for veterans and family members tocope with problems that are part of PTSD. Theclassroom “feel” of MFG can be normalizingand comfortable. Veterans are assured that theprogram will not involve trauma processing,which can decrease anxiety and facilitate en-gagement in the psychoeducational program.

Similarly, the problem-solving model taughtin MFGs can provide veterans and families witha set of practical skills that may generalize tomany issues they face, both during and aftertreatment. The group format also allows veter-ans/family members to learn from solutionsgenerated by the group for others’ problems.After completing a course of MFG, a veteranreflecting on his participation in an MFG said,“. . . when you hear from other people and theirperspective and what’s kind of worked forthem, you kind of walk away with okay that’ssomething really different, I could try that. Yougot some tools that you could put in your toolkit and walk away with, and you could use lateron if that particular problem arises.”

Third, the MFG format provides opportuni-ties for veterans to improve their relationships,both with their family members and with otherveterans/families. The groups offer veterans asafe forum to reveal their personal struggle totheir family members. Many veterans in ourprograms report that the support of other veter-ans enables them to tell their family membersabout their symptoms/difficulties for the firsttime. This intimate sharing is often quite pow-erful, as many family members have little un-derstanding of the veteran’s experience andstruggle. Veterans in our programs report thatthe treatment provides them a unique forum tobring their family members into their healthcare. As one veteran in our program for veteranswho experienced a brain injury noted, “A lot of


veteran groups are strictly veterans, I don’tknow another opportunity when somebodyother than a veteran is allowed into a circle andI think it’s good . . . I used to wander around atall hours of the night, she [my wife] thought thatI was out doing whatever, but I used to wanderaround because I could, because I felt free,because I wouldn’t be stuck in combat, carryingmy rifle around everywhere . . . . I would doweird and crazy things and I wasn’t going to tell[my wife] everything . . .”

Not only do MFGs promote family relation-ships, they also broaden veterans’ and families’support systems. In our experience, not only aremany of these veterans quite socially isolated,their family members are as well; therefore,expanding the social network is useful for bothmembers of the dyad. Consistent with the re-covery movement and its emphasis on peer-support, MFGs, by their nature, encouragementoring and mutual support. This may beparticularly important for combat veteranswhose exceptional experience often leaves themfeeling isolated from family and society atlarge. The activities during the intervention it-self (particularly the brainstorming during theproblem-solving sessions) are powerful forumsfor families to connect with others and to realizethat they are not alone. One family membershared, “Just the fact that there are other coupleshere helped, just to know that ok I’m not theonly one . . . who’s going through this situa-tion.”

Members feel empowered in helping theirpeers, and the process fosters a sense of com-petence. The informal socializing that occursbefore and after sessions, and that sometimesextends to informal contacts or get-togethersduring the week, are also very powerful in cre-ating and strengthening peer relationships. So-cial support is well known to be beneficial totrauma survivors (Brewin, Andrews, & Valen-tine, 2000; Ozer, Best, Lipsey, & Weiss, 2003),and it has been shown to be associated withbetter adjustment in people caring about some-one living with mental illness (Lee et al., 2006).

Fourth, MFGs can be rewarding for clini-cians, many of whom are experiencing burnoutfrom a heavy caseload of exposure therapycases (Voss Horrell, Holohan, Didion, & Vance,2011). Shifting into a classroom, psychoeduca-tional format can be a pleasant diversion fromtrauma-processing work. Further, we have

found that providing these multifamily groupsessions is often quite rewarding, as the familiesbond with one another quickly and express agreat deal of appreciation for the support andinformation.

Adaptations of the MFG Model forVeterans and Their Families Dealing With

PTSD

To set the stage for our description of how weadapted the MFG model for PTSD, we brieflydescribe our two pilot programs. Developmentof the Reaching out to Educate and AssistHealthy, Caring Families (REACH) Programwas funded by mental health enhancementfunds from VA Central Office in 2005. Detailsof the program and how the structure and con-tent of the original MFG model were modifiedto meet the unique needs of PTSD veterans aredescribed elsewhere (Sherman, Fischer, So-rocco, et al., 2009). In the first year of imple-mentation, REACH yielded very positive satis-faction data and high within-phase retentionrates (89-95% per phase; Sherman, Fischer,Bowling, et al., 2009). In considering the first100 dyads that completed the evaluation com-ponent of REACH, statistically significant im-provements ( p � .05) have been found in: in-terpersonal relationships, problem solving andcommunication, family coping, the Brief Symp-tom Inventory General Severity Index, and em-powerment and PTSD knowledge for both vet-erans (n � 100) and family. Improvements inperceived social support approached signifi-cance ( p � 0.05– 0.07). Improvements inREACH-targeted-skills predict improvements infunctional outcomes (Sherman, Doerman, & Fi-scher, 2011). Approximately 200 dyads have par-ticipated across the 32 9-month cohorts to date,and the clinical intervention is ongoing. Both thecurriculum/therapist manual and the student work-book are available for free download on the Inter-net (www.ouhsc.edu/REACHProgram).

Development of a MFG intervention to meetthe needs of veterans who sustained mild-moderate Traumatic Brain Injury (TBI) whiledeployed to Afghanistan or Iraq was funded byan award from the Department of Defense(W81XWH-08 –2-0054). In the MultifamilyGroup for Veterans with TBI (MFG-TBI) inter-vention, clinicians worked with 6 – 8 veteran/family member dyads to address everyday prob-


lems and to improve communication. All veter-ans in the MFG-TBI trial had either a currentdiagnosis of PTSD (91%), or a history of treat-ment for PTSD (9%;Straits-Troster et al., 2011).To date, MFG-TBI has been implemented infour groups of veterans and families across twosites: the Durham VA Medical Center (Durham,NC) and the JJ Peters VAMC (Bronx, NY).Design of the MFG-TBI intervention for veter-ans was based in part on Rodgers et al.’s (2007)adaptation of the MacFarlane model for brainand spinal cord injury survivors and their fam-ilies, in which TBI survivors participating intheir 12 month multifamily treatment programreported a decrease in depressive symptoms andanger expression and increased overall life sat-isfaction, while caregivers reported a significantreduction in family burden.

The modifications that both programs(REACH and MFG-TBI) made to the originalmodel focused on three key domains: 1) tailor-ing the contents and format of the educationalmaterial, 2) including a focus on relationship-building skills, and 3) using problems in theproblem-solving process that are commonlyfaced by veterans with PTSD and their families.

Contents and Format of Education

In both REACH and MFG-TBI, delivery ofeducational material is extended beyond the1-day comprehensive workshop format in theoriginal MFG model. In both of our approaches,education begins in the individual family join-ing phase. After performing a thorough assess-ment of the history of the illness and thefamily’s social support network, introductoryinformation about PTSD (and TBI in the MFG-TBI groups), coping skills, and managingstrong emotions is presented. After addressingthe standard content for the joining sessions,the clinician tailors the ancillary education tothe specific dyad’s needs.

Education continues in Phase 2; REACH in-volves six, weekly 75-min classes and MFG-TBI has two, 3-hr sessions. The expansion ofthe educational components was done to ac-commodate the volume and scope of contentmaterial. Each REACH Phase 2 class has aspecific topic—addressing issues of the impactof PTSD on relationships, communicationskills, stress management, anger management,depression management, and problem-solving

skills. In the MFG-TBI program, education isprovided about neuroanatomy and blast injury,the pathophysiology and symptom profile asso-ciated with TBI, and the recovery trajectory of acluster of interrelated conditions (PTSD, sub-stance abuse/use disorders, and depression). Di-dactics about reintegration challenges are pro-vided (e.g., marital distress around parenting,financial planning, and intimate relations), thenthey are reframed as common problems relatedto the strains of separation and reintegration.Compensatory strategies for memory problemsrelated to TBI are discussed and “Family Guide-lines” are presented to facilitate coping withfrustration and problematic symptoms (Perlicket al., 2011).

Both programs provide take-home educa-tional material to encourage participants tomore systematically relate educational materialto the problems they encounter in their dailylives, and to rehearse skills through the use ofhomework assignments (Sherman, Fischer, etal., 2009). In REACH, formal homework as-signments follow each of the six Phase 2 edu-cational sessions.

Interestingly, initial feedback from pilotgroup participants in the MFG-TBI postinter-vention focus groups indicated a preference formore education to be incorporated with theproblem-solving sessions. For example, in dis-cussing the workshop, one veteran noted: “Ithink that it [the workshop material] shouldhave been revisited . . . probably at the 6 weekor 7 week phase or something, come in and kindof revisit that, how are you guys understanding,are you processing, you know, make it gearedtoward an area of your life, you know . . .”.Veterans and family members felt that while theinitial material was critical (“I learned stuff thatI didn’t know about the frontal lobe and all that. . . and I know that she [his wife] had no clue”),veterans wanted more repetition to help extrap-olate the key points to their daily life experi-ences.

Focus on Relationship-Building Skills

As discussed above, veterans living withPTSD often experience challenges in intimaterelationships—struggling with trust, communi-cation, and intimacy. For newly returning vet-erans, the process of reintegration into civilian


life can be difficult, as skills essential for sur-vival in combat are not adaptive in rebuildingfamily relationships postdeployment.

To address the paramount need for strength-ening relationships, both MFG models include aformal focus on relationship-building skills tosupplement the basic problem-solving model inMFG. Attention to the intimate relationship be-gins in the joining phases, and it is interwoventhroughout the entire treatment process. Manyof these skills have been adapted from bothinterventions for couples with PTSD (e.g.,Glynn et al., 1999; Sherman, Zanotti, & Jones,2005), as well as from individual models offamily psychoeducation which emphasize com-munication training (e.g., Miklowitz et al.,2008; Mueser & Glynn, 1999).

Numerous relationship-building exercises areintroduced over the course of REACH, includ-ing perspective taking, active listening, increas-ing gratitude and expressing appreciation to oneanother, and general communication skills. Spe-cific training in managing conflicts and anger isalso provided. These skills are taught via didac-tic lectures, role-plays, and in-class activities,and between-session practice is strongly en-couraged. Also, break-out sessions for veteransand family members in REACH Phase 2 alloweach group to share their difficulties and suc-cesses in employing positive relationship skills,generating empathy and group cohesion.

In MFG-TBI, clinicians introduce one skillthe dyad can use to counteract threats to therelationship posed by conflict, avoidance and/ordepression in the Joining Phase. This helps tocement the therapeutic alliance, and it providesfamilies with an early success experience thatengenders hope. The therapist tailors the partic-ular skill to the particular couple’s needs. LikeREACH, MFG-TBI also incorporates role-playing of communication skills into the basicMFG group problem-solving model in subse-quent phases. Role-playing within a group set-ting offers the unique opportunity for membersto learn relationship-building skills both as anactor and observer; as an actor, they feel sup-ported by other members who have had similarproblems, whereas as an observer, they canappreciate the impact of unchecked expressionof negative emotions on the other partner froma neutral perspective.

Problem-Solving Issues Unique to PTSDVeterans/Families

In our MFGs, issues presented for problemsolving often revolved around problems relatedto the symptoms of PTSD and/or TBI, problemswith relationship functioning reflecting symp-toms of PTSD, and problems the veteran expe-rienced in reintegration to society at large. Prob-lem solving frequently centers on a couple’sresponse to PTSD avoidance symptoms, as cou-ples often struggle with issues of closeness-distance, social withdrawal, and emotionalnumbing/disengagement. For example, spousessometimes interpret the veteran’s avoidance as apersonal rejection. Solutions often include cor-recting the misattribution, supporting the spousein coping with feelings of rejection and anger,and providing a structure in which the veterancan achieve the distance he or she needs, butsimultaneously be encouraged to communicatewith the spouse and “check in” at a specifiedlater point in time. Additional problems de-scribed by veterans with PTSD include feelingdamaged or undesirable in some way, poten-tially reinforcing depression and avoidancesymptoms.

In MFG-TBI, memory-related problems arecommon, in addition to the relationship andemotion regulation issues described above. Dif-ficulties such as losing keys and phones anddifficulty remembering doctors’ appointments,school events and/or taking medication arecommon. Helpful solutions range from use of a“white board” in the home as a memory aid forimportant dates/chores to use of a pill containerfor remembering medication.

Discussion

In sum, the adaptation and inclusion of MFGas an intervention for PTSD in the VA spectrumof services are timely, important efforts due tofive key factors. First, there has been a recentfocus by the VA and other federal agencies onengaging veterans’ families to support their re-covery, and MFG offers a cost-effective meansto involve families in the veterans’ care. Incontrast to couple’s therapy, where the focus ison the intimate relationship, MFG addresses thebroader range of problems confronting veteransand family members dealing with PTSD. Sec-ond, inclusion of MFG broadens the choice of


treatment options for PTSD and related condi-tions, and the classroom, problem-solving ap-proach may offer a more acceptable, less stig-matizing entry into treatment for veteransand/or families. Third, the focus in MFG ondeveloping relationship skills and strengtheningsocial supports—through interactions withother group members as well as the veteran’sown family—may be particularly helpful forPTSD, where as noted above, evidence suggeststhat persistent PTSD symptoms may erode so-cial support over time (Kaniasty & Norris,2008).

Fourth, the generic, problem-solving ap-proach of MFG suggests that it may be appli-cable to veterans with comorbid conditions suchas TBI or depression, and/or to those with sub-syndromal PTSD as well. Interestingly, the VAhas recently adapted and piloted a 4-sessionproblem-solving education intervention (Nezu,Nezu, & D’Zurilla, 2007) to help engage andbuild generic problem-solving skills in return-ing combat veterans. The intervention is pro-vided outside traditional mental health clinicservices. Family members are not yet routinelyincluded in this program. Finally, the pilot pro-grams described in this article have demon-strated feasibility, acceptability, and prelimi-nary efficacy of MFG in Operation EnduringFreedom (OEF)/Operation Iraqi Freedom(OIF)/Operation New Dawn (OND) and Viet-nam-era veterans with PTSD. Program retentionand satisfaction rates were high among the 30 �cohorts of largely Vietnam-era veterans withPTSD and their families who have participatedin REACH since 2006 (Sherman et al., 2011),and 80% of those enrolled in our initial trial ofMFG-TBI completed the treatment, with over60% of participants attending most sessions.The group format may be particularly attractiveto veterans who have formed strong bonds withand come to rely on their fellow service mem-bers. Partners of veterans living with PTSDoften feel isolated and alone, and they oftenwelcome the opportunity to connect with otherspouses or family members.

Future Directions

Although there are many promising aspectssupporting the use of MFG for treatment ofveterans with PTSD, several questions need tobe addressed to move toward implementation.

First, randomized controlled trials of MFG ver-sus treatment as usual or alternate forms ofsupport (e.g., family social hour) are needed toevaluate the benefits of the problem-solving,education, and relationship-building skills thatcharacterize MFG. Second, the question ofwhether veterans with cooccurring disorderssuch as TBI, depression, and those with subsyn-dromal PTSD can also benefit from MFG needsto be addressed systematically. This is a partic-ularly important issue in view of the high ratesof cooccurrence of these disorders in veteranswith PTSD from the OEF/OIF/OND era (Seal etal., 2009). Third, a larger trial will permit us todetermine the therapeutic mechanisms respon-sible for observed treatment effects, allowing usto make future generations more targeted andefficient. Along these lines, a recent surveystudy of veterans with TBI found that gains infunctional status were mediated by reductionsin cooccurring PTSD symptoms (Pietrzak,Johnson, Goldstein, Malley, & Southwick,2009). This pattern of results would also sug-gest that veterans with TBI and/or other comor-bid conditions could benefit equally from MFGtargeting PTSD symptoms and focusing on ed-ucation and relationship-building skills. Inter-estingly, in MFG-TBI as well as REACH, themajority of problems identified by participantsdealt with relationship issues such as commu-nication and shared activities—confirming ourclinical sense of the importance of relationshipskills impacted by PTSD for veterans and theirfamily members.

Future studies should incorporate a system-atic, detailed evaluation of participation and re-tention rates, including differentiating betweenrates from different referral/recruitmentsources. Such studies should also attempt tointerview veterans and/or family members whodecline to participate or who drop out prior to orearly in treatment. Although participation andretention rates for our pilot programs have beengood to date, interview data from those whodecline would provide information about gen-eralizability of the findings as well as identifytreatment barriers which might be addressed.This is particularly important for the newestcohort of veterans who have significantly lowerrates of session attendance and higher treatmentdrop out relative to earlier veteran cohorts(Erbes, Curry, & Leskela, 2009), and who re-port high levels of concern about stigma (Hoge


et al., 2004). In summary, while much work isneeded before MFG might be considered anevidence-based practice for inclusion in the VAspectrum of care for PTSD, our initial experi-ences suggest that it is a feasible, well-accepted,and promising intervention that fills many gapsin the current continuum of services.

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Received September 30, 2011Revision received March 5, 2012

Accepted March 9, 2012 �

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