BACKGROUND/RATIONALE:
Supporting veterans' efforts to fully engage in evidence-based psychotherapies (EBPs) for PTSD may provide a powerful tool for maximizing veterans' chances for recovery. One central and underutilized resource in this effort is families. VA/DoD treatment guidelines explicitly recommend family-involvement in PTSD care. However, the degree to which these recommendations are implemented in practice is unknown. Additionally, these guidelines are not based in evidence demonstrating enhanced patient outcomes.

OBJECTIVE(S):
Our goal is to generate data to inform evidence-based recommendations for family-involvement in EBPs for PTSD. Our Specific Aims are:
1) To identify important family, patient, and provider level barriers and facilitators of veterans' adherence to EBPs for PTSD that can be targeted through family-involvement.
2) To assess the current frequency and quality of family-involvement in EBPs for PTSD.
3) To identify stakeholder preferences for family-involvement, using case examples with poor adherence.
4) To identify barriers and facilitators to implementing family-involvement in EBPs for PTSD.

METHODS:
To achieve our aims we conducted a pre-post observational study of veterans and a key significant other (SO) as veterans completed EBPs for PTSD (i.e., Prolonged Exposure or Cognitive Processing Therapy) across three sites. We mailed paper-and-pencil surveys to 193 veterans and 88 of their nominated SOs as veterans were referred to EBPs for PTSD (Time 1). We then surveyed this group again 4 months later (Time 2). We also conducted in-depth interviews with a small group of veterans (N = 7), their SOs (N = 6), and their therapists (N = 7) who continued to screen positive for PTSD after treatment and reported poor treatment adherence.

FINDINGS/RESULTS:
Veterans who completed surveys (N = 132; 68.4%) were frequently male (97.8%) and White (62.9%; 13.7% Black; 10% Latino/Hispanic); 35.2% were recently deployed (OEF/OIF/OND; 13.3% First Gulf War; 40.0% Vietnam War, 20.0% peacetime). Sixty-seven percent (66.7%) of veteran respondents nominated an SO for participation. SOs (N = 79; 88.6% response rate) were usually intimate partners (69.9%), female (80.6%), and 47.5 years old (SD = 14.44), on average. The qualitative sample included four Vietnam War era veterans and two OEF/OIF veterans.

AIM 1: We conducted a series of mixed regression models examining associations between family-related predictors and study outcomes: 1) completion of an adequate dose of treatment to achieve benefit; i.e., 8 or more sessions; 2) veteran commitment to completing the EBP; 3) veterans' posttreatment PTSD severity (controlling for Time 1 PTSD severity). All models controlled for study site, treatment type, and veteran-related predictors (i.e., attitudes about treatment, therapeutic alliance, severity of perceived practical barriers to treatment adherence). After imposing the above controls, any contact between veterans' SOs and therapists continued to predict treatment completion. Secondly, SOs' beliefs about the credibility of the EBP continued to uniquely predict veterans' commitment to treatment. Unique associations between veterans' treatment commitment and SOs' encouragement of avoidance as a coping strategy were approaching significance (p=.067). Finally, unique associations were approaching significance between post-treatment PTSD scores and the quality of the veterans' relationships with their SOs (p=.090), SOs' perceptions of treatment credibility (p=.070), and the degree to which veterans feel they can share trauma-related feelings/symptoms with SOs (p=.081). Remaining unique associations between family-related variables and the above outcomes of interest were non-significant.

AIM 2: While 71.0% of veterans and 95.8% of SOs reported that they were at least 'a little' interested in therapist-to-family contact, only 21.8% of veterans reported that their therapist had contacted their SO in the last 6 months. This contact was typically with veterans' intimate partners (85.2%) and frequently a single contact (51.9%; 14.8% twice; 22.2% 3-4 times; 11.1% 5 or more times). This contact was typically perceived as quite a bit/extremely helpful (55.6%; 40.7% at little/somewhat; 3.7% not at all; Median = 'Quite a bit').

AIM 3: Survey data indicated that 54.3% of SOs were interested in talking to veterans' therapists over the phone, 66.7% were interested in coming to a few therapy sessions with the veteran, 47.1% were interested in coming to therapy sessions with the veteran on a regular basis (at least monthly), 44.9% were interested in a support group for SOs, 27.9 % were interested in participating through v-tel from their closest VA, and 30.4% were interested in participating from home through their personal computer. In qualitative interviews, veterans, their SOs, and the therapists expressed interest in family-involvement in multiple forms. However, veterans' also expressed a need for family-involvement to be tailored to their own or their support networks' specific needs and circumstances.

AIM 4: Individuals from each category of respondent (i.e., veterans, SOs, and therapists) expressed beliefs that family-involvement could benefit the veterans' treatment. At the same time, some veterans expressed reservations about involvement. Veterans expressed a need for ground rules about what was discussed and who was involved. Respondents in each category also expressed beliefs that someone else (the therapist, the veteran, the SO) should verbalize a desire for family-involvement in order to initiate efforts to include SOs in care, potentially leading to miscommunication and missed opportunities for family-involvement. Veterans also expressed uncertainty about the effects of involvement, given the potential risk. They verbalized concerns that involving a family member would involve risk taking on their part within their relationships and/or potentially create added burden for the SO. Veterans also had not discussed the benefits and drawbacks of family-involvement with their providers in order to make an informed decision about family-involvement.

IMPACT:
This study provides highly needed and detailed information on potential intervention points for involving families during veterans' participation in EBPs in a way that will increase family support, strengthen family relationships, and help veterans get the most out of treatment. Completion of these objectives directly addresses the mission of MH QUERI by closing gaps in our knowledge and paving the way for quality improvement in MH QUERI focus areas, including PTSD treatment and recovery-oriented mental health care.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, Chard KM, Crowley J, Eftekhari A, Finley EP, Hamblen JL, Harik JM, Kehle-Forbes SM, Meis LA, Osei-Bonsu PE, Rodriguez AL, Ruggiero KJ, Ruzek JI, Smith BN, Trent L, Watts BV. A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. Administration and policy in mental health. 2016 Nov 1; 43(6):957-977. [view]
2. Meis LA, Noorbaloochi S, Hagel Campbell EM, Erbes CR, Polusny MA, Velasquez TL, Bangerter A, Cutting A, Eftekhari A, Rosen CS, Tuerk PW, Burmeister LB, Spoont MR. Sticking it out in trauma-focused treatment for PTSD: It takes a village. Journal of consulting and clinical psychology. 2019 Mar 1; 87(3):246-256. [view]
3. Thompson-Hollands J, Burmeister LB, Rosen CS, O'Dougherty M, Erickson EPG, Meis LA. Veterans with poor PTSD treatment adherence: Exploring their loved ones' experience of PTSD and understanding of PTSD treatment. Psychological Services. 2021 May 1; 18(2):216-226. [view]

Conference Presentations

1. Meis LA, Spoont MR, Erbes CR, Polusny MA, Noorbaloochi S, Hagel Campbell EM, Eftekhari M, Kattar A, Rosen K, Tuerk P, Velasquez TL, Erickson E, Thompson K, Stewart K, Vang T. Because I asked you to: The role of family in Veterans' engagement in trauma-focused treatment for PTSD. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA. [view]
2. Meis LA, Spoont MR, Noorbaloochi S, Hagel Campbell EM, Erbes CR, Polusny MA, Eftekhari A, Rosen C, Tuerk PW, Kattar KA, Velasquez TL, Cutting AH, Burmeister LB, Henriksen KR, Baltutis E, Rynda KM. Can Families Help Shape Former Service Members' Adherence to Trauma-Focused Treatments for PTSD? Poster session presented at: Military Health System Research Symposium; 2016 Aug 16; Orlando/Kissimmee, FL. [view]
3. Meis LA, Spoont MR, Erbes CR, Polusny MA, Noorbaloochi S, Hagel Campbell EM, Bangerter AK, Eftekhari A, Kattar K, Tuerk P. Can Families Help Shape Veteran's Opinions of and Response to Evidence Based Treatments for PTSD? Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL. [view]
4. Meis L, Spoont M, Erbes C, Polusny M, Noorbaloochi S, Hagel EC, Bangerter A, Eftekhari A, Kattar K, Tuerk PW. The Role of Individual Beliefs and Family Involvement in Understanding Veterans’ Commitment to Evidence Based Treatments for PTSD. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none