Office of Research & Development
Office of Research & Development
VA Research Currents archive
November 23, 2016
Danielle Schultz is a therapist and project director with the multifamily rehab program at the Bronx VA. The program focuses on problem-solving techniques. (Photo by Yang Zhao)
Dr. Debbie Perlick, a clinical psychologist, is the associate director for family assessment and intervention at the James J. Peters VA Medical Center in the Bronx, New York.
In recent years, she has learned of VA programs to help post-9-11 Veterans with posttraumatic stress disorder reconnect with their spouses and partners, and to reintegrate those Vets into the community. At the same time, she realized there were no family-based programs to address the needs of Veterans with mild traumatic brain injury [mTBI], "despite the high prevalence of this injury and its comorbidity with PTSD," she says.
Perlick and her colleagues moved to fill this critical gap. They launched a program that was initially designed to address the needs of partnered combat Vets who fought in Iraq or Afghanistan and were battling mTBI, also known as a concussion. Today, the eligibility criteria have expanded: Vets with PTSD or combat-related stress with no formal PTSD diagnosis, with or without mTBI, can also take part.
Family life can be tumultuous for Vets with these disorders, some of the symptoms of which can overlap: irritability, restlessness, memory loss, fatigue, dizziness. The problems can lead to possible communication breakdowns with couples, domestic violence, and even separation or divorce. Fifty-four percent of couples that include a Vet from the wars in Iraq and Afghanistan have reported marital conflict and domestic violence.
Mild traumatic brain injury, the signature wound for Veterans who served in Iraq and Afghanistan, accounts for nearly 80 percent of all TBIs. Up to 20 percent of those with an mTBI will continue to suffer from post-concussion syndrome, a complicated mix of symptoms and impairments. Among Vets with mTBI, at least 4 in 10 also have PTSD.
"Our final sessions tend to be quite moving, with couples holding hands."
"The often profound difficulties that Veterans and their partners experience in understanding the problems they face individually and together in rebuilding or building their lives in the greater community can certainly contribute to the already high rates of separation and divorce, with consequences for both partners as well as children," Perlick says.
Her program, the centerpiece of an ongoing VA study, is designed to improve relationships among married and cohabitating Iraq and Afghanistan Vets.
The goal is to enlist a total of 150 couples, Perlick says. So far about 75 couples, most of them heterosexual, have signed on. They are taking part in counseling sessions at the James J. Peters facility and in the VA NY Harbor Health Care System and the VA Maryland Healthcare System. Many of the couples are referred to Perlick and her team by VA health professionals who have learned of the Veterans' family challenges.
Once in the program, two groups of couples attend 14 meetings that include individual and multifamily sessions over a six-month period. The sessions are led by specialists in family intervention and multifamily group treatment.
The content and therapeutic approach differs for the two groups. One approach calls for educating Veterans and family members on mTBI, PTSD, and comorbid disorders, and it includes skills-training sessions in problem-solving for cognitive and emotional issues. The other approach focuses on health education without the skills training.
The couples are randomly assigned to one of the two groups. However, once a couple has completed the six-month program, they are no longer official study participants and can attend the other group's sessions on a clinical basis.
Couples tell the instructors about their family problems and are trained to use communication and problem-solving skills to reduce marital disruptions. Case in point: Because short-term memory loss is prevalent for Vets with mTBI, the couples are advised to put white boards and signs in the house and to program their smart phones to help the Veterans remember their goals, tasks, and schedules.
According to Perlick, combining emotion regulation training in a multicouples setting with behavioral models of family therapy, which have been around for decades, is novel.
Couples with a history of domestic violence are screened out of the program. "We hope to teach skills to avoid escalation of conflict to the level of domestic violence," Perlick says.
Perlick finds the couples to be "quite engaged."
"We discuss what they feel they've gained in our final session, and everyone has felt they've benefited both individually and as a couple," she says. "Specifics mentioned are emotion regulation skills such as `time outs,' better listening skills that have brought them closer together, and the support and growth from sharing with other couples dealing with similar post-deployment adjustment problems.
"Our final sessions tend to be quite moving, with couples holding hands," she adds.
In praising the program, one Veteran referred to a TV series from more than a half-century ago, "Leave it to Beaver," which portrayed a wholesome American family.
"Just coming here was like a first step and bringing it out in the open, instead of living like the `Cleavers,' where everything is happy and kept hush-hush," the Veteran says. "Bringing things up in front of other couples, that's a big first step."
Many of the Vets' spouses are finding the program impactful, too.
"He opened up a lot about his struggles with TBI and PTSD, and he shared it with everybody," one partner says. "And I was very impressed because I feel like six months ago, a year ago, he wouldn't have done that. It was pretty powerful."
At the end of the six-month study period, the couples are evaluated to assess their progress. The research is scientifically rigorous, and the outcomes are recorded whether a couple progresses or regresses. Couples that remain in distress are offered the chance to participate again only on a clinical basis.
Some couples have completed the program, but Perlick will not share final data while the study is in progress. Preliminary findings, she says, support the use of emotion regulation training in conjunction with evidence-based models of behavioral family therapy for 9-11 Veterans and their partners.
Perlick says the more progress the instructors make in teaching Vets and their partners how to control their emotions in tense situations, the more her program will lead to marital satisfaction. If successful, she says, the program could spread through the VA health care system.
She believes quick intervention to stem this cycle of family turmoil is needed.
"It is not unusual for us to sign a couple for the study, only to find out a week or so later, they are separating or divorcing," she says. "So while we maintain objectivity as researchers, we do feel a vital need to try to provide relationship-building skills to couples experiencing difficulties, to the extent we are able."
Below is a sampling of reactions from participants in the multifamily group treatment program:
Support and Opening Up
"I like it because it's like the one place I feel like I can be really honest about my emotions and what I'm feeling. I never felt held back. I never felt like I didn't get to express myself, and I never had an experience like that before. It was really helpful." - Partner
"Coming here is helping her understand the kind of support I need." - Veteran
"It takes patience, and the more education we get the more patient we are..." - Partner
"And the different perspectives on how to handle problems from other people and what's worked for them...so you got tools that you could put in your tool kit and use later on." - Veteran
"...a lot of this stuff I did utilize, like time-outs and stuff. There were times I wanted to fly off the handle; I had to remember some of the things you all taught me." - Veteran
Evaluation of Program
"When I first came back they put us in a room and a counselor explained, `We're here for you.' People saying they're here means nothing ... Show me that you're here for me [tearful]...that you're going to put programs like this in place so people have a place to go. That's what's showing me that you care." - Veteran