Appraise the differences between experimental and non-experimental research.

July-August 2019 • Vol. 28/No. 4 235

Linda Denke, PhD, RN, CCRC, is Director of Nursing Research, UT Southwestern Medical Center, Dallas, TX.

Sharon A. Denham, PhD, RN, CNE, is Professor, Houston J. & Florence A. Doswell Endowed Chair in Nursing for Teaching Excellence, Texas Woman’s University, Dallas, TX.

Family-Focused Treatments for Veterans with Post-Traumatic

Stress Disorder

Linda Denke Sharon A. Denham

A systematic review of the lit-erature was conducted to examine empirical evidence about family-focused treatments (FFT) in the management of Veterans with post-traumatic stress disorder (PTSD).

The primary question guiding this systematic literature review was as follows: Are FFTs effective in managing symptoms of PTSD in Veterans? As the investigators initi- ated this review, the following aims also were considered: • How do Veterans’ family mem-

bers access services needed to manage PTSD?

• Are Veterans’ family members prepared to assist with the daily management of PTSD?

• What needs do family caregivers express when their Veteran member has PTSD?

Problem Mental illness of any form can

be challenging for any family. When a Veteran develops a mental health condition, family members

need to be involved because they know the best ways to provide sup- portive care (National Alliance on Mental Illness [NAMI], 2013). Current care delivery models for PTSD often fail to incorporate fami- ly-focused care despite the availabil- ity of evidence-based family- focused programs for families of Veterans with any mental illnesses within the community at large.

When a previously well-func- tioning member returns after mili- tary deployment with avoidance behaviors, mood swings, and arous- al symptoms, the family is unlikely to be equipped to manage these changes. Logistics and costs associ- ated with the provision of needed forms of family-focused care must be weighed against long-term costs (e.g., substance abuse, homeless- ness, domestic violence, unemploy- ment, suicide) and the long-term implications for a multi-person

household over time need to be evaluated (Ohye et al., 2015). Addressing these concerns may require the commitment of a few researchers who complete longitu- dinal studies involving multiple family members and persons with PTSD to evaluate intervention effec- tiveness.

Significance About 7%-8% of persons in the

United States have PTSD at some point in their lives, or about 8 mil- lion adults in any given year (U.S. Department of Veterans Affairs [VA], 2018a). During the Vietnam War, about 15 of every 100 Veterans were diagnosed with PTSD. Rates have increased to 11-20 of every 100 Veterans serving in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom [OEF] (VA, 2018b).

Instructions for CNE Contact Hours

MSN J1911 Continuing nursing education (CNE)

contact hours can be earned for completing the learning activity

associated with this article. Instructions are available at amsn.org/journalCNE

Deadline for submission: August 31, 2021 1.3 contact hours

Nurses must be more aware of the links between physical and men- tal health. Nurses can play important roles in encouraging and supporting family-focused treatments when Veterans present with symptoms of post-traumatic stress disorder (PTSD). Including fam- ilies in treatments can influence PTSD symptoms and family rela- tionship functioning positively.

July-August 2019 • Vol. 28/No. 4236

Background to the Problem

Research about caregiver roles and family relationships on Veter – ans with PTSD has been limited. Most studies that consider family relationships have focused largely on the challenges associated with multiple deployments and the effects of war on families (Creech, Hadley, & Borsari, 2014). Little is known about how families assist Veteran members with PTSD as they navigate care systems and follow treatment plans (American Public Health Association, 2014; Michigan Government Report, n.d.; Reisman, 2016; Tanielian & Jaycox, 2008). Clear understanding about the ways caregivers are prepared to assist or manage PTSD in daily life is lacking.

Much of the care focus has shifted to the surge of psychological health problems, specifically PTSD, identified in Veterans. At the height of OIF, OEF, and Operation New Dawn, a major question was, What is the impact of deployment on service members and families? The question later shifted to, What is the impact of treatments and pro- grams on service members and fam- ilies? (Flynn, 2014). These Veteran groups have faced the hazards of combat zones with increased sur- vival rates and fewer casualties than in previous U.S. battles. De – ployment lasts a particular amount of time that begins when a service member departs for a combat mis- sion and ends when a stateside return occurs. However, the effects of multiple deployments and rein- tegration into the family have potential implications that can last years (Creech et al., 2014).

Veterans have endured multi- ple, longer deployments with short- er times at home with their family members. Over 2.2 million service members have deployed, leaving behind 1.1 million spouses and 2 million children under age 18 (Creech et al., 2014). By 2015, about 405,915 OEF/OIF Veterans were evaluated at Veteran healthcare facilities for PTSD following their deployment (VA, 2015). According to the American Psychiatric Assoc –

iation (APA, 2017), PTSD symptoms usually occur as intrusive memo- ries, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. These symptoms have been found to last longer than a few months and can disrupt multiple aspects of daily life.

Literature describes the scope of PTSD in Veterans linked with barri- ers, such as stigma to seeking care and gaps or challenges tied to care delivery (Institute of Medicine [IOM], 2014). Substance or alcohol use often are tied to PTSD concerns (Smith, Goldstein, & Grant, 2016). Varied treatments have been identi- fied to manage PTSD, including cog- nitive behavioral therapy, eye move- ment desensitization and reprocess- ing, pharmacological treat ments (e.g., antidepressants), and some trauma-focused forms of psycho – therapy (VA, 2017a). It would be beneficial to know more about fam- ilies and their caregiving roles, the effects of caregiving stress across the lifespan when a family member has PTSD, and which treatments best support family outcomes when a Veteran has PTSD. According to Bernardy (as cited in Reisman, 2016),

Shared decision-making has not been used widely, so we are trying to create a culture where providers meet with patients and discuss PTSD treatment options – the pros and cons of each – and then let patients and family mem- bers make the best decisions for their care. (p. 626)

This supports the claim that current care delivery models too often ignore family-focused care needs and the types of support members require. The paucity of family-focused research means little is known about the effectiveness of treatment interventions for military and Veteran families when PTSD is a concern. This lack of evidence sug- gests healthcare providers working with Veterans offer variable types or combinations of PTSD treatments that could result in military families receiving poor-quality psychological health care (IOM, 2014).

Definitions The following definitions were

used in this review: Post-traumatic stress disorder (PTSD)

is defined as a psychiatric disorder that can occur in persons who have experienced or witnessed traumatic events, such as natural disasters, serious accidents, terrorist acts, war/combat, rape, or other violent personal assaults (APA, 2017).

Methods of trauma-focused psychotherapy include the follow- ing: • Cognitive processing therapy. Re –

frames thoughts about the trau- ma.

• Prolonged exposure. Faces negative thoughts and feelings to regain control.

• Psychotherapy, medication thera- pies, and cognitive behavioral ther- apies known to be effective, indi- vidualized, recommended treat- ments for Veterans with PTSD.

• Cognitive behavior conjoint therapy (CBCT). Identifies thoughts, feel- ings, and behaviors with the focus on targeting current symptoms and changing the thoughts, feel- ings, and behaviors.

• Family-Focused Treatments (FFT). Treatments for Veterans with PTSD that not only address Veterans’ needs but also include needs of family members.

Search Methods The PRISMA-IPD (Preferred Re –

porting Items for Systematic Reviews and Meta-Analyses-Indi – vidual Participant Data) guidelines facilitate integrity, reporting of emerging issues, and exploration of variations of individual participant data for systematic reviews (Stewart et al., 2015). These guidelines pro- vided a checklist for critical apprais- al of published systematic reviews and the steps for this activity (Gray, Grove, & Sutherland, 2017). A search was conducted for peer- reviewed articles for 2000-2016 using Scopus, CINAHL, Medline, and PubMed. Search terms included caregivers, family, spouse, Veterans, technology, post-traumatic stress disor- der, and PTSD.

July-August 2019 • Vol. 28/No. 4 237

The search included random- ized controlled studies and quasi- experimental studies only. Descript – ive studies, case studies, PTSD clini- cal guidelines, and any study test- ing individualized treatments for Veterans with PTSD were excluded. No authors or co-authors were con- tacted in search of pending studies and grey literature was not searched. Authors independently screened research and excluded any studies in which participants were non-American Veterans and any family-related rather than family- focused therapies were used. Also excluded were randomized con- trolled trials (RCTs) without FFT for Veterans and PTSD, studies on structural equation modeling, descriptive or correlational studies on active duty military personnel, and articles written in any language other than English. Six articles were retained. All articles selected by one author were reviewed by the second author, a consensus formed, and articles scrutinized for final results.

Results In the last 16 years, only six of

the 215 articles screened met the threshold for inclusion criteria and research questions. Five studies met the search criteria and one addition- al article from the reference section of one of the five articles provided the total of six articles for the review. None of the studies tested the feasi- bility or effectiveness of technology in delivery of any treatment or iden- tified a framework for use of tech- nology in treatment for PTSD. All six studies found FFT resulted in PTSD symptom im provements, but researchers did not measure PTSD symptoms the same way.

Three studies measured PTSD symptoms using both the Clinician- Administered PTSD (CAPS) and the PTSD Checklist (PCL) (Monson et al., 2012; Monson, Schnurr, Stevens, & Guthrie, 2004; Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). Church and Brooks (2014) measured improvements in PTSD symptoms with the PCL. All four studies found improvement in PTSD symptoms.

Because Fischer, Sherman, Han, and Owen (2013) used a 29-item self-report instrument for PTSD- related knowledge and behaviors developed exclusively for that study, no comparisons to changes in PTSD symptoms can be made to the other five studies. Participants’ knowledge about PTSD in the study by Fischer and co-authors did improve; researchers also measured empowerment, family problem solving, communication, relation- ship satisfaction, social support, coping self-efficacy, and quality of life. However, none of these out- comes were measured in the other five studies so no comparisons can be made. Monson and colleagues (2012) measured intimate relation- ship satisfaction with the Dyadic Adjustment Scale and also meas- ured partner-rated PTSD symptoms and comorbid symptoms and adjustment. However, no other findings from the other articles in this review measured partner-rated PTSD symptoms or co-morbid symptoms so comparisons could not made and conclusions could not be drawn from these findings alone.

Only one study used the Per – sonal Beliefs and Reaction Scale- Modified and Trauma-Related Guilt Inventory as an outcome measure (MacDonald, Pukay-Martin, Wagner, Fredman, & Monson, 2016). Findings supported the value of couple-based intervention treat- ment for PTSD, not only for improved PTSD symptoms but also for improvement in trauma-related cognitions. Results also supported improvements in Veteran adjust- ment, attachment avoidance, and state anxiety. This was the only study in which Veterans’ partners showed significant reductions in attachment anxiety.

Fischer and co-authors (2013) found statistical significance in all measures; in particular, family members’ results for the Brief Symptom Inventory neared signifi- cance (p=0.054). Monson and col- leagues (2004) exclusively used the Beck Depression Inventory and State Anxiety and Trait Anxiety. They found statistically significant

improvements in results of both tools, as well as improvements in CAPS and partner PCL ratings of Veterans’ PTSD symptoms.

These findings provided addi- tional evidence FFT improves not only PTSD symptoms, but also sug- gested cognitive behavior conjoint therapy improves symptoms of anxiety in partners and in trauma- related conditions.

Synthesis and Strength of the Findings

Six articles (see Table 1) were appraised for the level of research using the Johns Hopkins Nursing Evidence Based Practice Evidence Level and Quality Guide (Dearholt & Dang, 2012). Three of the six stud- ies were appraised as Level I, with evidence based on experimental studies, RCTs, and systematic reviews of RCTs with or without meta-analysis (MacDonald et al., 2016; Monson et al., 2012; Sautter et al., 2015). The remaining three studies had Level II evidence (quasi- experimental studies, systematic reviews of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only with or without meta-analysis) (Church & Brooks, 2014; Fischer et al., 2013; Monson et al., 2004).

Discussion Findings of the systematic liter-

ature review suggest families play key roles in treatment for Veterans with PTSD (Church & Brooks, 2014). Findings from use of CBCT with Veterans with PTSD indicated this treatment not only reduces Veterans’ PTSD symptoms, but also appears to reduce PTSD symptoms in partners. If PTSD symptoms are present in Veterans and their spous- es who meet clinical criteria for PTSD, then FFT of Emotional Freedom Techniques (EFT), energy psychology, and energy modalities reduce stress and build resources. EFT appears not only to reduce PTSD symptoms, but also to improve family functioning as a result of improved symptoms and coping.

Family-Focused Treatments for Veterans with Post-Traumatic Stress Disorder

July-August 2019 • Vol. 28/No. 4238

TA B

LE 1

. Ev

id en

ce T

ab le

A ut

ho rs

S am

pl e

S

et tin

g R

es ea

rc h

D

es ig

n M

ea su

re s

In

te rv

en tio

n Fi

nd in

gs

C hu

rc h

&

B ro

ok s,

20

14

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ve ni

en ce

sa

m pl

e of

V et

er an

s (n

=1 09

), av

er ag

e ag

e 51

V

et er

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po us

es

(n =1

09 ),

av er

ag e

ag e

49

A ve

ra ge

1 .4

( 1-

3)

de pl

oy m

en ts

; av

er ag

e ye

ar s

of

de pl

oy m

en t 2

.3

N on

pr of

it ru

ra l

re tre

at c

en te

r in

so

ut hw

es te

rn U

.S .

fo un

de d

by V

A a

nd

lo ca

l g ov

er nm

en t;

pr og

ra m

s ar

e co

lla bo

ra tio

n by

lo ca

l bu

si ne

ss es

, co

ac hi

ng

or ga

ni za

tio ns

, N at

iv e

A m

er ic

an

co m

m un

ity

Le ve

l I I q

ua si

– ex

pe rim

en ta

l P

C L

ci vi

lia n

an d

m ili

ta ry

v er

si on

s 7-

da y

re tre

at s

in cl

ud ed

E

F T,

o th

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et ho

ds

to a

dd re

ss P

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sy m

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m

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bu ild

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ns w

er e

de liv

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in g

ro up

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rm at

a nd

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83 %

o f V

et er

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po us

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ea n

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41

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S E

± 1

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<0 .0

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po us

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nt ia

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( M

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1 .0

; p <0

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), w

ith 4

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fo llo

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( n=

63 )

fo un

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s ym

pt om

le ve

ls

fo r

sp ou

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(p <0

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), w

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ch er

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em po

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ad ap

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n of

m

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am ily

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up

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t, R

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tis tic

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in M

S P

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fic an

ce o

n B

S I s

co re

s.

co nt

in ue

d on

n ex

t p ag

e

July-August 2019 • Vol. 28/No. 4 239

Family-Focused Treatments for Veterans with Post-Traumatic Stress Disorder TA

B LE

1 . (

C on

ti n

ue d

) Ev

id en

ce T

ab le

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01 6

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0)

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s: V

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on to

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m on

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p os

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w ith

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rth er

s up

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ap pr

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to tr

ea t P

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ou p

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ge st

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m od

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e- to

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e ef

fe ct

s fo

r C

B C

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r P

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ve r

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fo r

m aj

or ity

o f o

ut co

m es

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in di

ng s

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po rta

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of

pa rtn

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tr au

m a-

re la

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be lie

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so n

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20 04

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=7 )

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de m

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s

W hi

te R

iv er

Ju

nc tio

n, V

T, V

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C Le

ve l I

I q ua

si –

ex pe

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ta l

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, a s

em i-

st ru

ct ur

ed

cl in

ic ia

n in

te rv

ie w

, tm

ea su

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P T

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di

ag no

st ic

s ta

tu s,

sy

m pt

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ev er

ity

co ns

is te

nt w

ith

th e

D S

M . P

T S

D

C he

ck lis

t P C

L is

a

17 -it

em s

el f-r

ep or

t m

ea su

re o

f P T

S D

sy

m pt

om s

fo un

d in

D S

M -IV

. A ls

o us

ed B

D I a

nd

S TA

I.

C B

C T

fo r

P T

S D

co

ns is

ts o

f 1 5

se ss

io ns

in

th re

e tre

at m

en t

ph as

es : p

sy ch

o- ed

uc at

io n

in P

T S

D a

nd

its r

el at

ed in

tim at

e re

la tio

ns hi

p pr

ob le

m s;

co

m m

un ic

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n sk

ill s

tra in

in g;

c og

ni tiv

e in

te rv

en tio

ns .

S ta

tis tic

al ly

s ig

ni fic

an t i

m pr

ov em

en ts

in

C A

P S

, P C

L- P

r at

in gs

o f V

et er

an s’

P T

S D

sy

m pt

om s.

V et

er an

s’ s

el f-r

ep or

te d

im pr

ov em

en ts

in P

T S

D s

ym pt

om s

on

P C

L- S

n ot

s ta

tis tic

al ly

s ig

ni fic

an t.

U si

ng r

el ia

bl e

ch an

ge c

rit er

ia fo

r P

T S

D

sy m

pt om

s, a

ll se

ve n

V et

er an

s w

er e

im pr

ov ed

a cc

or di

ng to

C A

P S

, fi ve

w er

e im

pr ov

ed a

cc or

di ng

to P

C L-

P, fo

ur w

er e

im pr

ov ed

a cc

or di

ng to

P C

L- S

. O

ne V

et er

an r

ep or

te d

de te

rio ra

tio n

in h

is

sy m

pt om

s. T

hr ee

V et

er an

s no

lo ng

er m

et

cr ite

ria fo

r P

T S

D d

ia gn

os is

a t t

he e

nd o

f tre

at m

en t.

T he

V et

er an

s se

lf- re

po rte

d st

at is

tic al

ly s

ig ni

fic an

t i m

pr ov

em en

ts in

B

D I,

S TA

I.

co nt

in ue

d on

n ex

t p ag

e

July-August 2019 • Vol. 28/No. 4240

TA B

LE 1

. ( C

on ti

n ue

d )

Ev id

en ce

T ab

le

A ut

ho rs

S am

pl e

S et

tin g

R es

ea rc

h

D es

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L =

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t L is

t

July-August 2019 • Vol. 28/No. 4 241

The REACH multifamily group study also showed improvements in relationship satisfaction, depres- sion, anxiety, and social function- ing in Veterans and their partners (Monson et al., 2004). However, partners of Veterans with PTSD self- reported improvement in relation- ship satisfaction while Veterans’ self-report of relationship satisfac- tion remained the same over time. Future studies about the effective- ness of FFT when the Veteran has PTSD need to assess relationship satisfaction improvements.

In three of the six studies, PTSD symptoms and family function not only appeared to improve consis- tently with FFT, but also were sus- tained over time (MacDonald et al., 2016; Monson et al., 2012; Sautter et al., 2015). As partners’ knowl- edge, skills, and understanding of PTSD improve, along with partner engagement in treatment, a shift appears to occur in relationship quality and family functioning. Findings from this review indicate Veterans who access services that include FFT report the greatest reduction of PTSD symptoms (Toscano & Roberts, 2014).

However, limited research in FFT may be one reason only indi- vidual forms of therapy have been verified as evidence-based treat- ments (eye-movement desensitiza- tion and reprocessing, exposure therapy, trauma-focused cognitive behavioral therapy) and are current- ly available for treatment of PTSD in Veterans (VA, 2017b). While psy- chosocial disturbances are experi- enced personally by Veterans, the impact of these disturbances perme- ates the entire family system. When both the Veteran and partner receive PTSD treatment, greater reduction in PTSD symptoms is experienced (Monson et al., 2012).

Implications for Practice, Education, and Research

Congress passed the Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230-113) in 2014, allowing eligible Veterans to seek care outside Veteran healthcare facilities. This means nurses who

care for Veterans in non-VA hospital settings need to understand more about Veteran family care needs. Nurses in all healthcare settings may be asked to provide coordinat- ed efforts for Veterans’ physical and psychological needs, and engage families in the treatment plans. Nurses caring for Veterans should be knowledgeable about PTSD symptoms and be prepared to assess need for FFT treatments in inpatient and community settings. More research is needed to test the effec- tiveness of FFT interventions for PTSD using consistent outcome measures that fully identify the benefits of FFT for Veteran families.

NAMI provides support to fam- ilies of persons with mental illness- es. As the largest grassroots mental health organization, NAMI grew out of the needs of family members who live with and are affected by members with mental illness. Programs include Family to Family and Homefront, a free, educational program for families, caregivers, and loved ones of Veterans (NAMI, 2013). This program is based on NAMI Family to Family, a national- ly recognized family education pro- gram for families affected by mental illnesses. In 2017, NAMI Family to Family education was included in the U.S. Substance Abuse and Mental Health Services Admini – stration Registry as an evidence- based program and practice.

Joining forces with the VA, the American Association of Colleges of Nursing developed the Enhancing Veteran Care Toolkit which provides multiple resources such as Veteran care competencies (McMillan et al., 2017). Nursing faculty are preparing nursing students to care for Veteran family care needs, with the under- standing the Veterans’ physical injuries often are accompanied by mental healthcare needs.

Limitations of the Review Limitations of this review

include the small sample of identi- fied studies, the inconsistent meas- ures used for PTSD, and variations in the ways FFT was interpreted. Although the findings failed to pro-

vide strong evidence for the value of FFT in PTSD treatment, they sug- gested more inclusion of family in care delivery is needed. The small number of studies suggests more consideration be given to Veteran families and their lived experience of PTSD. Further, the findings raise questions about the need to involve families and nontraditional part- ners in PTSD treatment.

Conclusion Nurses must be more aware of

the links between physical and mental health. For example, Veterans diagnosed with cardiovas- cular disease may have co-occurring depression and anxiety (Jankowski, 2016). As nurses recognize PTSD symptoms, they also must be aware PTSD can affect physical health adversely (Schnurr, 2016). Nurses can play important roles in encour- aging and supporting FFT when Veterans have PTSD symptoms. Finally, including families in treat- ments is shown to influence PTSD symptoms and family relationship functioning positively (Batten et al., 2009).

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