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Posttraumatic stress disorder (PTSD) is a disorder that not only affects the individual, but their relationships as well. PTSD is associated with decreased social and occupational functioning, poorer quality of life, increased aggression, and high levels of intimate relationship dysfunction (Birkley et al., 2016; Taft et al., 2011, McCaslin et al., 2015; 2016). Moreover, PTSD often results in self-isolation and numbing, impacts of which are also felt by loved ones.  
The interpersonal impact of PTSD has led to the development of conjoint interventions that involve a romantic partner or other loved one in the treatment (see Monson, Macdonald, et al., 2021). This approach allows the treatment to not only target PTSD, but also the negative impacts of PTSD on the relationship and the well-being of loved ones. Research has shown that conjoint interventions for PTSD do, in fact, lead to benefits in all three areas as intended (Monson, MacDonald, et al., 2021). However, significant barriers impact access to traditional face-to-face psychological treatments, including limited trained clinicians, geographical distance, scheduling, and stigma. 
To overcome these barriers, Couple HOPES (Helping Overcome PTSD and Enhance Relationships; www.couplehopes.com) was developed by Drs. Candice Monson, Skye Fitzpatrick, and Anne Wagner. Couple HOPES is a coach-guided, online couple intervention for PTSD. The program has seven interactive modules consisting of psychoeducational videos, training exercises, and pre-module assessments that allow the couple to develop new skills and track their changes over time. Each couple is also assigned a paraprofessional coach to help navigate them through the program and troubleshoot any questions or concerns. 
In initial uncontrolled investigations of Couple HOPES, couples saw improvement in PTSD symptoms, relationship satisfaction, and some individual functioning domains for the individual with likely PTSD. However, given the impact of PTSD on loved ones, it is also necessary to have interventions that improve the individual mental health and well-being for loved ones as well. This study evaluated whether Couple HOPES resulted in the intended improvement in these outcomes for the romantic partners of those with likely PTSD.
We examined how Couple HOPES impacted romantic partners' individual outcomes in three domains: relationship functioning, mental health, and well-being. To measure relationship functioning, we used a scale that measures the amount of perceived destructive communication. To measure improvements in mental health, the following outcomes were assessed: depression, generalized anxiety, trait anger, and alcohol misuse. To assess improvements in well-being, three outcomes were assessed: work functioning, perceived health, and quality of life.
We examined these individual outcomes in an uncontrolled trial  involving 27 romantic partners of Canadian military members, veterans, and first responders with likely PTSD. We found that those in Couple HOPES significantly improved in their ineffective arguing, anger, perceived health, and quality of life, but did not observe change in work functioning, alcohol use, depression, or generalized anxiety. However, by one month after the intervention, improvements in anger dissipated, while generalized anxiety improved, and perceived health continued to improve. For the outcomes that did not significantly change, it is unclear if these outcomes are too far removed from the focus of the intervention, if partners did not have much room to change due to symptoms being mild at the start, or if the intervention is not effective for these outcomes. 
Across the uncontrolled studies of Couple HOPES conducted so far, we find preliminary evidence that Couple HOPES results in improvement in PTSD symptoms, relationship functioning, and some domains of individual functioning for both partners. The impact of PTSD extends beyond the life of the person with PTSD and into relationships with loved ones. Therefore, treatments that involve loved ones may have particular promise to alleviate suffering and improve well-being for those with PTSD and their loved ones. 

Target Article

Crenshaw, A.O., Whitfield, K.M., Collins, A., Valela, R., Varma, S., Landy, M.S.H., Ip, J., Donkin, V., Earle, E., Siegel, A., Samonas, C., Bushe, J., Mensah, D.H., Xiang, A., Doss, B.D., Morland, L., Wagner, A.C., Fitzpatrick, S., & Monson, C.M. (2022). Partner outcomes from an uncontrolled trial of Couple HOPES: A guided online couple intervention for PTSD and relationship enhancement. Advanced online publication. https://doi.org/10.1002/jts.22878

Discussion Questions

  1. What unique challenges do you think the loved ones of people with PTSD experience?
  2. How might these findings regarding the impact of conjoint PTSD interventions on the wellbeing of intimate partners inform dyadic and couple PTSD psychotherapy research?
  3. How might we identify when involving loved ones (e.g., romantic partners, family members) in PTSD treatment would be helpful?

About the Authors

Alexis Collins, BSc., is a project coordinator at the IMPACT Lab at Toronto Metropolitan University.  Her research focuses on the evaluation, implementation, and dissemination of evidence-based interventions for PTSD. 

Elizabeth A. Earle, B.A., (she/her) is a lab manager and research coordinator in the Treating and Understanding Life-Threatening Behaviour and Posttraumatic Stress (TULiP) lab at York University. Her research and clinical interests include emotion regulatory processes in the context of intimate relationships, as well as expanding evidence-based couples therapies to be more inclusive of LGBTQ+ populations and non-traditional relationship structures in the treatment of psychological disorders characterized by emotion dysregulation and/or trauma. Elizabeth can be reached at eearle@yorku.ca
Alexander O. Crenshaw, PhD, C.Psych., is a Clinical Research Psychologist in the IMPACT Lab at Toronto Metropolitan University. His research focuses on how interpersonal processes impact relationship dynamics and outcomes, and using this knowledge to improve treatments involving couples. A second arm of his research focuses on improving statistical and methodological practices in the study of couples. 
Candice M. Monson, PhD, C.Psych., is a Professor of Psychologist at Toronto Metropolitan University and Founder and CEO of Nellie Health. She is well-known for her development, testing, and dissemination of science-based individual, group, and conjoint treatments for traumatic stress. She is a developer of Couple HOPES.   
Skye Fitzpatrick, PhD, C. Psych., is an Assistant Professor in the Department of Psychology at York University and a Clinical Psychologist. Her research focuses on optimizing interventions for borderline personality disorder and posttraumatic stress disorder. She is a developer of Couple HOPES. 
Anne Wagner, PhD, C.Psych., is the Founder of Remedy and Remedy Institute, and an Adjunct Professor in the Department of Psychology at Toronto Metropolitan University in Toronto, Ontario, Canada. Her research focuses on relationships, trauma-focused treatments, and psychedelic-assisted psychotherapy. She is a developer of Couple HOPES.  

References Cited

Birkley, E. L., Eckhardt, C. I., & Dykstra, R. E. (2016). Posttraumatic stress disorder symptoms, intimate partner violence, and relationship functioning: A meta-analytic review. Journal of Traumatic Stress, 29(5), 397-405. https://doi.org/10.1002/jts.22129
McCaslin, S. E., Maguen, S., Metzler, T., Bosch, J., Neylan, T. C., & Marmar, C. R. (2015;2016;). Assessing posttraumatic stress related impairment and well-being: The posttraumatic stress related functioning inventory (PRFI). Journal of Psychiatric Research, 72, 104-111. https://doi.org/10.1016/j.jpsychires.2015.10.016
Monson, C. M., Macdonald, A., Fredman, S. J., Schumm, J. A., & Taft, C. T. (2021). Empirically-supported couple and family therapies for PTSD. In M. J. Friedman, P. P. Schnurr & T. M. Keane (Eds.), Handbook of PTSD: Science and practice, (3rd ed., pp. 377-399). Guilford Press. 
Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79, 22-23. https://doi.org/10.1037/a0022196