Nicole Freeman-Favia, B.S., Mindy Merricle, Psy.M., & Jeremiah A. Schumm, Ph.D.
The following is a review of literature, focusing on Monson and Fredman’s (2014) Cognitive-Behavioral Conjoint Therapy (CBCT) for Posttraumatic Stress Disorder (PTSD) and its possible utility with couples concurrently presenting with PTSD and bereavement due to traumatic loss of a child. Suicide-bereaved parents and parents who have lost children to other traumatic deaths, frequently experience traumatic grief and symptoms of PTSD (Albuquerque, Pereira, & Narciso, 2016; Murphy et al., 1999; Murphy et al., 2003; Swan & Scott, 2009). Traumatic loss of a child is unique from other traumas because it may involve a shared traumatic loss that is experienced by both parents. Other forms of trauma can impact both partners in a dyadic relationship, but they may not experience the interpersonal loss in the same way (e.g., a military member witnesses the death of a close friend in combat who is not well-known to the civilian partner). CBCT for PTSD has been developed to treat an individual for PTSD while incorporating a partner, significant other, or a close loved one. The incorporation of concerned significant other aids in the effectiveness in treating the individual with PTSD as well as improving relationship satisfaction between the dyad. The use of CBCT can be effective when one or both partners have PTSD. However, research is limited on couples in which both partners exhibit PTSD. In addition to addressing PTSD, this treatment may also lend itself to addressing traumatic grief identified in parents bereaved by violent child death (i.e., suicide, homicide, accident).
Traumatic Loss of a Child
When a couple experiences the death of a child, the associated grief may be even more severe than when grieving other losses such as the death of a spouse (Sanders, 1980). This is especially true for parents bereaved by violent child death (i.e., suicide, homicide, accident). The sudden and catastrophic death of a child may lead to traumatic and complicated grief years after the loss (Rogers et al., 2008). A study from Ross, Kõlves, Kunde, and Leo (2018) examined suicide-bereaved parents and their response to traumatic grief, as well as parents who experienced other forms of sudden or catastrophic death. Researchers gathered interview data over a year period from parents who had lost their children through a traumatic experience. Based on self-report from the participants, Ross et al. found that while maladaptive coping methods like avoidance and alcohol abuse occurred, there was also the potential for post-traumatic growth and strengthening of relationships. The data collected had no clear indication that the participants were seeking additional supportive counseling to address their feelings around their loss, but several indicated the benefit of support groups (Ross, Kõlves, Kunde & Leo, 2018).
About 25 percent of mothers and 12 percent of fathers meet diagnostic criteria for PTSD five years after child death (Murphy et al., 1999; & Murphy et al., 2003). Conceptualizations of complicated grief and PTSD have shown several similarities including factors that maintain and exacerbate symptoms such as the inability to process loss into autobiographical memory, negative beliefs and interpretations of the grief, and avoidance of the loss (Boelen, van den Hout, & van den Bout, 2006). With child loss, parents can experience their grief while also being affected by their partner’s grief process. During such times, a couple often becomes disconnected from one another, and long-term grief becomes less manageable (McFarlane & Bookless, 2001). Similar to couples managing PTSD, bereaved parents may experience a decline in their relationship functioning (Albuquerque, Pereira, & Narciso, 2016). One study found that 12 percent of marriages end in divorce after the death of a child but also indicated that the death of the child might not have been the sole reason for divorce (The Compassionate Friends, 1999). Interventions including both parents can assess how the traumatic event has impacted their relationship regarding communication, sexuality, and intimacy (Albuquerque, Pereira, & Narciso, 2016; Amick-McMullan, Kilpatrick, & Resnick,1991; Barrera et al., 2009). When addressing PTSD in CBCT, communication and intimacy become target areas for change. These target areas are hypothesized to increase relationship satisfaction and reduce symptoms of PTSD (Monson & Fredman, 2012). We propose that CBCT for PTSD may similarly benefit couples experiencing traumatic grief related to traumatic child loss impacting their relationship satisfaction.
Cognitive Behavioral Conjoint Therapy for PTSD
In addition to emotional, cognitive, and behavioral changes that occur when an individual develops PTSD, multiple studies show that higher levels of PTSD symptoms may be associated with worse intimate partner relationship functioning (Birkley, Eckhardt, & Dyskstra, 2016; Monson, Fredman, & Dekel, 2010; Taft, Watkins, Stafford, Street, & Monson, 2011). Research has suggested specific symptoms of PTSD impact relationship functioning. For example, emotional numbing has been found to be negatively correlated with relationship satisfaction and intimacy, while hyperarousal has a strong positive association with intimate partner aggression (Birkley, Eckhardt, & Dyskstra, 2016; Riggs, Byrne, Weathers, & Litz, 1998).
CBCT is designed to target the symptoms of PTSD and improve relationship functioning with potential secondary benefits to reducing distress among concerned significant others (Monson & Fredman, 2012). This is accomplished by conducting conjoint structured sessions that focus on learning skills to improve positivity, manage conflict, improve communication, promote effective sharing of emotions and thoughts, increase problem solving, and promote changes in trauma-related cognitions. CBCT consists of 15 sessions that are broken into three stages. The first stage is focused on psychoeducation about PTSD and developing conflict management skills, which includes attention to avoiding aggression and promoting safety within the relationship. This stage is also designed to increase commitment to the conjoint therapy. The second stage incorporates behavioral interventions to increase positive behavioral exchange and to help improve communication skills between the dyad. Stage three focuses on cognitive interventions that begin addressing the maladaptive thinking patterns that maintain the PTSD symptoms and effect relationship functioning. Research on CBCT for PTSD has found that it is efficacious at reducing PTSD, unhelpful trauma-related cognitions, comorbid symptoms such as depression, anxiety, and anger, as well as improving intimate partner relationship functioning (Amick-McMullan, Kilpatrick, & Resnick, 1991; Barrera et al., 2009; Macdonald et al., 2016; & Monson et al., 2011).
CBCT for Violent Loss of a Child
Research on CBCT for PTSD has been conducted in couples with PTSD with one partner being diagnosed with PTSD or in mixed trauma samples, including those who have experienced combat-related trauma and interpersonal traumas such as sexual assault (Monson et al., 2012; Monson, Schnurr, Stevens, & Guthrie, 2004). CBCT with these populations focuses on education around PTSD, relationship satisfaction, and conflict management skills. Aspects of this approach can aide bereaved parents explicitly focusing on skills that may improve the relationship, emotional numbing, intimate aggression, and behavioral avoidance. Parents that have lost a child due to traumatic circumstances also report similar symptoms of PTSD and traumatic grief along with relationship disruption (Albuquerque, Pereira, & Narciso, 2016; McFarlane, & Bookless, 2001; Riggs, Byrne, Weathers, & Litz, 1998; & Swan, & Scott, 2009). Traumatic child death research suggests these conflicts and communication breakdowns can damage marital relations (Albuquerque, Pereira, & Narciso 2016; Oliver, 1999).
Although a traumatic death of a child may increase the risk for divorce and marital distress, there is also the potential for growth and strengthening of the relationship (Albuquerque, Pereira, & Narciso, 2016; Barrera et al., 2009; Murphy et al., 1999). CBCT for PTSD can be applied to couples experiencing traumatic loss of a child to foster increased feelings of connection and support and to help these couples to develop adaptive cognitions and behavioral coping strategies. Few services are available for bereaved parents and current options, such as support groups, may not help couples unable to adapt to new roles, fail to teach couples effective coping skills, or are not effective in improving their relationship functioning (Albuquerque, Pereira, & Narciso, 2016; & Barrera et al., 2009). CBCT for PTSD may be a viable option for helping parents who are struggling with symptoms of complicated grief and PTSD related to traumatic child loss.
Albuquerque, S., Pereira, M., & Narciso, I. (2016). Couple’s relationship after the death of a child: A systematic review. Journal of Child and Family Studies, 25(1).
Amick-McMullan, A., Kilpatrick, D. G., & Resnick, H. S. (1991). Homicide as a risk factor for PTSD among surviving family members. Behavior Modification, 15(4), 545-559.
Barrera, M., O’Connor, K., D’Agostino, N. M., Spencer, L., Nicholas, D., Jovcevska, V., & … Schneiderman, G. (2009). Early parental adjustment and bereavement after childhood cancer death. Death Studies,33(6), 497-520.
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. doi:10.1002/jts.22129
Boelen, P. A., van den Hout, M. A., & van den Bout, J. (2006). A Cognitive-Behavioral Conceptualization of Complicated Grief. Clinical Psychology: Science And Practice, 13(2), 109-128.
Macdonald, A., Pukay-Martin, N. D., Wagner, A. C., Fredman, S. J., & Monson, C. M. (2016). Cognitive–behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: Results from a randomized controlled trial. Journal Of Family Psychology, 30(1), 157-162. doi:10.1037/fam0000177
McFarlane, A.C., & Bookless, C. (2001). The effect of PTSD on interpersonal relationships: Issues for emergency service workers. Sexual and Relationship Therapy, 16(3), 261–267.
Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Therapist’s manual. New York: Guilford Press.
Monson, C. M., Fredman, S. J., & Dekel, R. (2010). Posttraumatic stress disorder in an interpersonal context. Interpersonal processes in the anxiety disorders: Implications for understanding psychopathology and treatment (pp. 179–208). Washington, DC: American Psychological Association.http://dx.doi.org/10.1037/12084-007
Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-Martin, N. D., Resick, P. A., & Schnurr, P. P. (2012). Effect of Cognitive-Behavioral Couple Therapy for PTSD. JAMA, 308(7), 700. doi:10.1001/jama.2012.9307
Monson, C. M., Fredman, S. J., Adair, K. C., Stevens, S. P., Resick, P. A., Schnurr, P. P., . . . Macdonald, A. (2011). Cognitive behavioral conjoint therapy for PTSD: Pilot results from a community sample. Journal of Traumatic Stress, 24(1),97–101. http://dx.doi.org/10.1002/jts.20604
Monson, C. M., Schnurr, P. P., Stevens, S. P., & Guthrie, K. A. (2004). Cognitive-Behavioral Couple’s Treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17(4), 341–344. http://dx.doi.org/10.1023/B:JOTS.0000038483.69570.5b
Murphy, S. A., Braun, T., Tillery, L., Cain, K. C., Johnson, L. C., & Beaton, R. D. (1999). PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children: A longitudinal prospective analysis. Journal Of Traumatic Stress, 12(2), 273-291.
Murphy, S. A., Johnson, L.C., Wu, L., Fan, J.J., & Lohan, J. (2003). Bereaved parents’ outcomes 4 to 60 months after their children’s death by accident, suicide, or homicide: A comparative study demonstrating differences. Death Studies, 27(1), 39-61.
Oliver, L. E. (1999). Effects of a child’s death on the marital relationship: A review. Omega: Journal of Death and Dying,39, 197–227. doi:10.2190/1L3J-42VC-BE4H-LFVU
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of the intimate relationships of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11(1), 87–101. http://dx.doi.org/10.1023/A:1024409200155
Rogers, C. H., Floyd, F. J., Seltzer, M. M., Greenberg, J., & Hong, J. (2008). Long-term effects of the death of a child on parents’ adjustment in midlife. Journal of Family Psychology, 22(2), 203–211. doi:10.1037/0893-3188.8.131.52
Ross, V., Kõlves, K., Kunde, L., & Leo, D. D. (2018). Parents’ experiences of suicide-bereavement: A Qualitative study at 6 and 12 months after loss. International Journal of Environmental Research and Public Health,15(4), 618. doi:10.3390/ijerph15040618
Savarese, V. W., Suvak, M. K., King, L. A., & King, D. W. (2001). Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans. Journal of Traumatic Stress, 14(4), 717-732. http://dx.doi.org/10.1023/A:1013038021175
Sanders, C.M. (1980), A comparison of adult bereavement in the death of a spouse, child, and parent. Omega,10(4),303-322.
Schumm, J. A., Fredman, S. J., Monson, C. M., & Chard, K. M. (2013). Cognitive-behavioral conjoint therapy for PTSD: Initial findings for Operations Enduring and Iraqi Freedom male combat veterans and their partners. American Journal of Family Therapy, 41(4), 277–287.http://dx.doi.org/10.1080/01926187.2012.701592
Swan, A. H., & Scott, C. (2009). Complicated grief: Implications for the treatment of post-traumatic stress disorder in couples. Sexual and Relationship Therapy, 24(1), 16-29.
The Compassionate Friends. (1999). When a Child Dies: A Survey of Bereaved. Retrieved July 30, 2018, from https://www.compassionatefriends.org/
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(1), 22-33. http://dx.doi.org/10.1037/a0022196
Nicole Freeman-Favia is a fourth-year doctoral student at Wright State University School of ProfessionalPsychology (SOPP). She is completing a generalist program with an emphasis in neuro/health/rehab.Currently, she is training at a neuroscience institute, administering neuropsychological evaluations. Her research interests relate to suicide motivation in the veteran population and identifying effective suicide interventions.
Mindy Merricle is a fourth-year doctoral student at Wright State University School of ProfessionalPsychology (SOPP). She is completing generalist training in her degree program at SOPP and is on track for graduation in 2020. Her early career goals consist of working within a Veteran’s Affairs setting incorporating Veterans, their significant others, and families intotreatment. Her clinical interest areas consist of the impact of posttraumatic stress disorder (PTSD), othersignificant traumas and mental health diagnoses onreintegration into civilian life after deployment.
Dr. Jeremiah Schumm is an Associate Professor in the Wright State University School of ProfessionalPsychology (SOPP). He is a national trainer in cognitive- behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD). He is primary developer of an integrated treatment that adapts CBCT for PTSD for treating individuals with co-occurring substance
use disorders and PTSD. He has published 45 peer- reviewed journal articles and 12 book chapters. He serves on multiple journal editorial boards, includingPsychological Trauma: Theory, Research, Practice, and Policy. Dr. Schumm also maintains an active private practice in which he utilizes CBCT for PTSD, along with a range of other empirically-supported treatments in treating individuals for PTSD.