Treating PTSD With Structured Approach Therapy

Drs. Frederic Sautter and Julia Becker Cretu discuss their research involving a new couples-based treatment for PTSD.

Article Citation

  • Sautter, F. J., Glynn, S. M., Cretu, J. B., Senturk, D., & Vaught, A. S. (2015). Efficacy of structured approach therapy in reducing PTSD in returning veterans: A randomized clinical trial. Psychological Services, 12(3), 199–212. http://dx.doi.org/10.1037/ser0000032

About the Guests

Drs. Frederic Sautter and Julia Becker Cretu are both professors of psychiatry in the Tulane University School of Medicine and psychologists in the Southeast Louisiana Veteran’s Health Care System. In addition to researching and treating post-traumatic stress disorder (PTSD) in veterans, they developed the Fortify the Family program to aid the families of veterans affected by PTSD.

About the Journal

Cover of Psychological Services (small)

Psychological Services publishes high-quality data-based articles on the broad range of psychological services delivered in organized care settings. Organized care settings refers to jails, prisons, courts, Indian Health Service, the military, Department of Veterans Affairs, university clinics, training hospitals, etc.

Visit the Psychological Services website.

Transcript

Marla Bonner: Hello, I’m Marla Bonner. Welcome to APA Journals Dialogue, a podcast featuring research from the journals program of the American Psychological Association.

In today’s episode, we welcome Drs. Frederic Sautter and Julia Becker Cretu, who are both professors of psychiatry at the Tulane University School of Medicine and psychologists in the Southeast Louisiana Veteran’s Health Care System. Together, along with their colleagues, they developed a couples-based therapy for PTSD known as structured approach therapy (SAT).

In their article, “Efficacy of structured approach therapy in reducing PTSD in returning veterans: A randomized clinical trial,” they examined the effects of this therapy in comparison to another couples-based therapy.

Here with us to discuss their article are Drs. Frederic Sautter and Julia Becker Cretu.

What is structured approach therapy, and how does it differ from other treatments for PTSD?

Dr. Sautter: Structured approach therapy is a couple-based treatment for post-traumatic stress disorder. It’s provided by a single clinician to one veteran with PTSD and to the veteran’s partner. Most evidence-based treatments for PTSD include simply the person with PTSD and a clinician. This treatment is provided really to the veteran and to the veteran’s partner so that it can impact the relationship of the veteran.

Perhaps Julia would like to get into the parts of the SAT intervention.

Dr. Becker Cretu: Sure. So structured approach therapy is a couples-based treatment for PTSD, like Fred said, and it includes a veteran and a partner, but it uses strategies in a very structured manner to target PTSD recovery.

It begins with providing the couple with education about PTSD and also relationship skills to help the couple become aligned and reduce relationship conflict, and also enhance positive feelings within the relationship. Then, once the couple becomes a cohesive unit, they’re then able to target the PTSD symptoms together where they go into their lives and to support the veteran approaching things that are normally avoided as a result of PTSD and helping the partner to respond in an empathetic and healing way.

Then, in the last part of SAT, the couple discuss the traumatic event and it helps them to process thoughts and feelings and memories that continue to cause stress within the veteran and also within the relationship. So using the relational interaction between the veteran and their co-habitating partner to process and master ongoing negative feelings and effects from being exposed to combat.

Dr. Sautter: Often, with PTSD treatment, the treatment is just provided to the person with PTSD. We work for the Department of Veterans’ Affairs, so we’re providing the treatment to veterans who’ve been deployed to Iraq and Afghanistan and have combat-related PTSD.

Often the veterans will come in, and they’ll get a treatment from a clinician, and then they’ll go home and their family unit, their relationship unit, will have very little understanding of what kind of treatment the person’s going through. It’s difficult for them to support the work that the veteran’s doing in trying to overcome their PTSD.

We provide — we really involve the partner in the treatment, so that the veteran’s relationship can become a long-standing therapeutic relationship that works on PTSD. So, that means that the veteran can always be getting support in his or her battle against PTSD rather than just having to remember the benefits of the lessons they had from working with their therapist. They have the person — the therapist, in a sense, becomes a part of their family unit.

Marla: That’s a very important point, that the therapist becomes part of the family unit. So as a comparison treatment, I understand that you chose to use PTSD Family Education (PFE). Why did you choose to go that route?

Dr. Sautter: When we were designing the study, to test the efficacy of structured approach therapy, we wanted to have a design that really established that SAT was more effective than other comparable treatments. We chose PFE because it involves the partner and it consists of 12 sessions, so it’s structured in a way that’s very similar to SAT.

But SAT, of course, includes a very unique psychological change component that emphasizes the veteran and the partner consistently approaching and confronting trauma as trauma affects their lives, and talking about trauma, and the veteran’s partner supporting the veteran’s efforts in an empathic, supportive way so that they get used to constantly approaching and confronting PTSD.

That’s a very unique couples-based approach, and PFE is something that is very educational, focused on education and not the psychological process that occurs in the relationship. It’s a very useful comparison for demonstrating SAT effectiveness.

Marla: What, in your opinion, are the most notable outcomes of this study?

Dr. Sautter: A randomized clinical trial showed that SAT significantly reduces PTSD in the veteran. Every veteran that participated in structured approach therapy showed a clinically and a statistically significant reduction in PTSD. At the conclusion of their participation in SAT, 60% of the veterans no longer met DSM-IV-R criteria for PTSD. So, SAT really had a really dramatic impact on PTSD in a sample that showed very high levels of PTSD going into treatment.

The other two major findings were improvement in relationship functioning and also improvement in emotion regulation. The couples were able to cope with challenging emotions that are associated with trauma memories. They were able to regulate their emotions much more effectively after participating in SAT. We found that the emotion regulation improvement mediated improvement in PTSD, so that appears to be a key factor in reducing PTSD.

Marla: Is the SAT approach similarly effective with redeployed veterans and their partners, or could it be?

Dr. Sautter: In our sample, 50% of the veterans that participated in our treatment had more than one deployment. As I indicated previously, every veteran that received SAT showed significant improvement in PTSD. So, it appears SAT is effective in veterans, regardless of how many deployments they have or how much trauma exposure they have. It’s a remarkably robust treatment for reducing PTSD in veterans who have high levels of combat exposure.

Structured approach therapy is the only couples-based treatment that was designed specifically for veterans who have been exposed to combat-related PTSD. Because it was designed specifically for that population, it’s uniquely suited to help the population of veterans that can really avoid emotions and intimacy, and many of the factors that are underlying their relationships with their intimate partners.

So, because they avoid emotion, SAT is structured to help veterans and their partners approach emotions and increase their emotional experience so that they can confront trauma memories that stimulate emotions that are unpleasant and therefore reduce the impact of PTSD on the veteran’s psychological functioning, but it also allows the veteran and their partner to increase emotional experiences that are absolutely essential to intimacy and having an effectively functioning family unit where emotions occur between the veteran, their partner, and their children.

So it allows the couple to have access to a full range of emotional experience that then provides the foundation for moving on in life and not just overcoming PTSD symptoms, but having an improved intimate relationship and having an improved relationship with their children and throughout the family unit. It really restores their experience of emotions to where it would be hopefully if the veteran had never been deployed and experienced the kind of terrible trauma exposure that are experienced when you’re deployed to Iraq or Afghanistan. It’s the only treatment that does that.

Marla: Results indicated greater rates of improvement in PTSD symptoms for participants in the SAT group compared with those in the PFE group. So what are the distinguishing factors of these two treatment approaches and what is the argument, if any, in favor of the continued use of both?

Dr. Becker Cretu: Well, in our study, we definitely did the education control as well as the structured approach therapy control, so we got to have outcomes that showed that both were favorable for couples, but really, when it comes down to it, by having the education control, we did get to see that PTSD and learning about PTSD for families is important for them to be informed on the education side.

It’s also beneficial — it’s more beneficial — and there were greater treatment outcomes for the family members to be involved in a treatment and play an active participant role in their loved ones’ treatment for PTSD. That was more desirable and significant than just learning about PTSD and its common associated problems and other symptoms, other conditions related to PTSD.

Structured approach therapy provides the couple not only with the education, but the therapist helps the couple to retrain and become more efficient and effective again together, which most couples report is more challenging after exposure to trauma. They come in saying that they have difficulty working together and having loving and joyful and calm experiences at home, compared to before they were exposed to combat.

In SAT, they learn about PTSD, but they learn about it in a different way than in PFE, and they’re learning about PTSD within the context of the relationship and how it pops up in their daily life. In PFE, they learn about the different diagnostic symptoms and categories for PTSD that healthcare professionals look for.

Really, SAT looks at, “how does PTSD show up within that relationship at home with the veteran?” In SAT, the couple trains with their therapist to become their own experts on how PTSD exists within their relationship, and then also develop a new manner that works to produce a new outcome where both partners are feeling understood and important and supported. The couple begins to feel better about their abilities within their relationship and within their social roles, even outside their relationship — at work, at home, and within their communities.

Within the second half with SAT, they then use those new skills that they’re learning to have a different outcome, and to then master approaching things that are challenging from the past, not just in the current. They don’t get that in the education condition.

In SAT, they become experts on how to use the SAT skills to feel better and to improve their ability to navigate everyday life stressors, but also now PTSD-related thoughts, behaviors, problems, and feelings that develop as a result of the trauma exposure. Then, as a result, the couples in SAT are demonstrating that they can then take control in situations in which they felt previously stuck or distressed, and they’re able to share in a new behavioral pattern they’re developing together, which then results in a reduction in their PTSD versus the veteran going and learning new ways to cope just with an individual therapist.

By getting the couple (not just the veteran) unstuck and getting them out of the PTSD cycle, the couple is then able to discuss past trauma and approach situations and things that remind them of their past combat experiences. Then the couple is a unit that is achieving recovery together versus just the therapist and the veteran.

That’s important because then the couple is having the opportunity to not only recover in the current moment while they’re going through structured approach therapy, but they’re also learning how to maintain improvement and learning a method to maintain improvement after the treatment has ended.

So I think that, really, the education condition is appropriate and I think that the studies show that family members should be educated, but because of the outcomes for supporting SAT’s efficacy and effectiveness, partners and family members should really be encouraged to play an active role and to be utilized and supported as part of a veteran’s PTSD recovery.

Marla: Fantastic. Well, I want to say thank you both for joining us today and for your important work that’s going to go a long way in helping our veteran communities, and we hope that you’ll come back and speak with us again.

Dr. Sautter: Thank you very much.

Marla: Thanks so much.

To read this article and others from Psychological Services, please visit our website at http://www.apa.org/pubs/journals/ser.

Thank you for joining us. I’m Marla Bonner, with APA Journals Dialogue.

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