Discussion: Clinical Supervision: This Paper Discusses A Fam ✓ Solved
Discussion: Clinical Supervision: This paper discusses a family case
Discussion: Clinical Supervision: This paper discusses a family case in which the husband has posttraumatic stress disorder (PTSD) and the wife has generalized anxiety disorder (GAD). The husband developed PTSD after military service, experiencing nightmares and flashbacks, with the wife anxious about his wellbeing and its impact on family life. They underwent cognitive behavioral therapy (CBT) for both partners, but after about 8 weeks the husband’s nightmares persisted and the wife’s anxiety sometimes relapsed in response to his episodes. The assignment asks to evaluate the CBT approach, consider prolonged exposure therapy for the husband, and discuss pharmacological interventions for both partners, with attention to informed consent and ethical considerations. The paper should integrate DSM-5 criteria for PTSD and GAD, discuss potential challenges in family-focused psychiatric care, and propose an integrated treatment plan with rationale and outcome measures.
The case arises in the context of common difficulties in family-based mental health care, where trauma-related symptoms in one partner can reverberate through the home system and affect both partners’ daily functioning and future family plans. It also highlights practical decision points in clinical supervision and collaborative care, such as choosing trauma-focused interventions, assessing readiness for exposure-based therapies, handling relapse of anxiety in a partner, and ensuring informed consent for pharmacological strategies. The discussion should address why CBT was initially chosen, how PTSD and GAD symptom clusters interact within a couple, and how to balance safety, engagement, and functional goals while maintaining ethical standards in treatment planning.
Finally, the instructions call for proposing an evidence-based, integrated plan that may include prolonged exposure therapy for the husband and pharmacological interventions for both partners, with clear rationale, potential risks and benefits, anticipated outcomes, and proposed metrics to monitor progress. The plan should consider barriers such as sleep disturbance, relationship strain, caregiving demands, and access to resources, and should outline a structured path for reassessment and adjustment of treatment as needed.
Paper For Above Instructions
Introduction
The presented family case involves a husband who developed PTSD following two recent military deployments and a wife who meets criteria for generalized anxiety disorder (GAD) related to concern about her husband’s safety and the couple’s future. The husband experiences nightmares, intrusive memories, avoidance, hyperarousal, and negative mood/sleep disturbance consistent with PTSD, while the wife’s symptoms reflect pervasive worry, sleep disruption, and functional impairment consistent with GAD. The DSM-5 criteria support these diagnoses, with PTSD characterized by exposure to traumatic stressors and at least one-month symptom pattern across intrusion, avoidance, negative alterations in cognition and mood, and hyperarousal; GAD characterized by excessive worry and associated symptoms that cause clinically significant distress or impairment (APA, 2013). The couple initiated CBT for anxiety and trauma-related symptoms, yet after approximately eight weeks, the husband continued to experience nightmares and flashbacks, whereas the wife reported improvement but showed anxiety relapse when her husband had episodes. This scenario underlines the importance of ongoing assessment, potential treatment augmentation, and family-centered planning in psychiatric care (Bjorkman, Andersson, Bergström, & Salzmann-Erikson, 2018).
Evaluation of the Initial CBT Approach
CBT is widely supported as an effective first-line intervention for PTSD and GAD, emphasizing modification of maladaptive thoughts, exposure to feared memories, and skills to regulate distress and improve functioning (Watkins, Sprang, & Rothbaum, 2018; Hirsch, Beale, Grey, & Liness, 2019). In this case, CBT helped the wife reduce worry and contributed to overall family coping; however, the husband’s persistent nightmares suggest incomplete processing of trauma and potential under- or mis-timed exposure components. Evidence-based guidelines emphasize that when PTSD symptoms persist after initial CBT, trauma-focused exposures (e.g., prolonged exposure therapy) can yield substantial later gains, provided there is adequate engagement, safety planning, and consideration of the patient’s readiness (Foa, Hembree, & Rothbaum, 2007; Bisson et al., 2013). The case also illustrates the challenge of comorbidity and interdependence within a couple, where one partner’s symptoms can undermine the other’s progress, highlighting the need for a family-informed treatment perspective (NIMH, 2023; VA/DoD, 2017).
Rationale for Prolonged Exposure Therapy for the Husband
Prolonged Exposure (PE) therapy is a leading trauma-focused treatment that systematically scaffolds confrontation with trauma memories and reminders to reduce fear-based avoidance and distress. PE has robust empirical support for PTSD across civilian and veteran populations and is endorsed in major guidelines as a core component when CBT alone yields incomplete response (Foa et al., 2007; Resick, Monson, & Chard, 2017; Bisson et al., 2013). In this case, the husband’s ongoing nightmares and flashbacks indicate that trauma memory processing remains partially unintegrated, suggesting a transition to or augmentation with PE could promote more durable symptom relief and functional recovery. PE can be delivered in individual sessions with careful monitoring for distress, safety, and sleep disruption; for some patients, combining PE with stabilization and sleep-focused components may enhance tolerability (Foa et al., 2007; VA/DoD, 2017). Clinicians should assess readiness, provide psychoeducation about PE, and establish collaborative goals with the couple to preserve safety and autonomy.
Pharmacological Interventions for PTSD and GAD
Pharmacotherapy can complement psychotherapy, particularly when intrusive recollections, sleep disturbance, irritability, and functional impairment persist. For PTSD, selective serotonin reuptake inhibitors (SSRIs) such as sertraline and paroxetine, and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, have demonstrated efficacy and are commonly recommended as first-line options in major guidelines (VA/DoD, 2017; NICE, 2018; NIMH, 2023). For GAD, SSRIs/SNRIs are also first-line, with benzodiazepines generally discouraged due to dependency risk and side effects; sleep disturbances in PTSD may respond to prazosin in some cases, though evidence is variable and should be weighed against potential hypotension and side effects (Resick et al., 2017; Watkins et al., 2018). When introducing pharmacotherapy, clinicians should involve both partners in informed consent, monitor adverse effects, adjust dosing with ongoing psychotherapy, and coordinate care to support adherence and engagement in trauma-focused work (NIMH, 2023; NICE, 2018).
Informed Consent, Ethics, and Family-Centered Considerations
Treatment planning must prioritize informed consent, cultural sensitivity, and the couple’s shared goals. Given the couple’s desire to start a family, clinicians should discuss how PTSD and GAD treatments may influence mood stability, sleep, and functioning, and how pharmacotherapy might intersect with future pregnancy planning if relevant. A family-centered approach may include joint psychoeducation, couple or family sessions to improve communication, and safety planning regarding potential crises. Ethical considerations include respecting autonomy, balancing risk and benefit, and ensuring that each partner has opportunities to express preferences and concerns about exposure-based therapies and medications (APA, 2013; Bjorkman et al., 2018).
Integrated Treatment Plan and Outcome Metrics
An integrated plan could proceed in phases:
- Phase 1: Stabilization and engagement (2–4 weeks). Continue CBT for the wife with anxiety-focused modules; begin psychoeducation about PE for the husband; implement sleep hygiene and stress-management strategies for both; assess safety and crisis planning; establish shared goals for family functioning.
- Phase 2: Trauma-focused exposure for the husband (8–12+ weeks). Initiate Prolonged Exposure therapy with close monitoring of distress, sleep, and daytime impairment. Address nightmares with evidence-based sleep interventions and consider pharmacologic augmentation if needed. Ongoing coordination with the wife to minimize relapse risk and support her coping.
- Phase 3: Pharmacotherapy optimization (as indicated). Initiate or optimize SSRI/SNRI treatment for PTSD in the husband and/or GAD in the wife; evaluate sleep-related medications judiciously; ensure medication management aligns with psychotherapy to maximize therapeutic synergy.
- Phase 4: Relapse prevention and family strengthening. Incorporate brief booster sessions, ongoing monitoring of PTSD and GAD symptoms, and family-based skills training to maintain gains and promote planning for a possible family expansion.
Outcome measures should include standardized symptom scales and functional indices:
- PTSD severity: Clinician-Administered PTSD Scale (CAPS-5) or PTSD Checklist for DSM-5 (PCL-5).
- GAD severity: Generalized Anxiety Disorder 7-item scale (GAD-7).
- Sleep quality: Pittsburgh Sleep Quality Index (PSQI) or sleep diaries.
- Functioning: Sheehan Disability Scale or work/family functioning metrics.
- Treatment engagement and satisfaction: patient-rated scales and therapist assessments.
Regular reassessment at 4–6 week intervals will guide continuation, modification, or augmentation of treatment. Evidence from meta-analyses and guidelines supports such an approach, emphasizing the value of trauma-focused interventions for PTSD, CBT for GAD, and pharmacotherapy when indicated (Bisson et al., 2013; VA/DoD, 2017; NICE, 2018; NIMH, 2023).
Discussion and Implications for Clinical Supervision
This case demonstrates several important themes for clinical supervision and psychiatric practice. First, while CBT can yield meaningful improvements in both PTSD and GAD, PTSD symptoms may warrant progression to a more intensive trauma-focused approach such as Prolonged Exposure therapy when residual distress persists. Second, the family system context matters: one partner’s symptoms can drive relapse in the other, underscoring the importance of integrated, family-informed care and ongoing communication. Third, pharmacotherapy, when aligned with psychotherapy, can enhance treatment response, particularly for sleep disturbance and intrusive symptoms. Finally, informed consent and ethical considerations must guide decisions about exposure-based therapies, pharmacological augmentation, and family involvement, ensuring that the patient’s and couple’s values and goals are respected throughout the treatment process. The literature supports a stepwise, patient-centered approach that integrates evidence-based psychotherapies with medications when indicated, while maintaining a focus on safety, functioning, and quality of life (APA, 2013; Watkins et al., 2018; VA/DoD, 2017; NICE, 2018; NIMH, 2023).
Conclusion
In this military veteran–spouse case, initial CBT achieved partial gains, but residual PTSD symptoms in the husband and relapse risk in the wife suggest a need for augmentation with Prolonged Exposure therapy and a coordinated pharmacological plan. An integrated, family-centered strategy—combining trauma-focused exposure for the husband, supportive CBT for the wife, careful pharmacotherapy, and ongoing measurement of PTSD and GAD symptoms and functioning—offers the best chance for durable improvement, safer family functioning, and progress toward shared life goals.