Evaluating complex interventions: Multi-Family Therapy with veteran-families

Soldiers on a mission can be exposed to extreme stress and multiple potentially
traumatic experiences. The result of these experiences may be immediate or
delayed stress reactions, such as acute stress disorder, post-traumatic stress
disorder (PTSD), or another mental illness. Research has shown that about 5% of
the Dutch veterans develop PTSD. In addition, 15% develop one or more symptoms
of PTSD. Often, the problems also involve drug and/or alcohol abuse (De Kloet,
Vermetten & Unck, 2002; Kilgore et al., 2008). Research has shown that symptoms
of PTSD symptoms significantly influence how veterans perceive parenting and
the relationship with their child (Ruscio, Weathers, King & King, 2002; Samper,
Taft, King & King, 2004). More recent studies among veterans and other
populations show that PTSD is not only associated with an altered perception,
but an actual change in the quality of the interaction, impaired psychosocial
functioning of children and more attachment problems (Ahmadzadej & Malekian,
2004; Galovski, & Lyons 2004; Solomon et al, 2011; Van Ee et al, manuscript,
Van Ee, Sleijpen, Kleber & Jongmans, 2013). In addition there is an association
with relationship issues between partners (Kimhi & Doron, 2013) and family
functioning (Wiezelman, 2011). PTSD symptoms of parents can thus impact family
functioning and the functioning of the child. At the same time, the functioning
of the family impact the coping of the veteran with PTSD symptoms. A quiet
stable home environment is an important protective factor for veterans to
accomplish the necessary adaptation process after return of a mission (Shock,
2009; Camp and Shock, 2012). The family is one of the main sources of, on the
one hand, resilience and thus a healthy development and, on the other hand,
vulnerability in response to trauma (Bronfenbrenner, 2005; Hobfoll, 2001).
Multi Family Therapy (MFT) is a promising therapy to a combination of problems
within families. The therapy consists of a combination of group psychotherapy,
structural and systemic therapy Mentalisation Based Treatment, supplemented
with techniques from other schools (Hilliger, 2013). The model has been
successfully applied to a variety of serious problems, such as multi-problem
families, schizophrenia, eating disorders, severe depression, autism and school
in children and adolescents (Asen and Scholz, 2009). Up to now, there has been
little empirical knowledge about the effective factors of the MFT in general,
and the effectiveness of MFT applied to veterans families. Recently, a study
was published on the implementation of multi-family group treatment for
veterans with brain injury (Perlick, Straits Foster et al, 2013). The results
indicate an enhanced aggression control in veterans and an increase in capacity
and empowerment of the family members. Not examined, though, were factors to
which this improvement could be ascribed. A better understanding of the active
factors and effectiveness of the MFT could improve the MFT model for veteran
families and thus enhance clinical practice.

Clinical experience with the MFT with veteran families indicate a positive
result. Participants gave positive evaluations of the treatment and indicated
that they learned a lot. Factors that are mentioned are:
- The relationships in the family improved
- There are fewer conflicts
- The carrier problem: the veteran with PTSD, is less central to the family
system
- There is more openness
- The fear of the family reduces
The perception is that clinicically improvements can be experienced differently
by the veteran himself, partners and children. There is a need to support the
clinical experience through empirical research on the usefulness and
effectiveness of the MFT applied to veterans families.
MFT is a very intensive treatment, which requires much effort from the
participants and requires highly specialized knowledge of the therapists. It is
therefore necessary to understand who benefit from participation in a manner
that allocation to treatment is acceptable.

The aim of the research is therefore:
- To understand the effect of the MFT on family and individual functioning in
veteran families.
- To understand the active therapeutic factors of the MFT as a treatment method
for veterans families.
- To contribute to the further development of the MFT method

Vanaf hier
Complex interventions include various components that interact with each other.
In the treatment process of veterans families different components, such as
problems and/or disorders, functioning and resilience of the different family
members and the family as a whole, developmental stages, variety of possible
changes and thus results, therapy factors and contextual factors, interact.
Therefore, this study follows the development-implementation evaluation process
of the 'Developing and Evaluating complex interventions: new guidance from the
Medical Research Center (2008).
To evaluate MFT as a complex intervention the study is done in different phases:
Phase 1) Pilot
Phase 2) Evaluation of the change processes (n = 1 series)
Phase 3) Evaluation of the effectiveness (stepped wedge design)
Phase 4) Implementation
The first phase consists of the standard treatment with the standard
diagnostics, the second phase of the standard treatment with added diagnostics,
the third phase consists of a phased treatment with added diagnostics.

Participation in the study does not cause additional risk, since only
questionnaires are added to the treatment. Families would otherwise also
complete this treatment. Completing questionnaires costs time and
questionnaires related to stressful events can sometimes cause a greater amount
of experienced stress. However, this does not apply to the questionnaires for
the children. It is expected that any burden is outweighed by the benefit of
the therapy and even that completing questionnaires may lead to additional
insights.

The used set of instruments consists of different types of questionnaires:
A. Individual functioning
B. Family Functioning
C. Active therapy factors

Completing these short questionnaires takes about 30-40 minutes at a time.
Participants are asked to fill in these questionnaires 2 -12 times (depending
on the phase of the study).