Cognitive-behavioural conjoint therapy for PTSD

1. Introduction

Version followed: the 15-session manual by Monson & Fredman (2012), Cognitive-Behavioral Conjoint Therapy for PTSD: Harnessing the Healing Power of Relationships (Guilford), using its published session titles, with session contents taken from Monson's CBCT training slides (2019 versions). The 8-session Brief CBCT (B-CBCT) and the weekend multi-couple retreat format (AIM-CBCT) are noted as variants. The full manual text was not available to open. Detail inside sessions that comes only from recall of the manual or from other secondary sources is tagged [uncertain]. [source: Guilford product and contents pages; GVSU and cptforptsd.com CBCT slide decks]

Cognitive-behavioural conjoint therapy for PTSD (CBCT for PTSD) is a manualised, time-limited couple therapy. It treats one partner's PTSD and the couple's relationship together, with both partners present in every session. It comes from cognitive processing therapy and cognitive-behavioural couple therapy. It is trauma-focused but does not use imaginal exposure. The slides call it a front-line PTSD treatment that also aims to improve the relationship. [source: CBCT slides]

Core idea of change: PTSD and relationship problems feed each other, and PTSD is understood as a natural recovery that got stuck. Change comes through three routes:

• Undermining avoidance. The couple approaches avoided situations together.
• Reducing negative relational patterns. Conflict management and communication skills lower conflict, and better sharing counters numbing.
• Revising trauma appraisals together. The partner acts as a supportive reality-tester as the couple reworks the stuck meanings the trauma left about acceptance, blame, trust, control and closeness.

[source: CBCT slides; ClinicalTrials.gov NCT02720016 protocol]

2. Framework

Format. The standard format is 15 conjoint sessions of about 75 minutes each, usually weekly. Both partners attend every session. One partner has PTSD. Most of the evidence comes from couples where the other partner does not have PTSD. The manual also covers couples where both partners have PTSD. [source: CBCT slides; Guilford product page]

Before treatment: assessment. Assess on two levels. [source: CBCT slides; manual Ch. 2 title]

• Individual. PTSD (self-report plus the partner's collateral report) and comorbid conditions in both partners.
• Relationship. Satisfaction and areas of conflict; violence and sense of safety; intimacy and emotional expression; sexual functioning; infidelity; an observed communication sample.
• Relationship satisfaction measure. The slides use the Couple Satisfaction Index (CSI-32), which has a published clinical cut-point of 104.5.
• Exclusions specific to the relationship. Current severe violence, and minimal commitment to the relationship.
• Trial exclusions (B-CBCT protocols). Severe physical or sexual aggression in the past year, active substance dependence, uncontrolled psychosis, imminent suicidality or homicidality, and severe cognitive impairment in either partner. [source: NCT02720016; NCT05207436]

Choosing CBCT. The slides list four decision factors:

• whether another trauma-focused PTSD treatment is already under way
• whether the trauma work should extend into the couple
• how much distress or accommodation there is
• how much the significant other can take part, from not at all, through sessions with the significant other only, to full conjoint therapy

[source: cptforptsd.com slides]

[source: Guilford contents page; CBCT slides]

Session structure in Phases 2–3. Each session follows the same order: [source: GVSU slides]

1. Review the out-of-session assignments.
2. New session content.
3. Trauma-relevant practice of the skill in session.
4. Plan couple-level in vivo approach.
5. Set new out-of-session assignments.
6. Check-out.

In Phase 3, each themed session runs U.N.S.T.U.C.K. on thoughts about that theme, covering both daily events and trauma appraisals, while in vivo approach continues. [source: CBCT slides]

Moving between phases. The manual is paced session by session. The sources give no formal criteria for moving to the next phase. [uncertain] Practical gates: [synthesis]

• Into Phase 2: no aggression since Session 2; both partners can name early warning signs and have used, or agreed to use, time-out and time-in.
• Into Phase 3: the couple can run listening, sharing and U.N.S.T.U.C.K. on a low-stakes event without escalating, and in vivo approach has begun.
• If a skill has not taken hold: repeat or extend that session rather than move on. Treat this as a clinical judgement, not as a manual rule.

Variants.

• Brief CBCT (B-CBCT). Eight 75-minute sessions, in person or by video. Sessions 1–2 cover rationale and safety (anger warning signs, conflict management). Sessions 3–7 cover avoidance psychoeducation, a list of avoided people, places, situations and feelings, graduated couple-level in vivo approach chosen to double as shared rewarding activities, and enhanced communication. Session 8 consolidates gains and anticipates future challenges. B-CBCT keeps Phases 1–2 and leaves out the full Phase 3 meaning-making sessions. The protocols do not say which components were shortened. [source: NCT02720016; NCT05207436]
• AIM-CBCT. An abbreviated, intensive, multi-couple group format delivered over one weekend retreat to 2–6 couples, with two co-therapists. It keeps much of the core CBCT content. Its detailed schedule was not available. [source: Fredman et al. 2020 abstract (PubMed); Penn State news] [uncertain]
• Telehealth. CBCT has been delivered by home-based video (VA Video Connect). [source: NCT02720016]

3. Guiding principles

Tags: the CBCT slides are the source for every principle except the last three, unless a different tag is given.

• The couple is a team against PTSD. Frame PTSD as the shared problem and avoid frames that cast one partner as the patient. Practical meaning: use "us versus PTSD" language; the "U" (Unified) step in U.N.S.T.U.C.K. puts this into practice.
• Systemic fit. PTSD and relationship distress are reciprocally linked. Practical meaning: every intervention targets both symptoms and relationship patterns, and you track how each partner's behaviour maintains or shrinks PTSD.
• Both partners may have difficulties. The significant other may bring their own problems, through assortative mating, the burden of the illness, or both. Practical meaning: assess the partner too, and do not treat them as a co-therapist without needs.
• PTSD is impeded natural recovery. Practical meaning: explain that avoidance and stuck meanings stall recovery, and that the work is to restart it.
• Trauma-focused, but without imaginal exposure. Practical meaning: work on the meanings and the avoidance; do not ask for a detailed trauma narrative to be told to the partner.
• The partner is a reality-tester, not a judge. Practical meaning: coach the partner to ask curious questions and to offer evidence, rather than argue or reassure.
• Collaborative, non-judgemental, open-minded process. Practical meaning: model curiosity; stop criticism, mind-reading and lecturing in session.
• Avoidance is the main maintaining target, at couple level. Practical meaning: every session ends with a couple approach assignment. [source: CBCT slides; NCT02720016]
• Safety first. Practical meaning: put conflict management in place in Session 2, before any emotionally loaded work, and do not start with couples where severe violence is current.
• Skills are practised in session on trauma-relevant content. Practical meaning: rehearse each new skill on how PTSD affects the couple, not on neutral topics only. The slides' prompt for this is to imagine having "shrunk the role of PTSD in your relationship".
• Out-of-session practice drives change; change feels awkward at first. Practical meaning: review assignments first in every session, and normalise that new thoughts feel unnatural until rehearsed (the "Use" and "Keep practising" steps).
• Treatment contracting. Practical meaning: in Session 1, agree attendance, assignments and the time-limited structure with both partners.
• Balanced alliance. Practical meaning: give both partners equal airtime and validation, and watch for siding with either partner. [synthesis]
• Positive exchange alongside problem work. Practical meaning: "Catch Each Other Doing Something Nice" runs from Session 1 to build goodwill before harder content. [source: CBCT slides; purpose wording is synthesis]

4. Intervention inventory

What the sources establish: the session titles, the components listed for each session, the order of the session routine, the steps of U.N.S.T.U.C.K., and the names of the assignments. They do not give the manual's step-by-step instructions for most skills. Steps below are in my own words. Where a step goes beyond what the sources state, it is tagged [uncertain] (likely manual content not verified) or [synthesis] (standard CBT or couple-therapy practice). All example language is illustrative.

4.1 Assessment and case conceptualisation (before Session 1)

• Purpose: Confirm PTSD and comorbidity, rule out contraindications, and map how PTSD and the relationship interact. [source: CBCT slides; manual Ch. 2 title]
• Steps:
  1. Run a structured PTSD assessment with the identified partner. Collect the partner's collateral report of symptoms.
  2. Screen both partners for depression, substance use, suicidality and their own trauma or PTSD.
  3. Assess relationship satisfaction (e.g., CSI-32), areas of conflict, intimacy, emotional expression, sexual functioning and infidelity.
  4. Watch a short communication sample: the couple discusses a moderate conflict topic for a few minutes while you observe.
  5. Screen for aggression with each partner interviewed separately, using a validated measure (the protocols used CTS-2 short form and IPV screens). Ask about fear of the partner and about safety at home. [source: NCT02720016; NCT05207436; separate interviewing is synthesis consistent with protocols]
  6. Decide: CBCT, CBCT with concurrent individual treatment, or individual treatment first (see the decision factors in Section 2).
• Example language (illustrative): "I'll meet each of you on your own for part of today. Everyone gets the same questions, including about safety at home."
• Watch for: fear of the partner, coercive control, or severe aggression in the past year (do not start conjoint work); minimal commitment, such as a secret plan to leave; an untreated substance use disorder.

4.2 Introduction, rationale and treatment contracting (Session 1)

• Purpose: Give both partners a shared model of PTSD as a relational problem and agree how therapy will run. [source: CBCT slides; Guilford contents]
• Steps:
  1. Give an overview of the 15 sessions, three phases, and both partners' roles.
  2. Psychoeducation on PTSD symptoms in an interpersonal context. For each cluster (re-experiencing, hyperarousal, avoidance, numbing), ask how it shows up between them.
  3. Explain PTSD as impeded natural recovery. The slides show natural recovery versus persistent PTSD over about 12 weeks.
  4. Explain how avoidance keeps PTSD and relationship distress going.
  5. Explain meaning-making: how the trauma changed beliefs about self, others, the world and the relationship.
  6. Contract: attendance, out-of-session assignments, the time limit, and no aggression.
  7. Assign "Catch Each Other Doing Something Nice" (4.3) and the Trauma Impact Questions (4.4).
• Example language (illustrative): "PTSD has moved into your relationship like a third party. Our job is to help the two of you shrink it together."
• Watch for: blaming ("it's all his PTSD"); a partner who sees themselves only as a helper. Bring in the partner's own experience early.

4.3 Catch Each Other Doing Something Nice (Sessions 1–2 onward)

• Purpose: Raise positive exchanges and shift attention from what is wrong to what goes well. [source: CBCT slides (named assignment); purpose and steps are synthesis] [uncertain]
• Steps:
  1. Each partner notices, every day, positive things the other does, and writes them down.
  2. Each partner tells the other what they noticed. Brief, specific acknowledgement is enough.
  3. Next session: each reads out a few items. The receiving partner says how it felt to be noticed.
• Example language (illustrative): "Pick something small. 'You made coffee before I woke up' counts."
• Watch for: sarcastic or backhanded items; an empty log from one partner, which may signal withdrawal or depression. It is working when both partners report noticing more without being prompted.

4.4 Trauma Impact Questions (TIQ)

• Purpose: Elicit each partner's beliefs about why the trauma happened and how it has affected them and the relationship. This gives the baseline of stuck meanings for Phase 3. [source: CBCT slides (named assignment in Session 1)]
• Steps (beyond the source): [uncertain]
  1. Assigned in Session 1. Each partner writes answers on their own, at home.
  2. The patient writes about why the trauma occurred and its effects on views of self, others and the world.
  3. The partner writes about how the trauma and PTSD have affected them and the relationship.
  4. The answers are shared in Session 2 and used to pick themes for Phase 3.
  5. The TIQ is re-done near the end (Session 15) and compared with the first answers.
• Example language (illustrative): "Write what you really believe, not what you think you should believe. We're looking for the thoughts that keep you stuck."
• Watch for: writing the trauma narrative in graphic detail (not required, and it can distress the partner); not writing at all, which is avoidance (see 5.4).

4.5 Safety building: disclosure, negative behaviours, primary and secondary prevention (Session 2)

• Purpose: Lower the risk of escalation before loaded work begins. [source: CBCT slides; NCT02720016]
• Steps:
  1. Review the assignments, including the TIQ.
  2. Discuss disclosure: what is shared about the trauma, and how. [uncertain about exact manual content]
  3. Name negative behaviours that harm safety: yelling, threats, breaking things, pushing, and hyperarousal-driven blow-ups.
  4. Primary prevention: reduce triggers of conflict, for example fatigue, alcohol, or raising hard topics at bad times. [synthesis detail]
  5. Secondary prevention: spot early warning signs, then use time-out and time-in (4.6).
  6. Assign "Learning About My Anger", time-out/time-in practice, and continued Catch Each Other.
• Example language (illustrative): "Everything we do later depends on you both feeling safe here and at home. Let's build a plan for when things heat up."
• Watch for: new disclosure of aggression during this session. Assess it privately (5.1).

4.6 Learning About My Anger, and time-out / time-in

• Purpose: Each partner learns their own anger cues, and the couple has an agreed way to stop escalation and return to the topic. [source: CBCT slides (assignment names); NCT02720016 (early warning signs, conflict management). Steps: synthesis from standard couple conflict-management practice] [uncertain]
• Steps:
  1. Each partner lists body, thought and behaviour warning signs on a 0–10 anger scale, for example a hot face, clenched jaw, "she's doing it on purpose", or pacing.
  2. Agree a neutral time-out signal (a word or a T-hand sign). Either partner may call it, for themselves only.
  3. Separate for an agreed period. Use calming activities, not rumination, alcohol or driving.
  4. Time-in: come back at the agreed time, check whether both are calm, and then return to the topic or schedule it.
  5. Rehearse in session with a mild topic.
• Example language (illustrative): "Time-out is something you call on yourself, not on your partner. 'I'm at a 6, I'm taking 30 minutes, I'll be back at 8.'"
• Watch for: time-out used to avoid (no time-in), or used as a weapon ("you need a time-out"); one partner following the other.

4.7 Listening (Session 3)

• Purpose: Build accurate, non-defensive listening to counter misunderstanding and emotional distance. [source: Guilford contents; NCT02720016 (enhanced communication). Steps: synthesis] [uncertain]
• Steps:
  1. Set roles: one speaker, one listener. The speaker talks in short segments using "I" statements.
  2. The listener paraphrases the content and the feeling, without adding their own view, then checks accuracy.
  3. The speaker confirms or corrects. Switch roles.
  4. Practise first on a positive topic, then on a trauma-relevant one, such as how PTSD has affected a shared activity.
• Example language (illustrative): "Before you respond, tell her what you heard her say and what you think she was feeling. Then ask if you got it right."
• Watch for: paraphrase turning into rebuttal; the patient flooding or numbing. Working: accurate reflections, softer tone, and the speaker says they feel understood.

4.8 Couple-level in vivo approach (from Session 3 to the end)

• Purpose: Undermine avoidance by approaching avoided people, places, situations and feelings together, picking activities that are also rewarding for the couple. [source: NCT02720016; NCT05207436; CBCT slides]
• Steps:
  1. Explain how avoidance spreads beyond trauma reminders and keeps both PTSD and relationship distress going.
  2. Together, list what the couple avoids because of PTSD: crowds, restaurants, driving routes, social events, conversations, touch, feelings.
  3. Rate how distressing each item is, and order them into a graduated list. [rating method: synthesis]
  4. Choose an approach activity that is manageable and pleasant for both. Plan when, where, how long, and what each partner will do.
  5. The partner's role is to come along and support approach, not to rescue or shorten it. Plan in advance how to cope with distress without leaving early.
  6. Next session: review what happened, what was learned, and what each partner predicted versus what occurred. Then pick the next step.
• Example language (illustrative): "What's one thing the two of you used to enjoy that PTSD has taken off the table? Let's take back a small piece of it this week."
• Safety and consent: Get explicit agreement from both partners for each item. Do not include situations that are truly dangerous, or interpersonal situations where the risk is real. Screen out current substance dependence and imminent suicidality before starting. Plan how to manage panic and dissociation. Either partner may pause a step, but should reschedule rather than drop it. [source: protocol exclusions; rest synthesis]
• Watch for: safety behaviours, such as sitting by the exit throughout or the partner doing all the talking; partner accommodation; leaving early. It is working when distress falls with repetition and the couple adds activities on their own.

4.9 Trauma-relevant in-session practice (every Phase 2 session)

• Purpose: Apply each new skill straight away to how PTSD affects the couple. [source: GVSU slides]
• Steps:
  1. After teaching the skill, give a prompt: what would you stop avoiding, and how might you feel, if you "shrunk the role of PTSD in your relationship"?
  2. The couple uses the new skill to discuss it while you coach.
  3. Link the discussion to the next in vivo assignment.
• Example language (illustrative): "Use the listening skill now. Tell each other what you'd want to do again if PTSD took up less room."
• Watch for: the conversation drifting into old grievances. Redirect to the prompt.

4.10 Sharing thoughts and feelings: emphasis on feelings (Session 4)

• Purpose: Counter emotional numbing and build emotional intimacy by naming and sharing feelings. [source: Guilford contents; NCT02720016]
• Steps (beyond the source): [synthesis] [uncertain]
  1. Psychoeducation: emotions are useful signals; numbing and avoidance shut down positive feelings as well as negative ones.
  2. Help each partner widen their feeling vocabulary. Use a feelings list, and distinguish primary feelings (hurt, fear) from secondary ones (anger).
  3. The speaker shares a feeling linked to a specific situation ("I felt ___ when ___"). The listener uses the listening skill.
  4. Practise on a trauma-relevant topic. Assign daily feeling-sharing.
• Example language (illustrative): "Under the irritation, what else was there? Sometimes anger is the bodyguard for fear or hurt."
• Watch for: "I feel that you..." (a thought dressed as a feeling); feelings overflowing. Slow the pace.

4.11 Sharing thoughts and feelings: emphasis on thoughts (Session 5)

• Purpose: Teach the link between thoughts, feelings and behaviour, and have partners share their interpretations, so that cognitive work is possible. [source: Guilford contents; CBCT slides (cognitive theory base)]
• Steps (beyond the source): [synthesis] [uncertain]
  1. Explain that the same event can lead to different feelings depending on the thought about it.
  2. Each partner picks a recent event, then names the thought, the feeling and the action.
  3. The listener reflects the thought without disputing it yet.
  4. Assign daily logging and sharing of events, thoughts and feelings.
• Example language (illustrative): "When he didn't answer your text, what went through your mind? And then what did you feel?"
• Watch for: thoughts given as facts; the partner jumping in to correct. Disputing waits for Session 6.

4.12 Getting U.N.S.T.U.C.K. (dyadic cognitive intervention, Session 6 onward)

• Purpose: A joint process the couple uses to examine and revise interpretations of daily events and of the trauma. The partner acts as a reality-tester. [source: GVSU and cptforptsd.com slides]
• Steps:
  1. U, Unified: turn your chairs to face the problem together, and agree to be curious, not critical.
  2. N, Notice: each partner identifies and shares the thoughts and feelings about the event, and both agree on what they are.
  3. S, Storm alternatives: brainstorm as many other ways of seeing it as possible, including odd ones, without judging them yet.
  4. T, Table test: weigh the evidence for and against each thought, and pick the most balanced.
  5. U, Use the best: try the balanced thought on, expecting it to feel awkward at first.
  6. C, Changes: notice changes in feelings and behaviour.
  7. K, Keep practising: repeat, because it will not be automatic at first.
• Worksheet: the slides' worksheet records the noticed thought, alternative big-picture thoughts, changed feelings and behaviours, and a practice plan. A slide example of a stuck belief: "If I am in control of my surroundings, then there are no surprises". The balanced alternative allows that some surprises are good. [source: GVSU slides]
• Teaching sequence (beyond the source): start with a neutral or mildly annoying daily event, then a relationship event, then trauma appraisals (Phase 3). Coach the partner to ask questions rather than argue. Use Socratic questions from CPT, such as evidence, alternatives, and what you would say to a friend. [synthesis]
• Example language (illustrative): "Let's get unified first. This thought is the problem on the table, not either of you."
• Watch for: the partner pushing a "right answer"; reassurance in place of examination; a balanced thought too rosy to be believed. It is working when the couple runs it without you and the feeling intensity drops.

4.13 Problem Solving to Shrink PTSD (Session 7)

• Purpose: A structured way to solve joint problems that PTSD creates or keeps going, such as logistics, avoidance and roles. [source: Guilford contents; steps are standard problem-solving synthesis] [uncertain]
• Steps:
  1. Agree one specific, solvable problem and define it in neutral, behavioural terms.
  2. Each partner shares thoughts and feelings about it, using the listening skill.
  3. Brainstorm solutions without evaluating them.
  4. Weigh the pros and cons of each, and pick one or combine them.
  5. Plan who does what, when, and how you will review it.
  6. Try it, then review next session and adjust.
• Example language (illustrative): "One problem only, and describe it so neither of you is the villain: 'Saturdays turn into him staying home and you going out alone.'"
• Watch for: problems defined as character flaws; solutions that build in avoidance, such as "you just go without me".

4.14 Phase 3 themed session routine (Sessions 8–14)

• Purpose: Apply U.N.S.T.U.C.K. to trauma appraisals and to their effects on the relationship, one theme per session, while approach work continues. [source: CBCT slides; Guilford contents]
• Steps:
  1. Review the assignments: worksheets, approach activities, Catch Each Other.
  2. Introduce the theme briefly: typical stuck thoughts in each partner, and how they show up between them.
  3. Draw out theme-related thoughts. Use the TIQ answers and recent events. [use of TIQ: uncertain]
  4. Run U.N.S.T.U.C.K. together in session on at least one trauma appraisal and one daily or relationship event.
  5. Plan an approach activity linked to the theme. Assign worksheets on the theme.
  6. Check-out.
• Example language (illustrative): "Today's theme is trust. Let's look at what each of you came to believe about trust after what happened."
• Watch for: sessions turning into general relationship complaints. Bring each one back to the theme and the specific thought.

4.15 Acceptance (Session 8)

• Purpose: Work on difficulty accepting that the trauma happened, and the "why" and "if only" thinking that blocks recovery. [source: Guilford contents (title); content focus: synthesis from CPT lineage] [uncertain]
• Steps: Draw out non-acceptance thoughts. Examples: it shouldn't have happened; I should be over it; if I had acted differently it would not have happened. Use U.N.S.T.U.C.K., with the partner offering evidence and other views. Separate accepting that it happened from approving of it. Address the partner's non-acceptance too, such as "I want the person I married back".
• Example language (illustrative): "Accepting it happened isn't saying it was okay. It's stopping the fight with the past so you can live in the present."
• Watch for: the partner pushing the patient to "move on". Reframe that as wanting relief, and slow down.

4.16 Blame (Session 9)

• Purpose: Revise distorted self-blame, guilt and misplaced blame of others, including blame between the partners. [source: Guilford contents; cptforptsd.com slides]
• Steps:
  1. Draw out blame thoughts. The slides' example is a service member re-examining self-blame about firing a weapon at close range, and the decision made in the moment.
  2. Use U.N.S.T.U.C.K. to examine what was known at the time, intent, choices actually available, and hindsight. [Socratic content: synthesis from CPT]
  3. Separate responsibility from blame and fault.
  4. Address blame inside the couple, such as the patient being blamed for PTSD behaviour.
• Example language (illustrative): "What did you know in those seconds, and what do you know now? Which one are you judging yourself by?"
• Watch for: real culpability or moral injury, which is not distorted self-blame. Here the work moves towards accountability and repair, not reappraisal alone [synthesis]. Watch also for the partner minimising ("it wasn't your fault, stop") instead of examining.

4.17 Trust (Session 10)

• Purpose: Revise extreme beliefs about trusting oneself, the partner and others. [source: Guilford contents; content: synthesis] [uncertain]
• Steps: Draw out trust thoughts. Examples: I can't trust my judgement; people always betray you; she'll leave if she knows. Run U.N.S.T.U.C.K. Build graded, behavioural trust experiments between the partners, such as small disclosures followed by a response. Link to approach activities.
• Example language (illustrative): "Trust doesn't have to be all or nothing. What small piece of trust could be tested this week?"
• Watch for: infidelity or betrayal that has not been dealt with (see 5.9).

4.18 Control (Session 11)

• Purpose: Revise beliefs about control and power: over-control, hypervigilant management of surroundings, and feeling helpless. [source: Guilford contents; GVSU slides]
• Steps: Draw out control beliefs. The slides' worksheet example is "If I am in control of my surroundings, then there are no surprises". Storm alternatives, then table-test the costs of over-control to both partners. Agree a behavioural experiment in sharing control, such as the partner choosing the restaurant or the route.
• Example language (illustrative): "What does trying to control everything cost the two of you? And what happens on days you let go of a little?"
• Watch for: controlling behaviour that is coercive rather than anxiety-driven. Assess privately (5.1).

4.19 Emotional Closeness (Session 12)

• Purpose: Address numbing, detachment and beliefs that block emotional intimacy. Examples: if I let her in I'll fall apart; he'll see me differently. [source: Guilford contents; NCT02720016 (emotional intimacy target); content: synthesis] [uncertain]
• Steps: Draw out closeness-blocking thoughts in both partners. Run U.N.S.T.U.C.K. Practise sharing thoughts and feelings at a slightly deeper level in session. Assign shared activities that build closeness.
• Example language (illustrative): "What do you predict will happen if you tell her how scared you were? Let's check that against what's happened when you've shared before."
• Watch for: the partner's hurt from years of distance surfacing. Validate it, then hold to the theme.

4.20 Physical Closeness (Session 13)

• Purpose: Address avoidance of touch, affection and sex, and the beliefs behind it, such as hyperarousal or trauma reminders during touch. [source: Guilford contents; cptforptsd.com slides ("physical intimacy"); steps: synthesis] [uncertain]
• Steps: Talk openly about touch and sexual intimacy, using the communication skills. Draw out beliefs about the body, safety and sex. Run U.N.S.T.U.C.K. Agree graded, consensual non-sexual touch exercises at home, with an explicit right to pause and an agreed signal. Address medication side effects or sexual dysfunction through referral where needed.
• Example language (illustrative): "Either of you can pause any time, with no explanation needed. A pause isn't a rejection. It's how you both stay safe enough to keep going."
• Watch for: pressured or coerced sex; sexual trauma history in either partner; dissociation during touch. Refer for sex therapy if the problem is primary.

4.21 Posttraumatic Growth (Session 14)

• Purpose: Help the couple identify positive changes, strengths and meaning they have built, individually and as a couple, without denying the harm. [source: Guilford contents; content: synthesis] [uncertain]
• Steps: Ask each partner what they have learned, valued or built since the trauma and during therapy. Run U.N.S.T.U.C.K. on thoughts that rule out growth. Agree on shared values or goals going forward.
• Example language (illustrative): "Alongside what PTSD took, has anything grown: in you, in each other, in how you handle hard things?"
• Watch for: forced positivity, or one partner pushing "silver linings".

4.22 Review and Reinforcement of Treatment Gains (Session 15)

• Purpose: Consolidate gains, plan for future challenges, and end treatment. [source: Guilford contents; cptforptsd.com slides; NCT02720016 (B-CBCT final session)]
• Steps:
  1. Review each skill: time-out and time-in, listening, sharing, U.N.S.T.U.C.K., problem solving, approach.
  2. Compare current beliefs with early ones. The re-done TIQ is likely used here [uncertain].
  3. Each partner names the changes they see in self, partner and relationship.
  4. Anticipate high-risk times (anniversaries, deployments, stressors) and write a joint maintenance plan. [synthesis]
  5. Repeat the measures. [synthesis]
• Example language (illustrative): "If PTSD starts creeping back in a year, what will be the first sign, and what will the two of you do?"
• Watch for: remaining symptoms that call for further individual treatment; a partner's own untreated difficulties.

4.23 Out-of-session assignment review and check-out (every session)

• Purpose: Build in practice and keep track of how both partners are experiencing the therapy. [source: GVSU slides (session structure)]
• Steps: Open each session by reviewing every assignment: praise what was done, and problem-solve what was not. Close with a check-out in which each partner says how the session felt and anything left unsettled. Do not let a couple leave mid-escalation.
• Example language (illustrative): "Before you go, on a scale of 0–10, how settled are you each feeling? Anything we need to cool down before the drive home?"
• Watch for: high post-session distress. Make a brief plan (time-out, time apart, a check-in call) before they leave. [synthesis]

5. Handling problems

The sources cover selection and exclusion, and procedures for violence, suicidality and distress in the trials. Almost all the other troubleshooting below is my own synthesis from couple therapy and CPT practice. It is tagged in each item.

• 5.1 Aggression or coercion disclosed or suspected mid-treatment.
  • What the sources say: severe physical or sexual aggression rules out conjoint treatment. In the trials, the affected partner was referred to domestic-violence resources and the couple was moved to individual treatment. [source: NCT02720016; NCT05207436; CBCT slides]
  • What to do: see each partner alone. Assess fear, injury, coercive control and risk. If either partner is unsafe, pause conjoint sessions, safety-plan with the at-risk partner, and offer individual PTSD treatment (e.g., CPT or PE) to the patient. Never confront the aggressor in joint session with information the victim gave privately. [synthesis]
  • Minor, mutual, low-level verbal aggression without fear can continue, with time-out strengthened and an explicit no-violence agreement. [synthesis]
• 5.2 Suicidality or marked worsening in either partner.
  • What the sources say: the trials flagged rising suicidal ideation for clinician follow-up and offered crisis lines. [source: NCT02720016; NCT05207436]
  • What to do: assess risk with the at-risk partner individually, using standard structured risk assessment. Make a collaborative safety plan, and use the partner as a support for it only if that partner agrees and is safe. Do lethal-means counselling: secure storage or temporary removal of firearms and medications. Pause trauma-focused themes until the person is stable. [synthesis]
• 5.3 Escalation in session.
  • Call a time-out yourself, using the model from Session 2. Separate the partners briefly if needed, then do time-in. [synthesis]
  • Afterwards, use it as practice: what were the warning signs, and when could each partner have called time-out? [synthesis]
  • Do not end a session hot (see 4.23).
• 5.4 Non-adherence to out-of-session assignments.
  • Review assignments first, every time (session structure). [source: GVSU slides]
  • Treat non-completion as possible avoidance. Ask what got in the way, and what thought came up when the time came to do it. [synthesis]
  • Shrink the task, set a specific time and place, and do part of it in session. [synthesis]
  • If one partner always does the work and the other does not, address the imbalance directly. [synthesis]
• 5.5 Partner accommodation. The partner protects the patient by avoiding triggers, speaking for them, or taking over tasks.
  • Name accommodation as understandable but as feeding PTSD. [source: slides list accommodation as a selection factor; responses: synthesis]
  • Turn accommodated situations into approach items.
  • Coach the partner to tolerate the patient's short-term distress during approach.
• 5.6 Stuck appraisals that will not shift.
  • Check that the thought is specific and that both partners agree on it (the N step).
  • Storm more alternatives, including odd ones, before testing. Look for the meaning underneath.
  • Pair the cognitive work with a behavioural test through in vivo approach.
  • Remember that a balanced thought will feel unnatural at first. [source: CBCT slides on awkwardness and practice; the rest is synthesis]
  • If guilt reflects real wrongdoing (moral injury), shift to accountability, repair and self-forgiveness work. [synthesis]
• 5.7 Partner as prosecutor or as cheerleader.
  • Return to the "Unified" step and to the reality-tester role: curious questions, not verdicts. [source: CBCT slides]
  • Coach the partner in their wording live, and ask the patient how the question landed. [synthesis]
• 5.8 Overwhelm during approach or trauma-themed work.
  • What the sources say: B-CBCT therapists manage distress with psychoeducation, coping and problem-solving skills, and direct intervention. [source: NCT05207436]
  • What to do: use grounding for dissociation. Step back down the approach list rather than drop it. Remember that CBCT does not need trauma details to be told to the partner, so set limits on graphic disclosure if it overwhelms either partner. [source on no imaginal exposure: CBCT slides; the rest is synthesis]
• 5.9 Infidelity, secrets or minimal commitment.
  • Minimal commitment rules CBCT out. [source: CBCT slides]
  • Assess affairs and secrets privately at intake. Agree a policy on secrets (e.g., limited confidentiality: no keeping secrets that sabotage the couple work). If a current affair is undisclosed and ongoing, CBCT is not appropriate until it is addressed. [synthesis]
• 5.10 Both partners have PTSD, or the partner's distress is high.
  • The manual addresses dual-trauma couples. [uncertain about specifics] The B-CBCT trial excluded partners with probable PTSD. [source: NCT02720016]
  • Run U.N.S.T.U.C.K. and approach for both partners' trauma appraisals. Balance the time. Consider individual treatment for the partner in parallel. [synthesis]
• 5.11 Substance use.
  • Active dependence was an exclusion in the trials. [source: NCT02720016; NCT05207436]
  • Ban alcohol during time-outs and approach tasks. Refer for substance use treatment, and add a substance-use item to the maintenance plan. [synthesis]
• 5.12 Alliance rupture or perceived siding.
  • Name it openly. Ask each partner how balanced the sessions feel, and repair by validating the partner who feels left out. [synthesis]
  • Review balance of airtime at check-out.
• 5.13 Dropout risk and missed sessions.
  • The trial lessons tie dropout to pre-treatment relationship functioning. [source: Monson et al. 2024 abstract]
  • Contract for attendance in Session 1. Contact the couple after any missed session. If one partner cannot attend, hold a brief session on assignments but no new joint content. [synthesis]
• 5.14 Military or occupational secrecy, and moral injury content.
  • Partners do not need operational detail. Work at the level of meaning ("what this says about me") rather than events. [synthesis]
• 5.15 Telehealth.
  • Confirm both partners are in a private space. Agree a protocol for a disconnected call during escalation (e.g., phone back within 2 minutes). Make sure local emergency information is to hand. [B-CBCT telehealth delivery: NCT02720016; the procedures are synthesis]

Sources

Sources:

• Cognitive-Behavioral Conjoint Therapy for PTSD – Guilford Press (authors/product page)
• Cognitive-Behavioral Conjoint Therapy for PTSD – Table of contents (Guilford)
• CBCT for PTSD training slides, May 2019 (handouts), GVSU
• CBCT for PTSD 1–2 hour presentation (Monson), cptforptsd.com
• Cognitive-Behavioral Conjoint Therapy (CBCT) Project protocol, NCT02720016
• Brief CBCT for PTSD with adjunctive intranasal oxytocin protocol, NCT05207436
• Intensive, multi-couple group therapy for PTSD: a nonrandomized pilot study (PubMed abstract)
• Study shows promise for two-day therapy to treat PTSD, improve relationships (Penn State News)
• CBCT versus prolonged exposure for PTSD in military service members and veterans (UT Health San Antonio scholars page)

Books and papers cited (not drawn on in full):

• Monson, C. M., & Fredman, S. J. (2012). Cognitive-Behavioral Conjoint Therapy for PTSD: Harnessing the Healing Power of Relationships. Guilford Press.
• Fredman, S. J., et al. (2020). Intensive, multi-couple group therapy for PTSD: A nonrandomized pilot study with military and veteran dyads. Behavior Therapy, 51(5), 700–714.
• Monson, C. M., et al. (2024). Cognitive–behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial. European Journal of Psychotraumatology, 15(1), 2330305.
• Monson, C. M., Fredman, S. J., & Adair, K. C. (2008). Cognitive-behavioral conjoint therapy for PTSD: Application to an Operation Enduring Freedom veteran. Journal of Clinical Psychology. [uncertain]

The manual's full text and Guilford's sample chapter are not drawn on. For this reason, in-session procedures for most skills are marked [uncertain] or [synthesis].