Partner Abuse, Volume 5, Number 1, 2014
“Strength at Home” Intervention to Prevent Conflict and Violence in Military Couples: Pilot Findings Casey T. Taft, PhD Jamie Howard, PhD National Center for PTSD, VA Boston Healthcare System, and Boston University School of Medicine
Candice M. Monson, PhD Ryerson University, Toronto, Ontario, Canada
Sherry M. Walling, PhD Fresno Pacific University, California
Patricia A. Resick, PhD Boston University
Christopher M. Murphy, PhD University of Maryland Baltimore County
In this article, we report on a pilot study of Strength at Home-Couples (SAH-C), a 10-session cognitive-behavioral couples-based group intervention designed to prevent intimate partner violence (IPV) in military couples. The primary purposes of this pilot study were to determine feasibility of recruiting, retaining, and assessing SAH-C participants in addition to those participating in a comparison Supportive Therapy (ST) group-based couples intervention. Recruitment was challenging for this pilot study and we report on several barriers to recruitment as well as “lessons learned” for enhancing recruitment and overall intervention efforts. Preliminary pilot data were promising with respect to reductions and prevention of IPV in
© 2014 Springer Publishing Company41 http://dx.doi.org/10.1891/1946-6560.5.1.41
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Taft et al. those receiving the SAH-C intervention. Initial results for the secondary intervention targets were less favorable for the SAH-C intervention, with effect sizes suggesting a trend in which relationship satisfaction increased more in the ST intervention.
KEYWORDS: violence; abuse; prevention; couples; Veterans Intimate partner violence (IPV) is a significant problem in military populations. Prevalence rates of IPV perpetration in nonclinical military samples are up to three times higher than rates found among representative studies of the general population (see Marshall, Panuzio, & Taft, 2005). Further, service members who experience military deployments are at risk for lower relationship satisfaction and higher rates of separation and divorce (Allen, Rhoades, Stanley, & Markman, 2010; Goff, Crow, Reisbig, & Hamilton, 2007), and low relationship adjustment has been shown to serve as a risk factor for IPV perpetration in samples of Veterans (Taft, Street, Marshall, Dowdall, & Riggs, 2007). Although relatively little systematic research has been conducted regarding the effects of IPV perpetration by active duty servicemen and Veterans, it is clear that IPV results in far-reaching consequences that are similar to the types of consequences suffered among civilian samples (Marshall et al., 2005). Family problems that may result from IPV may also contribute to health and occupational problems in the service member as well as lower military morale and readiness (Saltzman et al., 2011; Segal, 2006; Vinokur, Pierce, & Buck, 1999; Wiens & Boss, 2006). The significance of the IPV problem among this population is underscored by the fact that 21.8 million Veterans reside in the United States (American Community Survey, 2010), and the total U.S. military force is currently composed of more than 1.4 million active duty personnel, most of whom are married (Department of Defense, 2011). Unfortunately, there is currently no empirically validated IPV intervention for military personnel or Veterans exposed to combat trauma. Only one experimentally controlled evaluation of IPV intervention effectiveness has been conducted in a military setting. Among a large sample of married U.S. Navy couples in which the husband perpetrated IPV, Dunford (2000) found that none of the randomly assigned year-long intervention modalities (i.e., a cognitive-behavioral men’s group, a cognitive-behavioral couples group, and a rigorously monitored group) were effective in reducing IPV at 6 and 12 months postintervention compared to a no-intervention control group. It is important to note that none of the interventions used in this study incorporated components that dealt with trauma exposure or PTSD. Dunford’s (2000) findings highlight a need for program modification efforts to meet the needs of families of Veterans that experience IPV and also mirror unimpressive findings from studies of IPV programs in nonmilitary settings. In a meta-analysis of the efficacy of IPV interventions for violent men, Babcock, Green, and Robie (2004) found that these programs had only modest effects. Specifically, it was shown that those receiving active abuser interventions averaged a reduction in recidivism of only
Strength at Home43 5% relative to untreated groups. Further research has shown no significant differences in efficacy among theoretically and technically distinct interventions for partner violence (Morrel, Elliott, Murphy, & Taft, 2003; O’Leary, Heyman, & Neidig, 1999; Saunders, 1996). The limited efficacy for standard interventions for identified perpetrators of IPV highlights a need for use of alternative approaches to target this problem. Although no prevention programs for IPV among military populations have been empirically evaluated, some limited preliminary evidence from civilian samples suggests the potential benefit of preventive interventions, particularly those that make use of cognitive-behavioral skills–based techniques (see O’Leary, Woodin, & Fritz, 2006). However, most prevention programs focus on adolescents and less is known about how to prevent IPV in older at-risk populations (Niolon et al., 2009). The Strength at Home-Couples (SAH-C) program was developed through a collaborative agreement with the Centers for Disease Control and Prevention in response to the need for a military-specific IPV prevention program. SAH-C is a cognitivebehavioral couples–based group intervention designed to prevent IPV in returning male service members and their intimate female partners. This intervention is informed by a social information processing model for IPV perpetration among military populations (Taft, Walling, Howard, & Monson, 2011). This model derives from prior theoretical and empirical work highlighting information processing deficits among IPV perpetrators (Eckhardt, Barbour, & Davison, 1998; Holtzworth-Munroe, 1992) and models for aggression in military populations that emphasize faulty threat perception and hostile attribution biases among those who have been exposed to trauma (Chemtob, Novaco, Hamada, Gross, & Smith, 1997; Novaco & Chemtob, 1998). The program draws on existing cognitive-behavioral interventions, specifically incorporating components of cognitive-behavioral therapy (CBT) for IPV (Murphy & Scott, 1996), anger management and assertiveness training for Veterans (Grace, Niles, Quinn, & Taft, unpublished manual), and relationship-focused treatment of posttraumatic stress disorder (PTSD; Monson & Fredman, in press) and has tailored intervention components to be relevant for military couples. The intervention is designed to prevent IPV by helping participants to develop effective conflict resolution skills, increase intimacy and closeness in their relationships, and improve communication with one another. The program is intended for couples that are experiencing relationship difficulties but are not engaging in a pattern of physical IPV or coercive, controlling behavior. The program was written with several goals in mind. First, we wanted to provide enough structure and group tasks to guide leaders who have little prior experience with couple therapy and conflict management. Second, we wanted to retain flexibility so that leaders have time and freedom to explore and expand upon material that arises during sessions. Programmatic flexibility also allows group leaders to build a healthy and constructive group process by dealing with conflicts within the group, engaging in problem solving around current life difficulties, and addressing the needs of group members at different stages of the change process.
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SAH-C is administered in a group format rather than an individual format for several reasons. Research has shown that group process factors such as group cohesion and the working alliance predict positive treatment outcomes for problems with IPV (e.g., Taft, Murphy, King, Musser, & DeDeyn, 2003), poor relationship adjustment (Symonds & Horvath, 2004), and PTSD (Cloitre, Koenen, Cohen, & Han, 2002; Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004). Although group process variables have been understudied among military populations, clinical observations suggest that process factors may play a particularly important role for this population, given the sense of camaraderie among service members and family members. Group interventions are regularly delivered for military Veterans and military families because this format may reduce their sense of isolation and enhance social support. Group interventions are also the format of choice for IPV intervention programs and use less time and resources than individual-based interventions. We recently completed the pilot phase of this project in which we tested the feasibility of conducting a controlled clinical trial comparing the efficacy of SAH-C relative to a Supportive Therapy (ST) couples group intervention. The primary outcomes of interest in the clinical trial include prevention of physical IPV and reductions in psychological IPV; secondary outcomes of interest include enhanced relationship satisfaction and reductions in PTSD symptomatology. In this report, we describe the SAH-C intervention and present preliminary data acquired during the initial pilot phase of this project. In the spirit of testing the feasibility of the intervention and since it is not possible to truly examine a prevention effect in such a small pilot sample, we broadened inclusion criteria and allowed military members/Veterans who endorsed low level physical IPV to participate in the program. The specific aims of the pilot program were to (a) demonstrate feasibility of recruiting from this population, (b) demonstrate feasibility of attendance for a 10-week group, (c) conduct a preliminary examination of the outcomes of interest and demonstrate the safety of the SAH-C and ST conditions, and (d) establish feasibility of follow through for postintervention assessments. Regarding the outcome data, we present data on baseline to 6-months postintervention across the two conditions, with some direct comparisons between conditions when indicated. We primarily focus on effect sizes in our presentation given the small sample size of this pilot study.
METHODS Recruitment and Retention Couples were recruited primarily through clinical referrals, flyers, mailings, and military events in the Greater Boston area over a period of 12 months. Study staff provided program information and referral forms to clinical staff at local VA hospitals and Vet Centers. Study staff also promoted the program at Veteran’s support groups
Strength at Home45 through local nonprofit organizations serving Veterans and through military and Veteran’s chaplaincy programs. Despite expressed interest from collaborating clinicians and community members, recruitment proceeded more slowly than expected. Information about the program (a brochure and brief form letter) was also mailed to approximately 1,300 Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans. Of the packets mailed, approximately 8% were returned or undeliverable, 2 stated they were disinterested, and 5 stated they were interested in learning more about the study. The remainder was lost to contact. Only one participant was successfully recruited using this method. It took approximately 1 year to fill the initial pilot groups. Prior to being formally assessed for inclusion, couples were screened briefly in person (e.g., at a military event) or via telephone for preliminary eligibility. Preliminary eligibility required that (a) both partners endorsed being in a committed, heterosexual relationship; (b) at least one partner endorsed relationship dissatisfaction; and (c) the male partner endorsed significant trauma exposure. Approximately 60 couples were informally screened for participation in the pilot study. From this pool, 15 couples were formally assessed to participate in the study. To be included, both partners had to be willing to participate, literate, at least 18 years old, and married or living together, and at least one partner must have endorsed significant relationship dissatisfaction as measured by the Quality of Marriage Index (QMI; Norton, 1983). In addition, the male partner must have been deployed in support of OEF or OIF, met diagnostic criteria for PTSD, and must not have endorsed perpetrating severe IPV in the past year, measured by the Revised Conflict Tactics Scales (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Of the 15 couples assessed, two were ineligible for the program because the male partner did not meet diagnostic criteria for PTSD, and four dropped out of the program. Three of the four couples who dropped out failed to engage in treatment following the initial assessment, and one couple dropped out after the first session. The treatment completer sample contained nine couples (18 individuals) who completed the first assessment and attended at least 70% of the intervention (i.e., 7/10 sessions). All participants but one female partner (active treatment) completed the 6-month follow-up assessment. Participants Couples were sequentially assigned to the active intervention, SAH-C, or the ST group. The first two cohorts (three couples each) were assigned to SAH-C and the final three couples were assigned to ST for the third group. The mean age of participants was 41.22 (SD 5 9.39) years; 78% of the participants (n 5 14) chose White as their racial identity, and the remaining participants identified themselves as African American. Three participants chose Hispanic as their ethnic identity. Two thirds of the couples were married (n 5 6), five out of six in SAH-C and one out of three in ST. Couples’ relationship length ranged from 6 months to 321 months, with an average
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relationship duration of 103.5 months (SD 5 103.18). Fifty-six percent of participants had children (n 5 10). All participants completed high school, 72% completed at least some college, and 67% were employed full- or part-time. MEASURES Physical IPV was measured using the 12-item Physical Assault subscale of the CTS2 (Straus et al., 1996). The acts of physical IPV were further broken down into mild (e.g., grabbing partner) and severe (e.g., punching partner) IPV. The reliability and validity of the instrument have been well-documented (Straus, 1979, 1990). Male Veterans and female partners reported the frequency with which they engaged in IPV behaviors toward their partner in the past 6 months on a scale ranging from 0 (never) to 6 (more than 20 times). They also reported the frequency with which they were recipients of IPV from their partner in the past 5 months on the same scale. Veteran and partner scores were combined such that the larger of veteran-reported and partner-reported items were used in the calculation of CTS2 scores. From these ratings, Physical Assault subscale scores were computed by summing the number of positively endorsed items, with total scores ranging from 0 to 9. Scores derived from this computation method, known as “variety scores,” have desirable psychometric properties and have been advocated for measuring physical IPV (Moffitt et al., 1997). This approach reduces skewness caused by a small number of high-rate offenders, gives equal weight to each IPV behavior, and is least affected by memory bias in retrospective recall. Variety scores were log-transformed to further reduce skew and kurtosis. Psychological IPV toward one’s partner was assessed using the 8-item Psychological Aggression subscale of the CTS2 (Straus et al., 1996). The CTS2 Psychological Aggression subscale is composed of items categorized as mild (e.g., shouted/yelled at partner) or severe (e.g., destroyed something belonging to partner). The Psychological Aggression subscales were calculated similarly to the Physical Assault subscales, that is, both male Veterans and female partners reported on their own and their partner’s behavior, and the larger of the two reports were used. However, a variety score for psychological IPV could lead to a significant loss of information and variance because this form of abuse occurs in higher frequencies. Thus, psychological IPV was calculated by recoding each item to reflect the estimated frequency of the behavior (e.g., “3 to 5 times” received a score of 4) and then summing the recoded items. As with physical IPV, scores were log-transformed to reduce skew and kurtosis. Relationship quality was assessed using the 6-item QMI (Norton, 1983). On five of six items, participants indicated their degree of agreement with broad statements about their relationship (e.g., We have a good relationship) on a 7-point Likert scale. On the sixth item, participants indicated their overall degree of happiness in their relationship on a 10-point Likert scale (1 5 unhappy; 10 5 perfectly happy). To participate in the study, at least one member of the couple must have obtained a score of 29 or below on the QMI, which is a score often used to distinguish between distressed and nondistressed couples (e.g., Slep, Heyman, Williams, Van Dyke, & O’Leary, 2006).
Strength at Home47 In this study, the QMI had good internal consistency (alpha coefficients 5 .86 for male Veterans, 88 for female partners). The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) is a semistructured clinician interview that assesses PTSD diagnostic status and symptom severity, consistent with Diagnostic and Statistical Manual (DSM-IV) criteria (American Psychiatric Association, 2000). PTSD diagnostic status was based on DSM-IV symptom criteria requiring 1 reexperiencing symptom, 3 avoidance/numbing symptoms, and 2 hyperarousal symptoms (to be counted, minimum symptom frequency 5 1 and intensity 5 2) and a minimum severity score of 45. The psychometric properties of the CAPS have been well-established (e.g., Weathers, Keane, & Davidson, 2001). The Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) is a semistructured clinician interview that contains symptom-specific questions about various psychiatric disorders. It has demonstrated good validity and reliability (Sheehan et al., 1998). The MINI was used to assess for study exclusion criteria, which included organic mental disorder, psychotic disorder, and substance dependence. None of the 15 couples assessed were excluded based on their responses on the MINI. PROCEDURE All participant data were collected at a VA hospital in accordance with IRB-approved procedures. Written consent was obtained from both couple members prior to initiating study procedures. Partners were consented and assessed separately to avoid coercion or response bias. All assessments were completed onsite prior to initiating treatment, after completion of the group, and at 6 months after treatment completion. Trained master’s- and doctoral-level psychology staff conducted all consent and assessment procedures. Three doctoral-level psychology staff—the first, second, and fourth authors—administered the interventions in male–female dyads. INTERVENTIONS SAH-C is a 10-week couples group intervention that is designed to prevent IPV and improve intimate relationships among returning Veterans and their romantic partners. Although the program is not a direct treatment for PTSD, it was designed to be highly sensitive to the fact that many military couples have histories of traumatic stress exposure that negatively affect their relationships and thus emphasizes the unique stressors of deployment separation and combat exposure. Specifically, the program targets social information processing mechanisms hypothesized to underlie the relationship between PTSD and IPV as well as common themes that may underlie PTSD and relationship difficulties. The groups are conducted in a multicouple, closed-group format, with three-to-five couples in each group. The group atmosphere is supportive and nonconfrontational. Each 2-hour session contains brief didactic material; group activities to discuss, learn, and practice new behaviors; and flexible time to solve ongoing problems; explore change efforts; and build group cohesion.
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The initial phase (Sessions 1–3) of the SAH-C group focuses on psychoeducation about PTSD and how trauma exposure and deployment separation may contribute to relationship difficulties. Specific core themes covered include trust, power and control, self- and other esteem, and intimacy. Emphasis is placed on articulating healthy relationship behaviors, clarifying treatment goals, and increasing positive interactions between intimate partners. The second phase (Sessions 4–6) focuses on conflict management, including teaching skills to help couples identify and effectively manage difficult situations when they arise. Partners are encouraged to carefully analyze their individual conflict management styles, including the influence of military training on anger expression, and are taught to monitor their own behavior for healthy (i.e., assertive) and unhealthy responses to conflict situations with their partners. The third phase (Sessions 7–9) of the program focuses on learning and practicing basic communication skills, including active listening, giving assertive messages, and identifying and communicating emotions to one another. Couples practice these skills in and out of session on salient issues in their relationships. The final session reviews gains achieved over the course of the intervention and plans for continued change. Across all of the sessions, group members are also encouraged to increase the positive elements of their relationships via intimacy enhancing exercises (e.g., self-monitoring of positive relationship behaviors). Partners complete in-session practice exercises and are provided “practice assignments” to consolidate material covered in group. ST is a group intervention that was derived from the manualized ST intervention used by Morrel et al. (2003) in their examination of the relative efficacy of CBT and ST for reducing IPV perpetration. The intervention is based on the work of Jennings (1987) and on Yalom’s (1995) primary therapeutic factors for group intervention. ST involves minimal therapist-directed intervention beyond encouragement of a mutually supportive environment and focus on relationship issues and preventing IPV. Weekly 2-hour sessions are conducted in a closed-group format of three-to-five couples per group. In ST, the therapists allow group members to set the session agenda and address themes and topics that spontaneously emerge in the group interaction. The therapists emphasize a collaborative group norm and refrain from using active skills-training interventions. Therapists are instructed to address the group as a whole rather than individuals, and use brief verbalizations and nonverbal gestures to stimulate vigorous and helpful group interactions. This intervention was chosen to examine the relative benefits of the cognitive and behavioral skills taught in SAH-C because ST contains no such active intervention material. In both intervention conditions, the treating psychologists attended weekly supervision with the treatment developer, a couple’s therapy expert, and an IPV expert. STATISTICAL ANALYSES Repeated measures ANOVAs were used to assess change in the primary outcomes of interest, physical and psychological IPV, as measured by the CTS2. Repeated measures ANOVAs were also used to assess secondary outcomes of interest, including
Strength at Home49 change in relationship satisfaction, as measured by the QMI (Norton, 1983), and change in PTSD symptoms, as measured by the CAPS (Blake et al., 1995). Effect sizes (partial h2) were calculated to measure the magnitude of change, which are described according to statistical conventions suggesting that partial h2 5 0.01 is a small effect, partial h2 5 0.06 is a medium effect, and partial h2 5 0.14 or above is a large effect (Kittler, Menard, & Phillips, 2007). Because this is a pilot study with a small sample size, statistical significance is difficult to detect because of low statistical power. Effect sizes provide quantitative data on the degree of change in the absence of a relevant p value. RESULTS Primary Outcomes Veteran-Perpetrated Physical IPV. Couples in the SAH-C groups endorsed a mean of 3.17 incidents of male Veteran-perpetrated mild physical IPV and 0 incident of male Veteran-perpetrated severe physical IPV at baseline, whereas couples in the ST group reported 0 incidents of male Veteran-perpetrated mild and severe physical IPV at baseline. At the 6-month follow-up assessment, couples in the SAH-C groups endorsed 0 incidents of male Veteran-perpetrated mild and severe IPV. A one-way ANOVA was conducted, which revealed a trend by which couples receiving the SAH-C group reported reductions in male Veteran-perpetrated mild IPV (F 5 3.45, p 5 .07). The magnitude of this overall trend was large (partial h2 5 .41). Couples in the ST group also endorsed 0 incidents of male Veteran-perpetrated mild and severe physical IPV at 6-months posttreatment, indicating that they remained nonviolent. Veteran-Perpetrated Psychological IPV. Couples in the SAH-C groups endorsed a mean of 26.17 incidents of male Veteran-perpetrated mild psychological IPV at baseline and 15.67 incidents 6-months posttreatment; couples in the ST group endorsed a mean of 8.00 incidents of male Veteran-perpetrated mild psychological IPV at baseline and 4.33 incidents 6-months posttreatment. An independent samples t test of log-transformed data indicated that baseline differences in mild psychological IPV did not reach statistical significance. Therefore, repeated measures ANOVA was conducted on log-transformed data, and tests of between group effects revealed a trend by which mild psychological IPV decreased more over time in the SAH-C groups than the ST group (F 5 4.39, p 5 .08). The magnitude of this overall trend was large (partial h2 5 .39). Couples in the SAH-C groups endorsed a mean of 1.83 incidents of male Veteran-perpetrated severe psychological IPV at baseline and 1.50 incidents 6-months posttreatment, whereas couples in the ST group reported 0 incidents of male Veteran-perpetrated severe psychological IPV at baseline and 6-months posttreatment. A one-way ANOVA indicated that the magnitude of the reduction in male Veteran-perpetrated severe psychological IPV in the SAH-C groups was moderate (partial h2 5 .06).
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Female Partner-Perpetrated Physical IPV. Couples in the SAH-C groups endorsed a mean of 2.50 incidents of female partner-perpetrated mild physical IPV at baseline, and couples in the ST group reported 0 incidents of female partnerperpetrated mild physical IPV. At 6-months posttreatment, couples in the SAH-C groups endorsed 1.33 incidents of female partner-perpetrated mild physical IPV and those in the ST group endorsed a mean of .67 incidents. An independent samples t test of log-transformed data indicated significant differences between the treatment conditions at baseline (F 5 32.39, p , .01). Therefore, female partnerperpetrated mild physical IPV was examined separately for the two treatment conditions. Because of low sample size, this method was deemed preferable to conducting repeated measures ANOVA with the baseline score treated as a covariate. A one-way ANOVA using log-transformed data was conducted for the SAH-C group, which indicated that the magnitude of the reduction in female partner-perpetrated IPV was moderate (partial h2 5 .08). A separate one-way ANOVA using log-transformed data was also conducted for the ST group, which indicated that the magnitude of the increase in female partner-perpetrated IPV was large (partial h2 5 .33). Couples in the SAH-C groups endorsed a mean of 0.17 incidents of female partnerperpetrated severe physical IPV at baseline and 0 incidents 6-months posttreatment, whereas couples in the ST group endorsed 0 incidents of female partner-perpetrated severe physical IPV at baseline and 6-months posttreatment. Only one female partner had reported severe physical aggression at the start of the study, and she did not have reported severe aggression 6-months posttreatment. Because of the extremely low baseline score in the groups, combined with the small sample size, inferential statistics were not pursued. Female Partner-Perpetrated Psychological IPV. Couples in the SAH-C groups endorsed a mean of 27.50 incidents of female partner-perpetrated mild psychological IPV at baseline and 15.83 incidents 6-months posttreatment; couples in the ST group endorsed a mean of 7.00 incidents of female partner-perpetrated mild psychological IPV at baseline and 3.00 incidents 6-months posttreatment. An independent samples t test indicated that baseline differences in mild psychological IPV did not reach statistical significance. Repeated measures ANOVA was conducted, and tests of between group effects revealed a trend by which female partner-perpetrated mild psychological IPV decreased more over time in the SAH-C groups than the ST group (F 5 4.41, p 5 .07). The magnitude of this overall trend was large (partial h2 5 .39). Couples in the SAH-C groups endorsed a mean of 8.33 incidents of female partner-perpetrated severe psychological IPV at baseline and 2.33 incidents 6-months posttreatment, whereas couples in the ST group reported 0 incidents of female partner-perpetrated severe psychological IPV at baseline and 6-months posttreatment. A one-way ANOVA indicated that the magnitude of the reduction in female partner-perpetrated severe IPV in the SAH-C groups was large (partial h2 5 .35).
Strength at Home51 Secondary Outcomes Relationship Satisfaction. Couples in the SAH-C groups reported lower levels of relationship satisfaction at baseline (26.58) compared to the ST group (34.60) on the QMI. An independent samples t test indicated that baseline differences in satisfaction did not reach statistical significance. Repeated measures ANOVA were used to examine trends within and between groups in relationship satisfaction over time. At 6-months posttreatment, members of the SAH-C groups reported slightly lower relationship satisfaction (25.58), compared to members of the ST group, who reported slightly higher satisfaction (37.17). There were no significant differences within groups over time; the effect size for this within group relationship was small to medium (partial h2 5 .05). There was a trend toward significant between group differences, and the effect size for this relationship was large (F 5 4.22, p 5 .06, partial h2 5 .21). This indicates that both groups remained relatively stable in their relationship satisfaction over time, but the differences between groups increased over time. Posttraumatic Stress Disorder Symptoms. Veterans in the SAH-C groups reported lower levels of PTSD symptoms (54.50) at baseline compared to Veterans in the ST group (57.33) on the CAPS. An independent samples t test indicated that this was not a significant difference between groups. Therefore, repeated measures ANOVA was conducted to examine within and between group changes in PTSD symptoms over time. At 6 months posttreatment, members of the SAH-C groups reported lower levels of PTSD symptoms (52.83) compared to the ST group (56.67). There were no significant differences within groups over time (partial h2 5 .08) nor were there significant differences between groups (partial h2 5 .06). This indicates that both groups remained relatively stable in their PTSD symptoms over time. DISCUSSION The primary aims of this pilot study were to validate recruitment and assessment procedures for a larger randomized clinical trial comparing SAH-C and ST group interventions to enhance intimate relationship functioning and prevent conflict, and to obtain initial effect size estimates. Regarding the former, we were able to successfully recruit from the target population to fill the intervention groups, all but one of the couples that began the group interventions completed them, and we were successful in carrying out all scheduled assessments with participants with the exception of one partner at one time point. However, it is notable that only a relatively small percentage of eligible couples actually engaged in the interventions despite considerable expressed interest on the part of potential referral sources and group members, and we encountered several barriers in recruitment. We were not able to formally assess all possible reasons for a lack of follow-through, although anecdotally, project staff described some reported instances involving practical barriers such
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as transportation, work/school scheduling conflicts and child-care difficulties, as well as issues related to concerns about social stigma and fear of discussing relationship problems with other military couples. When couples did overcome such fears and presented for group, however, they rarely missed sessions and almost always finished the group. Results from examination of pilot data focusing on the relationship outcomes suggest the effectiveness of the SAH-C intervention in reducing IPV, although findings are tempered by low sample size and apparent lack of equivalency between the conditions on IPV status at baseline. All SAH-C Veterans who reportedly (either self- or partner-report) engaged in physical IPV toward their female partner during the pretreatment period evidenced complete cessation of this IPV at the 6-month follow-up assessment. Effect sizes for these reductions were large. Female partners participating in the SAH-C intervention also evidenced reductions in mild physical IPV perpetration with a moderate effect size, whereas female partners participating in the ST groups evidenced large increases in their physical IPV perpetration. The one female partner with reported severe physical IPV perpetration at baseline in the SAH-C group did not reportedly engage in severe physical IPV at 6-month follow-up. Of note, although we were not able to truly determine prevention of physical IPV in this small sample, we did find that none of the participants increased their IPV or went from nonviolent to violent after participating in SAH-C, whereas one of three ST female partner participants went from nonviolent to violent. Findings for psychological IPV perpetration were perhaps even stronger for the SAH-C intervention. There was a statistical trend suggesting that mild psychological IPV, perpetrated by both the Veteran and the female partner, decreased more in the SAH-C groups than the ST groups, and the effect sizes for these trends was large. Reductions in severe psychological IPV perpetrated by the Veteran and partner were moderate and large, respectively. Findings for the secondary outcomes of interest were less favorable for the SAH-C intervention. There was relatively little change in relationship satisfaction or PTSD symptoms over time for either condition, although there was a trend such that relationship satisfaction increased more in the ST condition than SAH-C, and the effect size for this difference was large. These initial findings suggest the possibility that the SAH-C intervention is most effective with respect to relationship conflict and IPV and is less effective for enhancing overall relationship satisfaction and well-being. Another possible explanation is raised through examination of relationship status data over time. Two of the six couples in the SAH-C groups were separated and pursuing divorce 6 months posttreatment, whereas none of the couples in the ST group ended their relationships. Couples in the SAH-C groups experienced more relationship dissatisfaction as well as IPV upon entering the program than couples in the ST group, although these differences did not reach statistical significance given the low sample size. Examination of patterns of findings across outcomes suggests the possibility that couples learned to communicate in
Strength at Home53 a less conflictual manner, although such new patterns of handling conflict did not necessarily lead to preservation of the relationship or greater satisfaction with the relationship. Lessons Learned Difficulties recruiting the target sample and contacts with participants and potential referral sources led to several changes in our recruitment strategy over time. Perhaps most importantly, we recognized that it was extremely important that project staff engage in significant outreach efforts to reach potentially interested OEF/OIF couples. We recognized early in the pilot study that traditional recruitment methods such as mailings, posting flyers, and talking to treatment providers would be insufficient. Thus, following the pilot phase, our team hired and trained an active outreach team of service members and/or military family members who, accompanied by the first author or other study staff, frequently met with military family groups and gave presentations at “Yellow Ribbon Events,” “Strong Bonds” events, or other events that involved providing assistance to service members. This allowed us to interact with Veterans and their family members in face-to-face, informal settings. Anecdotally, we found that talking to Veteran’s wives, girlfriends, or family members was a helpful recruitment connection. We convened an Advisory Board of local military family experts and military Family Advocacy Program leadership to help inform our recruitment efforts. We enlisted the assistance of public relations services to further assist our efforts using media outlets such as a project website, a Facebook page, and coverage in local news media. These strategies appeared relatively ineffective in directly recruiting participants. In sum, we recognized that recruitment of couples for this project would involve substantial, active efforts that involved direct interaction with military families and those who work with these families. Our understanding of military families and their reasons for seeking treatment improved greatly through the process of implementing this pilot program. We made several modifications to our protocol based on the difficulties we experienced recruiting the target population. Because three couples dropped out of the program prior to a group starting, we instituted a 3-month maximum wait for participants to start treatment. We eliminated PTSD diagnosis as an inclusion criterion because Veterans expressed frustration that military mental health providers tend to overfocus on PTSD rather than more general readjustment difficulties, and this requirement had made two couples ineligible for the program. Given that many returning Veterans are young and in new relationships, we modified our inclusion criteria such that participants no longer have to live together or be married to be included in the study; rather, they must endorse being in a committed relationship. In addition, we observed that Veterans and their partners explained their relationship difficulties openly during an informal interview, but they were reluctant to endorse relationship dissatisfaction on written questionnaires used to determine eligibility. We hypothesize that this may reflect cognitive dissonance, that is,
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articipants want to preserve their relationships and are seeking assistance to do p so, and endorsing significant distress may be experienced as incongruous with their motivation to improve the relationship. For this reason, we expanded the relationship distress criterion such that, in lieu of endorsing significant relationship dissatisfaction on the QMI, one member of the couple may endorse veteran-perpetrated psychological IPV (defined as scoring above 75 percentile on the CTS2 Minor Psychological Aggression subscale, or any endorsement of items on the Severe Psychological Aggression subscale on the CTS2 or the Dominance/Intimidation Scale of the Multidimensional Measure of Emotional Abuse, MMEA; Murphy & Hoover, 1999) to qualify for inclusion in the study. CONCLUSIONS This pilot study was invaluable in assisting us in gaining insight into how to best meet the needs of military couples and to reach out to this population. Perhaps most importantly, we learned the importance of actively engaging directly with military families and to do whatever we could to overcome potential barriers to recruitment and retention. Despite the challenges encountered in this pilot study, preliminary results suggested the possible effectiveness of the SAH-C intervention for preventing IPV and demonstrated that we were able to recruit, retain, and longitudinally assess participants from the target population. Upon completion of our larger ongoing clinical trial, we hope to be able to answer more definitely questions regarding the intervention efficacy and the degree to which the SAH-C intervention meets the needs of military families to prevent conflict and violence and reduce relationship problems and distress. REFERENCES Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. Journal of Family Psychology, 24(3), 280–288. American Community Survey. (2010). Veteran status: 2010 American community survey 1-year estimates. Retrieved from http://factfinder2.census.gov American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Babcock, J. C., Green, C. E., & Robie, C. (2004). Does batterers’ treatment work? A metaanalytic review of domestic violence treatment. Clinical Psychology Review, 23, 1023–1053. http://dx.doi.org/10.1016/j.cpr.2002.07.00 Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75–90. http://dx.doi.org/10.1002/jts.2490080106 Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross, D. M., & Smith, G. (1997). Anger regulation deficits in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 10, 17–36. http://dx.doi.org/10.1023/A:1024852228908
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Correspondence regarding this article should be directed to Casey T. Taft, VA Boston Healthcare System (116B-4), 150 South Huntington Avenue, Boston, MA 02130. E-mail:
[email protected]
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