Program Profile: Strength at Home Couples (SAH-C) Program to Prevent Military Partner Violence

This is a cognitive–behavioral, trauma-informed group intervention that is designed to prevent relationship conflict and intimate partner violence (IPV) among military couples. The program is rated Promising. There were statistically significant reductions in physical and psychological IPV for the treatment group, compared with the control group.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

The Strength at Home Couples (SAH-C) Program to Prevent Military Partner Violence is a cognitive–behavioral, trauma-informed group intervention developed for military couples who are experiencing relationship challenges but are not yet engaging in physical intimate partner violence (IPV) or coercive, controlling behavior. The program’s goal is to prevent relationship conflict and IPV in returning male military service members or veterans and their female partners.

Program Components

The SAH-C program is a 10-week intervention conducted in a multi-couple, close-group format of three to five couples in each group. Each session is 2 hours long and includes group activities in which participants discuss, learn, and practice new behaviors, with modules focused on understanding IPV and the effect of trauma on intimate relationships, conflict management and assertiveness skills, listening skills, strategies for improved emotional expression, and ways to avoid common communication pitfalls.

The first three sessions of SAH-C focus on psychoeducation about posttraumatic stress disorder (PTSD) and how trauma exposure and deployment separation may contribute to relationship challenges. Sessions four through six focus on conflict management, including teaching couples the skills to help identify and effectively manage difficult situations when they come up. Sessions seven through nine focus on learning and practicing basic communication skills such as active listening, giving assertive messages, and identifying and communicating emotions. The last session of SAH-C reviews the progress achieved over the course of the intervention and plans for continued change. There is built-in flexible time during each session to solve ongoing problems, explore change efforts, and build group cohesion. Participants are encouraged to increase the positive elements of their relationships through intimacy-enhancing exercises and completing practice assignments. The group atmosphere is intended to be supportive and nonconfrontational.

Key Personnel

The intervention is delivered by one doctoral-level male therapist and one doctoral or predoctoral-level female therapist acting as coleaders, and all sessions are videotaped.

Program Theory

SAH-C is informed by a cognitive–behavioral, social information-processing model for IPV perpetration among military populations, which recognizes that 1) trauma affects how people interpret and process information from the social environment, and 2) that trauma exposure can produce biases and deficits in social information processing within couples, which increases the risk of engaging in violence (Taft et al. 2010). The program was designed to be highly sensitive to the unique stressors of deployment separation and combat exposure and the ways that traumatic stress exposure can negatively affect relationships. The program modules focus on understanding the impact of trauma on intimate relationships and providing education on PTSD. SAH-C was also designed as a group therapy based on prior research demonstrating that group process factors (group cohesion and the working alliance) predict positive treatment outcomes for problems with IPV (e.g., Taft et al. 2003), poor relationship adjustment (Symonds and Horvath 2004), and PTSD (Cloitre et al. 2004).

SAH-C is a trauma-informed intervention, and the sessions incorporate elements from interventions for PTSD for both couples and individuals, including 1) cognitive–behavioral conjoint, a manualized couples therapy delivered to individuals with PTSD and their significant others to simultaneously treat PTSD symptoms and enhance relationship satisfaction (Monson and Fredman 2012); 2) exposure inhibition therapy, which has been used to treat PTSD in crime victims (Resick and Schnicke 1992); and 3) from research on IPV interventions (Taft et al. 2016).

Study

Taft and colleagues (2016) conducted a randomized controlled trial of the Strength at Home Couples (SAH-C) Program to Prevent Military Partner Violence. Participants were identified through clinician referral, self-referral from flyers hung in Veterans Affairs hospitals and community locations, and through presentations at military service member organization events in two major metropolitan areas in the Northeast. To be eligible for the study, participants had to meet the following four criteria: 1) the male participant and his partner had to be older than age 18, 2) the male participant had to be a veteran or service member who had been deployed to Iraq or Afghanistan, 3) the couple had to be living together, and 4) the couple had to indicate the need for intimate partner violence (IPV) prevention through one of the following: (a) one or both partners scored below 30 on the six-item Quality of Marriage Index (Norton 1983) or below 101 on the Dyadic Adjustment Scale (Spanier 1976); (b) one or both partners reported service member or veteran psychological IPV score above the 75th percentile on the Revised Conflict Tactics Scales (CTS2) Psychological Aggression subscale (Straus et al. 1996); or (c) any endorsement of service member or veteran severe Psychological Aggression score on the CTS2 or Dominance/Intimidation on the Multidimensional Measure of Emotional Abuse (MMEA) (Murphy and Hoover 1999). The Mini International Neuropsychiatric Interview (MINI) (Sheehan et al. 1998) was used to evaluate study exclusion criteria.

The study was conducted at two Department of Veterans Affairs hospitals with 69 couples. Participating couples (referred to as “dyads” in this study) completed an initial assessment, including diagnostic interviews and measures of physical and psychological IPV, and were randomly assigned to either the SAH-C treatment group (n = 37 dyads) or supportive prevention (SP) group (n = 32 dyads) through a cluster design generated and implemented by a study biostatistician. Those in the intervention group received SAH-C, the cognitive–behavioral, trauma-informed IPV preventive intervention. The control group received SP, a group intervention focused on relationship issues and preventing IPV that emphasizes group members setting the agenda and leading the sessions themselves with minimal therapist-directed intervention. Trained masters or doctoral-level psychology staff delivered both interventions.

Most of the dyads in the sample were married (81 percent). Just under 58 percent of the men in the sample were currently in the National Guard, and roughly 7 percent were on current active duty. The majority of veterans in the sample (89.9 percent) and their partners (86.9 percent) were white. The mean age of the veterans in the full sample was 35.44 years, and the mean age of their partners was 33.6 years. A little over 46 percent of the full sample had a PTSD diagnosis, as measured by the Clinician-Administered PTSD Scale. The authors found no differences by condition on any demographic characteristics or IPV outcomes at baseline.

Service member or veteran and partner data were obtained from assessments completed on site or through an online survey for hard-to-reach participants at three time points after the initial assessment: 1) immediately following the intervention, 2) 6 months postintervention, and 3) 12 months postintervention. At each time point, participants reported how frequently they had engaged in IPV behaviors, measured using the 12-item Physical Assault and the eight-item Psychological Aggression subscales of the CTS2 (e.g., “I twisted my partner’s arm or hair” or “I insulted or swore at my partner”) during the assessment window on a scale ranging from 0 (never) to 6 (more than 20 times). The MMEA was included as an additional measure of psychological IPV; it contains 28 items, with four 7-item subscales: Restrictive Engulfment, Hostile Withdrawal, Denigration, and Dominance/Intimidation. Respondents reported on the frequency of their and their partners’ aggression on an 8-point scale ranging from 0 (never) to 7 (more than 20 times). These scores were recoded as frequencies in the same manner as CTS2 Psychological IPV frequency scores.

The outcomes included physical IPV and psychological IPV at the 12-month follow up. To examine the effects of the intervention, they calculated Hedges’ g (with the correction for small sample sizes) effect sizes to examine between-conditions effects. Odds ratios and relative risk ratios were calculated to examine between-conditions effects on a dichotomized physical IPV outcome that was created by classifying participants as nonviolent (0 physical IPV) or violent (less than 0 physical IPV). The number needed to treat effect size was also calculated to examine differences in violence rates at the 12-month follow up. The study authors conducted subgroup analyses by gender, between male service members or veterans and their female partners, in both the SAH-C and SP groups.

In the Taft and colleagues (2016) study, the treating clinicians attended weekly supervision with the first author. All Strength at Home Couples (SAH-C) sessions were videotaped, and an expert clinician in SAH-C rated a randomly selected 10 percent of the possible intervention sessions for protocol adherence. The study authors found that 94 percent of SAH-C protocol essential elements were rated as completed. The study authors also used expert clinicians to measure therapist competence in delivering the specific components of the treatment as prescribed for each session by examining behaviors such as warmth, empathy, building alliances, and facilitating group discussion, for 10 percent of all SAH-C and SP sessions, These were scored on a 7-point Likert scale ranging from 1 (poor therapist competence) to 7 (excellent therapist competence). The therapist competence mean scores were 5.54 for SAH-C and 5.50 for SP.

Subgroup Analysis

Taft and colleagues (2016) conducted subgroup analyses by gender (male service member or veteran, female partner). The proportion of physically violent female partners was lower in the Strength at Home Couples (SAH-C) condition at the 12- month follow up, but this finding did not reach statistical significance. For female partners, SAH-C resulted in statistically significant reductions in psychological IPV levels (as measured by the Multidimensional Measure of Emotional Abuse) at the 12-month follow up. The magnitude of the effect size for these psychological IPV differences was small to moderate. Male service members or veterans who received SAH-C engaged in less physical IPV at the 12-month follow up, compared with those who received supportive prevention; however, this finding was not statistically significant. At the 12-month follow up, the relative risk of physical violence by men assigned to SAH-C was 0.53, compared with those assigned to supportive prevention.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Cloitre, Marylene, Chase K. Stovall-McClough, Regina Miranda, and Claude M. Chemtob 2004. “Therapeutic Alliance, Negative Mood Regulation, and Treatment Outcome in Child Abuse-Related Posttraumatic Stress Disorder.” Journal of Consulting and Clinical Psychology 73(3):411–16.

Monson, C.M., and S.J. Fredman. 2012. Cognitive-Behavioral Conjoint Therapy for PTSD: Harnessing the Healing Power of Relationships. New York, N.Y.: Guilford Press.

Murphy, Christopher M., and Sharon A. Hoover. 1999. “Measuring Emotional Abuse in Dating Relationships as a Multifactorial Construct.” Violence and Victims 14:39–53.

Norton, Robert. 1983. “Measuring Marital Quality: A Critical Look at the Dependent Variable.” Journal of Marriage and the Family 45:141–51.

Resick, Patricia A., and Monica K. Schnicke. 1992. “Cognitive Processing Therapy for Sexual Assault Victims.” Journal of Consulting and Clinical Psychology 60:748–56.

Sheehan, David V., Yves Lecrubier, K. Harnett Sheehan, Patricia Amorim, Juris Janavs, Emmanuelle Weiller, Thierry Hergueta, Roxy Baker, and Geoffrey C. Dunbar. 1998. “The Mini-International Neuropsychiatric Interview (M.I.N.I.): The Development and Validation of a Structured Diagnostic Psychiatric Interview for DSM–IV and ICD-10.” Journal of Clinical Psychiatry 59(Suppl 20):22–33.

Spanier, Graham B. 1976. “Measuring Dyadic Adjustment: New Scales for Assessing the Quality of Marriage and Similar Dyads.” Journal of Marriage and the Family 38:15–28.

Straus, Murray A., Sherry L Hamby, Sue Boney-McCoy, and David B. Sugarman. 1996. “The Revised Conflict Tactics Scales (CTS2): Development and Preliminary Psychometric Data.” Journal of Family Issues 17:283–316.

Symonds, Dianne, and Adam O. Horvath. 2004. “Optimizing the Alliance in Couple Therapy.” Family Process 43:443–55.

Taft, Casey T., Christopher M. Murphy, Daniel W. King, Peter H. Musser, and Judith M. DeDeyn. 2003. “Process and Treatment Adherence Factors in Group Cognitive-Behavioral Therapy for Partner Violent Men.” Journal of Consulting and Clinical Psychology 71:812–20.

Taft, Casey T., Jamie Howard, Candice M. Monson, Sherry M. Walling, Patricia A. Resick, and Christopher M. Murphy. 2014. “‘Strength at Home’ Intervention to Prevent Conflict and Violence in Military Couples: Pilot Findings.” Partner Abuse 5(1):41–57.

Taft, Casey T., Sherry M. Walling, Jamie M. Howard, and Candice Monson. 2010. “Trauma, PTSD, and Partner Violence in Military Families.” In S.M. Wadsworth and D. Riggs (eds.). Risk and Resilience in US Military Families. New York, N.Y.: Springer Science + Business Media, 195– 212.

Following are CrimeSolutions-rated programs that are related to this practice:

Interventions for Persons Who Committed Intimate-Partner Violence: Cognitive Behavioral Therapy

The practice includes interventions that are designed to reduce partner violence by identifying and changing the thought processes leading to violent acts and teaching new skills to control and change their behavior. These interventions use cognitive behavioral therapy as applied in a domestic violence setting. The practice is rated Ineffective in recidivism outcomes for violent offenses and ineffective in reducing victimization.

Evidence Ratings for Outcomes

	Crime & Delinquency - Violent offenses
	Victimization - Domestic/intimate partner/family violence

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?