Strength at Home Couples Program to Prevent Military Partner Violence
Phase: NA
Conditions: Intimate Partner Violence
Sponsor: Boston VA Research Institute, Inc.

1 
 
Joint Base Lewis-McChord Protocol Narrative   
 
 
 
v. 8 02/15/19 
Implementation of Strength at Home for Military Couples 
(1) Rationale 
(a) Statement of the Problem.  
Approximately 4.7 million women are physically assaulted by an intimate partner in the United States 
annually.1 The most likely assailant of a victim of violence is his or her relationship partner,2 and IPA 
victimization is associated with poorer physical and psychological health.3-8 Physical health problems range 
from injuries or conditions directly caused by physical assault, to other chronic nervous system, 
musculoskeletal, cardiovascular, gastrointestinal, and urogenital symptoms and conditions.9,10 Psychological 
and emotional problems often include posttraumatic stress disorder (PTSD), depression, anxiety, insomnia, 
substance abuse, and social difficulties.7,9,11 The children who witness IPA also suffer from a variety of 
emotional and social problems.12,13 As a result of IPA, society incurs substantial costs related to health care, 
criminal justice interventions, education, child and social services, housing, and lost worker productivity.14 
IPA prevalence rates in military samples vary widely, with rates ranging from 13.5% to 58%.15 IPA results 
in far reaching consequences not only for family members, but also for the service members themselves. IPA 
alienates service members and negatively impacts social support networks. This is particularly important in the 
context of traumatic exposure, as social support is a critical factor with regard to mitigating the negative impacts 
of trauma on health.16,17 Poor family functioning of military populations has been strongly associated with 
mental and physical health problems, increased use of medical and psychiatric services, and lost workdays.18-22 
Among active military, family problems are more powerful predictors of military morale, motivation, readiness, 
and retention than resource variables, unit-related factors, and work conditions.20,23-25 Service members 
experiencing intimate relationship problems are also more likely to exhibit concentration problems and deficits 
in cognitive acuity that may compromise mission safety and job performance.26 
(b) Hypotheses or Key Question.  
A Hybrid Type-I Implementation-effectiveness research design will allow the research team, comprising 
investigators with expertise in intervention development, efficacy and effectiveness research, and 
implementation science, to simultaneously investigate the effectiveness of SAH-C in a military population while 
identifying any barriers to implementation that would need to be addressed before SAH-C could be successfully 
implemented on a larger scale. The study site for this proposed effort is Joint Base Lewis McChord, 
Washington. 
The primary hypotheses are that those receiving SAH-C will evidence greater reductions in physical and 
psychological IPV, and greater increases in relationship satisfaction, relative to those receiving Supportive 
Prevention across the follow up time points. 
(c) Specific Objectives.  
AIM 1: To test the effectiveness of SAH-C for military couples on an installation, we will conduct a 
randomized trial comparing 10 sessions of SAH-C to 10 sessions of Supportive Prevention (SP) under 
representative conditions, with 140 couples who are at risk for the development of IPA (risk is established if at 
least one member of the couple reports at or below a score of 100 on the Dyadic Adjustment Scale (DAS), a 
cutoff score used to distinguish relationship distress, or they report the presence of psychological aggression in 
the past three months). This aim will be fulfilled by accomplishing the following subaims: 

2 
 
 
Subaim 1.1: To compare the frequency of physical IPA perpetration of both members of the couple across 
conditions as reported by service members and their collateral relationship partners at post-intervention and two 
3-month follow ups.  
Subaim 1.2:  To compare the frequency of psychological IPA perpetration of both members of the couple across 
conditions as reported by service members and their collateral relationship partners at post-intervention and two 
3-month follow ups.  
Subaim 1.3: To compare relationship satisfaction across conditions as reported by service members and their 
collateral relationship partners at post-intervention and two 3-month follow ups. 
AIM 2: To explore differences in compliance factors across conditions, we will compare session attendance. 
AIM 3: To facilitate future implementation of SAH-C, we will employ a mixed-methods approach, guided by 
complementary implementation frameworks, to examine potential barriers, facilitators, and potential for 
intervention refinement. This aim will be fulfilled by accomplishing the following subaims: 
Subaim 3.1: To identify system, facilitator, and dyadic-level barriers and facilitators to implementation. 
Subaim 3.2: To assess the acceptability of SAH-C among stakeholders in a military setting. 
(2) Background and Significance 
(a) Background.  
 
Only one experimentally controlled evaluation of IPA intervention effectiveness has been conducted in a 
military setting. Among a large sample of married Navy couples in which the husband used IPA, Dunford27 
found that none of the randomly assigned year-long intervention modalities were effective in reducing IPA at 
six and 12 months post-intervention. Dunford’s27 findings highlighted a need for program modification efforts 
to meet the needs of military families and also mirrored findings of a lack of program efficacy in civilian 
settings.28 These data highlight a need for prevention programs focusing on improving intimate relationships 
and reducing the risk of onset of IPA,29 particularly given that relationship conflict typically serves as a 
precursor to IPA,30 and more subtle forms of IPA early in relationships are predictive of later violence.31  
The SAH-C intervention is based on a social information processing model of IPA holding that trauma may 
negatively impact on one’s ability to interpret and respond to social situations effectively, and highlights the 
importance of cognitive behavioral strategies to monitor one’s thoughts and responses to difficult interpersonal 
situations. 32 The model derives from prior theory33,34 and research indicating that those who use IPA are more 
likely to exhibit irrational beliefs, problematic thinking, and hostile interpretations of others’ intentions.35-38 
Through the improvement of social information processing, conflict and IPA risk should decrease. Core themes 
that underlie social information processing and relationship problems, including those related to power and 
control conflicts, low self-esteem, and trust difficulties are also addressed throughout the program.  
 
(b) Significance.  
There is currently no empirically supported IPA prevention intervention used on military installations. The 
proposed research to utilize the SAH-C intervention, that has been shown to be efficacious in VA and 
community settings, is innovative in its application to target this problem in this unique context. Moreover, 
SAH-C in itself is novel in its integration of interventions focused on trauma, IPA, and couples-based 

3 
 
intervention approaches, as well as its focus on prevention of IPA rather than attempting to manage the 
repercussions of IPA once it is already ongoing. Clearly, since IPA is difficult to stop and manage once the 
cycle of violence begins, a focus on prevention is timely and much needed.  
Our proposed design is innovative as well. There is a well-documented gap between the identification of 
effective interventions and their implementation into service systems.48,49 This delay between research 
discovery and uptake is partially slowed by delimited research methodology, in which efficacy is first 
established, followed by effectiveness research, with little systematic effort to study or understand the potential 
for implementation of effective interventions. An innovative and efficient solution is to collect implementation 
information in the context of effectiveness research.48,49 Factors such as motivated participants, adequately 
trained provider, and a receptive context for implementation are crucial for effective implementation, and it is 
imperative to study whether and how these components interact systemically to facilitate translation from 
science to practice.50  
One strategy to bridge the implementation gap is to capitalize on both researchers’ and stakeholders’ 
knowledge to ensure fit between the intervention training, provider needs, and organizational context. Recently 
described by Curran and colleagues,48 a hybrid Type I implementation-effectiveness research design allows for 
the conduct of a rigorous effectiveness trial while simultaneously investigating potential barriers and facilitators 
to implementation. This information can guide future refinements to the intervention to improve the fit between 
the intervention and the service setting and inform the selection or development of an appropriate 
implementation strategy. Hybrid research methodologies, by increasing the efficiency of the research necessary 
to facilitate implementation, can reduce the time between the identification of effective interventions and their 
introduction into service systems and settings. The proposed design will position the research team and its 
operational partners to rapidly act on findings to enhance the effectiveness or fit of SAH-C in military settings if 
needed, and to roll the intervention out more broadly if our findings warrant doing so. 
(c) Outline of SAH-C 
 
SAH-C derives from a unique fusion of interventions for trauma and IPA, integrating elements of cognitive 
processing therapy for PTSD,39 couples therapy for PTSD,40 and a cognitive behavioral intervention for IPA.41 
SAH-C consists of 10 two-hour weekly sessions, led by a provider. This was the minimum length deemed 
necessary to incorporate components addressing the proposed IPA mechanisms and is consistent with the 
briefest IPA interventions.42 During each session, couples are provided assignments to practice skills together 
and to assist with the consolidation of material. A group couples format is used because group cohesion among 
clients appears to be associated with IPA prevention.43 Group interventions also use less time and resources 
than individual-based interventions. In this psychoeducation intervention, the couples participating in the 
program are the learners. What follows is a brief outline of each of the 10 SAH-C sessions.  
 
Session 1: Introduction and Welcoming 
 
This session introduces couples to the structure, expectations, and philosophy of the group. The main tasks 
are to begin establishing an alliance with each couple, to validate and address concerns, and to encourage 
healthy group interactions. Group leaders teach participants the skill of paraphrasing, the foundation of active 
listening. Leaders will refer to this skill and encourage participants to use it throughout the program. 
 
Session 2: Trauma and Relationships I     
 
Group members explore their beliefs about healthy and unhealthy relationships and review assignments 
designed to enhance intimacy and solidify mutual intervention goals. The session then shifts to discussing 
psychoeducational material that focuses on understanding forms of IPA and the impact of trauma on couples’ 

4 
 
functioning. The main tasks of the session are to enhance motivation, educate group members about abuse and 
trauma, and help members gain insight into the effects of trauma on their own relationship.  
 
Session 3: Trauma and Relationships II 
 
This session begins with a discussion of the practice assignment focusing on understanding how trauma has 
affected the couples’ relationship. The discussion shifts to themes related to trauma that can affect relationships, 
including trust, power and control, self-esteem, and intimacy. Group material facilitates further contemplation 
of behavior change and intervention goals, building upon psychoeducational material from Session 2. 
 
Session 4: Conflict Management I: Assertiveness 
 
This session focuses on conflict management and expressing anger assertively, with some material focused 
on how conflict management styles were learned in the military and elsewhere. The goals of this session are to 
further facilitate an understanding of the impact of trauma on relationships, and to help couples identify positive 
(i.e., assertive) versus harmful (i.e., aggressive, passive) communication styles during conflict.  
 
Session 5: Conflict Management II: Time Outs 
 
Group members review the self-monitoring assignment designed to assess group members’ assertive, 
passive, and aggressive responses to conflict situations. Discussion then focuses on developing strategies to 
deescalate conflict situations. Couples are asked to generate and put into practice a detailed “Time Out Plan” to 
use during conflict situations. Development of these plans is an important crisis management tool to ensure 
safety for the couple, and provides a skill that helps to lay the groundwork for future work on communication.  
 
Session 6: Communication Skills I: Active Listening 
  
After discussing Time Outs and self-monitoring practice assignments, good and bad communication is 
discussed. Listening skills are emphasized since they are the foundation of good communication, de-escalating 
conflict, and enhancing intimacy. Listening is particularly important when trauma symptoms are present 
because information processing abilities are often compromised by emotional arousal.  
 
Session 7: Communication Skills II: Assertive Messages 
 
After reviewing group members’ communication self-monitoring forms, group discussion focuses on how to 
give an assertive message. Group members are introduced to a role play depicting assertive messages and active 
listening and practice these skills in session. The continued focus on enhanced communication skills is intended 
to reduce the negative impact that deployments and trauma may have on communication, and to further enhance 
intimacy, improve relationship problem solving, and facilitate the sharing of trauma-related material. 
 
Session 8: Communication Skills III: Expressing Feelings 
 
Group members review their communication self-monitoring forms and the assertive messages and active 
listening practice assignment and then discuss how trauma-related avoidance can lead to difficulties in 
expressing emotions. Strategies for expressing feelings are provided and couples practice these skills during the 
session. Emotional expression skills are important for enhancing intimacy and understanding among couples.  
 
Session 9: Communication Skills IV: Common Communication Traps 
 

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Group material focuses on five communication traps that undermine assertive communication. These traps 
are particularly important for those experiencing deployments and trauma. Strategies to avoid these common 
communication traps and to cope productively when they arise are introduced and discussed.  
 
Session 10: Reviewing Gains and Planning for Future 
 
Group members explore gains made in the group. They identify goals and strategies for future change along 
with barriers to change and strategies to overcome these barriers. Much of the session is spent discussing 
thoughts and feelings about the group ending, exploring plans for future change, and saying goodbye.  
(d) Relevance to Veterans Health.  
There is currently no empirically supported IPA prevention intervention used on military installations. The 
proposed research to utilize the SAH-C intervention, that has been shown to be efficacious in VA and 
community settings, is innovative in its application to target this problem in this unique context. Moreover, 
SAH-C in itself is novel in its integration of interventions focused on trauma, IPA, and couples-based 
intervention approaches, as well as its focus on prevention of IPA rather than attempting to manage the 
repercussions of IPA once it is already ongoing. Clearly, since IPA is difficult to stop and manage once the 
cycle of violence begins, a focus on prevention is timely and much needed.  
(3) Work Accomplished 
(a) Preliminary Studies 
 
SAH-C Pilot Study  
For Phase 1 of a CDC funded trial, we examined SAH-C relative to SP in 9 couples and assessed IPA using 
the Revised Conflict Tactics Scales (CTS2).44 Results, published in the journal Partner Abuse: New Directions 
in Research, Intervention, and Policy suggest the effectiveness of SAH-C in reducing IPA.32 All SAH-C male 
Veterans who engaged in physical IPA during the pre-intervention period evidenced complete IPA cessation at 
3-month follow-up according to self and partner reports, with large effect sizes. Female partners participating in 
SAH-C also evidenced reductions in mild physical IPA perpetration with a moderate effect size, while female 
partners participating in the SP groups evidenced large increases in their physical IPA. Of note, while we were 
not able to truly determine prevention of physical IPA in this small sample, none of the participants increased 
their IPA or went from nonviolent to violent after participating in SAH-C, while one of three SP female partner 
participants went from nonviolent to violent. Mild psychological IPA, perpetrated by both the Veteran and the 
female partner, decreased more in SAH-C than SP and these effect sizes were large. Reductions in severe 
psychological IPA perpetrated by the Veteran and partner were moderate and large, respectively.  
SAH-C Randomized Clinical Trial  
 
We have recently examined the data from 78 returning male Veterans and their partners via Phase 2 of the 
CDC trial, with impressive results obtained. The mean incidents of Veteran and partner perpetrated 
psychological IPA, based on CTS2 and Multidimensional Measure of Emotional Abuse45 reports, are presented 
in Table 1. Analyses of Covariance (ANCOVA) at 6 months post-intervention (controlling for baseline scores) 
revealed a significant effect of group whereby psychological IPA was significantly lower among SAH-C 
couples than SP couples, F(1,46) = 6.37, p = .015 (Figure 1). For partner perpetrated psychological IPA, an 
ANCOVA demonstrated a significant effect of group with SAH-C couples reporting a significant decrease in 
partner-perpetrated psychological IPA at 6 month follow-up compared to SP couples, F (1,46)= 7.64, p = .008 
(Figure 2). MMEA results for Veteran and partner-perpetrated psychological IPA can be found in Figures 3 and 
4, respectively. While based on the MMEA there was no difference in male Veteran-perpetrated psychological 

6 
 
IPA at 6-month follow-up for either the SAH-C or SP conditions, there was a trend-level reduction in partner-
perpetrated IPA at the 6-month follow-up for SAH-C couples, F(1,46)=3.822, p= .057. 
 
 
The mean incidents of Veteran and partner perpetrated physical IPA are reported in Table 1. There was no 
significant effect of group type on physical IPA perpetration by either the Veteran or partner (p-values >.05; see 
Figures 5 and 6, respectively). As physical IPA was an exclusion criterion for the Veterans this study, we did 
not expect a significant decrease in this measure as a function of group. For both the SAH-C and SP groups, 
physical IPA did not significantly increase at 6-month follow-up. However, there appears to be a trend toward 
an interaction whereby those in the SAH-C group reported a decrease in partner perpetrated physical IPA, while 
those in the SP group reported an increase. Furthermore we see a greater (albeit non-significant) increase in 
Veteran-perpetrated physical IPA (Figure 6).  
Table 1. 
Reported IPA perpetration over time 
 
SAH Condition 
ST Condition 
Results of ANCOVA 
Type of IPA 
T1 (n=41) 
M(SD) 
T3 (n=31) 
M(SD) 
T1 (n=37)  
M(SD) 
T3 (n=18) 
M(SD) 
Veteran- 
Perpetrated 
      Psychological   
     (CTS) 
30.76 (25.9) 
15.26 (17.0) 
37.94 (26.7) 
35.78 (25.9) 
F(1,46)=6.37, p=.015 
     Psychological    
     (MMEA) 
66.98 (57.0) 
41.48 (52.9) 
95.46 (73.9) 
76.28 (77.1) 
F(1,46)=1.46, p= .233 
     Physical 
.44 (2.5) 
.74 (2.1) 
.14 (.48) 
.94 (2.1) 
F(1,46)=.378, p=.541 
 
Partner- 
Perpetrated 
     Psychological  
     (CTS) 
 
30.29 (24.3) 
 
11.94 (13.5) 
 
32.84 (21.5) 
 
32.40 (25.8) 
F(1,46)=7.64, p=.008 
     Psychological   
     (MMEA) 
52.76 (38.9) 
31.13 (34.1) 
61.96 (67.3) 
59.61 (67.8) 
F(1,46)=3.82, p= .057 
     Physical 
 
1.24 (3.4) 
 
.51 (1.7) 
 
.73 (1.7) 
 
1.00 (2.1) 
F(1,46)=.971, p=.330 
 

7 
 
 
SAH-C Community Implementation Study 
We examined the impact of the SAH-C intervention delivered in a community setting serving Veterans 
through a grant funded by the Blue Shield Foundation of California, with the results recently published in the 
Journal of Clinical Psychiatry.46 In a sample of 85 dyads, we first examined the impact of the intervention on 
psychological and physical aggression perpetrated by both Veterans and their loved ones. Descriptive statistics 
and effect sizes representing intraindividual changes for these outcomes are presented in Table 2. Results 
indicated significant decreases in psychological aggression from pre-intervention to program completion for 
0
5
10
15
20
25
30
35
Time 1
Time 3
Mean Frequency of Abuse
Time Point
SAH
Condition
Supportive
Condition
0
5
10
15
20
25
30
35
40
Time 1
Time 3
Mean  Frequency of Abuse
Time Point
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Time 1
Time 3
Mean Frequency of Abuse
Time Point
SAH
Condition
Supportive
Condition
0
20
40
60
80
100
120
Time 1
Time 3
Mean Frequency of Abuse
Time Point
0
0.2
0.4
0.6
0.8
1
Time 1
Time 3
Mean Frequency of Abuse
Time Point
0
10
20
30
40
50
60
70
Time 1
Time 3
Mean Frequency of Abuse
Time Point
SAH
Condition
Supportive
Condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1. Veteran Psychological IPA Perpetration 
(CTS) 
Figure 2. Partner Psychological IPA Perpetration 
(CTS) 
Figure 5. Veteran Physical IPA Perpetration 
Figure 6. Partner Physical IPA Perpetration 
Figure 3. Veteran Psychological IPA Perpetration 
(MMEA) 
Figure 4. Partner Psychological IPA Perpetration 
(MMEA) 

8 
 
both Veterans and their loved ones, and these effects were maintained when examining changes from pre-
intervention to follow-up. Again, as expected, there were no significant increases in levels of physical 
aggression perpetrated by Veterans or loved ones. 
Table 2. Means, Standard Deviations, and Intraindividual Effect Sizes (ESsg with 95% CI) for Aggression 
Perpetration and Secondary Outcomes 
 
T1 
T2 
T3 
T1- T2 
T1- T3 
T2- T3 
Outcome 
M 
SD 
M 
SD 
M 
SD 
ESsg 
95% CI 
ESsg 
95% CI 
ESsg 
95% CI 
Veteran Psychological  
Aggression 
4.01 
2.09 
3.21 
2.25 
2.95 
2.65 
-0.36 
-.64 : -.08 
-0.45 
-.75 : -.15 
-0.11 
-.41 : .19 
Veteran Physical 
Aggression 
.94 
1.66 
.87 
1.89 
.71 
3.16 
-0.05 
-.23 : .13 
-0.09 
-.40 : .22 
0.00 
-.32 : .32 
Partner Psychological 
Aggression 
3.54 
2.13 
2.92 
2.06 
2.84 
2.49 
-0.30 
-.56 : -.03 
-0.30 
-.59 : -.02 
-0.04 
-.35 : .27 
Partner Physical 
Aggression 
.79 
1.95 
.88 
2.06 
.87 
3.47 
0.05 
-.14 : .23 
0.03 
-.37 : .43 
-0.04 
-.40 : .31 
Veteran DAS 
99.88 
28.76 
94.17 
20.62 
90.19 
44.64 
-0.22 
-.48 : .04 
-0.26 
-.63 : .11 
-0.14 
-.50 : .22 
Veteran QRI 
66.27 
34.56 
61.82 
17.86 
64.54 
24.21 
-0.02 
-.26 : .21 
0.11 
-.10 : .32 
-0.11 
-.30 : .09 
Veteran PHQ 
12.06 
7.62 
9.62 
8.13 
18.12 
6.84 
-0.30 
-.51 : -.10 
0.85 
.60 : 1.11 
1.18 
.89 : 1.47 
Veteran PCL 
52.76 
18.48 
50.59 
21.94 
42.22 
22.27 
-0.12 
-.31 : .07 
-0.52 
-.74 : -.30 
-0.40 
-.59 : -.21 
Partner DAS 
91.51 
17.29 
96.64 
17.84 
89.69 
32.50 
0.33 
.09 : .57 
-0.07 
-.48 : .33 
-0.32 
-.72 : .07 
Partner QRI 
63.42 
17.93 
64.40 
15.08 
62.96 
17.24 
0.13 
-.22 : .47 
-0.02 
-.36 : .31 
-0.11 
-.37 : .15 
Partner PHQ 
9.30 
7.22 
5.79 
5.35 
13.96 
5.60 
-0.55 
-.77 : -.33 
0.72 
.45 : .99 
1.51 
1.17 : 1.85 
Partner PCL 
43.33 
17.00 
32.33 
15.75 
32.52 
16.78 
-0.54 
-.76 : -.31 
-0.52 
-.72 : -.32 
-0.02 
-.23 : .19 
 
 
We also examined Veterans’ and their loved ones’ perceived relationship quality and mental health 
(depressive and PTSD symptoms) as secondary outcomes of the SAH-C intervention. Descriptive statistics and 
effect sizes representing intraindividual changes for these outcomes are also presented in Table 2. Loved ones 
reported a significant improvement from pre-intervention to program completion in relationship adjustment, as 
measured by the Dyadic Adjustment Scale.47 Veterans and their loved ones also reported significant decreases 
in depressive and PTSD symptoms from pre-intervention to program completion, and the PTSD symptom 
improvements were maintained at follow-up.  
(b) Personnel 
The Principal Investigator (PI) for the proposed work is Dr. Casey Taft. Dr. Taft is a staff psychologist at 
the National Center for Posttraumatic Stress Disorder (PTSD) in the VA Boston Healthcare System, and 
Professor of Psychiatry at Boston University School of Medicine. Dr. Taft has served as PI on funded grants 
focused on understanding and preventing intimate partner aggression (IPA) through the Department of Defense, 
National Institutes of Mental Health, Department of Veterans Affairs, and the Centers for Disease Control. He 
is the primary developer and director of the SAH programs, the focus of the current proposal. Through his 
experience coordinating and directing randomized clinical trials for IPA in military populations, Dr. Taft is 
uniquely qualified to understand and address the needs of violent Veterans and lead this work.  
Dr. Shannon Wiltsey-Stirman will serve as a Co-Investigator on the proposed project. Dr. Wiltsey-Stirman 
is a clinical psychologist and researcher in the Women’s Health Sciences Division of the National Center for 
PTSD. She has background and training in conducting qualitative studies, implementation research, and 
treatment effectiveness research. She has experience in the implementation of evidence-based interventions for 
trauma and related problems and has familiarity with the implementation frameworks used to guide data 
collection. Dr. Wiltsey-Stirman will oversee implementation-related data collection, analysis, and interpretation. 
Dr. Suzannah Creech will serve as a consultant on the proposed project. Dr. Creech is a research 
psychologist and a licensed clinical psychologist at the Providence VAMC, and an Assistant Professor 
(research) at Brown University. She is also an affiliate of the VA National Center for PTSD. Dr. Creech 
conducts research in the area of improving family functioning in vulnerable Veteran populations (e.g. women 

9 
 
Veterans, homeless Veterans, returning Veteran parents). Dr. Creech has expertise developed through 3 years of 
experience as the project coordinator and then as the site PI for two Strength at Home clinical trials. Dr. Creech 
will contribute to all aspects of the proposed project. 
Ms. Brittany Groh will serve as a research coordinator on the proposed project. Ms. Groh is a recent 
graduate from Western Kentucky University M.S. Psychological Sciences program. She will oversee 
administration of the project on-site at Joint Base Lewis-McChord. This includes coordination with the project 
sites doing the implementation, recruitment of participants, administration of eligibility assessments and follow-
ups, facilitating groups, preparation of IRB submissions, and management of data received.  
Ms. Alecia Grady will serve as a consultant on the proposed project. Ms. Grady is the Director of Personnel 
and Family Readiness. She will assist in getting the letter of support from the Garrison Commander, 
recruitment, securing office space for the research coordinator and a conference room for the group. 
Ms. Karen Fox will serve as a consultant on the proposed project. Ms. Fox is the Intervention Branch 
Manager for the Family Advocacy Program, Prevention. She will assist in recruitment, securing office space for 
the research coordinator, and securing a conference room for the group. 
Ms. Kate Comtois will serve on the stakeholder advisory board. She is an implementation specialist with the 
University of Washington Medicine. 
Ms. Wendy Long will serve on the stakeholder advisory board. She is a licensed independent clinical social 
worker (LICSW) with the Department of Behavioral Health at Madigan Army Medical Center. 
Ms. Lynn Robinson will serve on the stakeholder advisory board. She is the family engagement program 
manager for children’s administration in Vancouver, WA. 
(4) Work Proposed  
(a) Timeline of Proposed Research 
Figure 7 presents the framework for the study, blending three distinct yet complementary implementation 
frameworks to guide an implementation process, understand potential influences on implementation, and guide 
assessment of key implementation outcomes: 1) Replicating Effective Programs (REP) framework;51-54 2) 
Consolidated Framework for Implementation Research (CFIR);55 and 3) the Proctor et al. taxonomy for 
implementation outcome variables.56 
As illustrated in Figure 7, the implementation process of the current study will use the REP framework.51,52 
Based on social learning theory57 and Diffusion of Innovations,58 REP focuses on identifying and addressing 
barriers to implementation among stakeholders, facilitators, and group participants in order to prepare 
interventions for implementation. REP attends to factors including packaging, training, and ongoing technical 
assistance. The stages of REP are conceptually separate, though sometimes chronologically overlapping,52,59 
allowing for formative, iterative research. This study will include activities recommended for the Pre-
Conditions and Pre-Implementation phases. The potential influences on implementation that will be examined 
in each of the REP stages are theoretically driven by the CFIR55,60 and are described in Figure 7. The CFIR55 is 
a “meta-theoretical” implementation framework generated specifically for research in health care that draws 
upon 19 different implementation models to create a typology of constructs to guide different phases of 
implementation studies. As such, specific CFIR variables will be studied at each of the REP stages, and findings 
will be used to guide future implementation efforts. Finally, the implementation outcome variables are based on 
Proctor et al.’s identification of implementation outcomes.56 We have narrowed our choice of implementation 

10 
 
outcomes based on the scope of the current study and ensured that they would best match study aims. However, 
future studies would examine additional implementation outcomes such as cost, efficiency, and penetration.  
 
 
 
 
 
 
 
 
 
 
 
Figure 7. Proposed Implementation Framework for Current Study 
 
 
This project will be carried out in two phases (Figure 8). Phase 1 (Pre-Conditions) will be conducted during 
the first ten months. Throughout this phase, the intervention manual, already developed via our prior studies 
with Veterans, will be reviewed and refined for use on a military base. During the first 6 months of Phase 1, the 
advisory board will be assembled, staff will be hired and trained, and pilot study intervention cases will be 
recruited to examine and refine the fit between SAH-C and the local setting.  The pilot interventions will include 
two groups of 5 couples (one from each condition), and will be conducted from month 6 through month 10. 
Baseline assessments will be conducted prior to the beginning and end of the groups to assess the effectiveness 
of SAH-C and SP strategies. These data and information provided by study facilitator and other stakeholders 
will be used to inform refinements to the manuals throughout this time period, as well as the refinement of SAH-
C integrity measures (months 6 through 10). This work will be accomplished with input from our stakeholder 
advisory board. IRB approval for Phase 2 of the study, including the refinements to the manuals, will be sought 
from months 6 to 10.  
During the second phase, a randomized controlled trial will be conducted among 140 couples to compare 
the SAH-C intervention to a SP condition, and the intervention manual and adherence measures refined in Phase 
1 will be field tested. Participants will be recruited and baseline assessments with the service member 
participants and their partners will be conducted during months 10 through 30. The interventions will be 
delivered from months 10 through 34, and follow-up assessments will be conducted with the service members 
and their partners from months 26 through 44. Data analysis and the preparation of conference presentations 

11 
 
and manuscripts for publication will begin in month 42 and continue through the end of the project. 
Additionally, these findings will be presented to our stakeholder advisory board, which will make 
recommendations for further refinement to SAH-C and assist with the selection of appropriate training and 
strategies for future implementation. 
Study activities involving human subjects will occur at Joint Base Lewis McChord, Washington. The PI will 
facilitate coordination across the two project locations (Boston and Washington). Local project staff will 
administer in session measures and primary study assessments will be conducted via REDCap, which is a 
secure online data collection system.   
Figure 8.  
Task 
 
 
 
 
 
 
 
 
 
 
 
 
 
PHASE I 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review and refine manual 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assemble advisory board 
 
 
 
 
 
 
 
 
 
 
 
 
 
Staff hiring and training 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recruit pilot intervention cases 
 
 
 
 
 
 
 
 
 
 
 
 
 
Conduct pilot intervention 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline and follow-up assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refine intervention integrity 
measures 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain IRB approval for Phase 1I 
 
 
 
 
 
 
 
 
 
 
 
 
 
PHASE II 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recruit participants 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
Deliver interventions 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
Analyze and write up results 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0 
4 
8 
12 
16 
20 
24 
28 
32 
36 
40 
44 
48 
                                                       Month of Study 
 
(b) Independent variables and Dependent (outcome) variables 
Questionnaires 
An electronic data collection tool, REDCap, will be utilized to collect self-report data. REDCap is a secure 
and widely used web application for collecting, managing online data. REDCap is designed to support data 
capture for research studies. This system provides and intuitive interface for users to enter data, and all 
information transmission is encrypted, and the data are stored on a protected network. All access to data is 
restricted on a role-specific basis. The REDCap system was specifically developed around HIPAA Security 
guidelines, and meets DoD information security standards. The REDCap system provides a number of 
advantages over traditional data collection methods. Participants are offered a higher level of privacy and 
convenience, which minimizes the likelihood that they will be observed or overheard and allows for 
confidential IPA assessments to be conducted in the military context. Participants are asked to enter responses 
using an electronic tablet and no verbalizations are required. The elimination of written data insures that 
information cannot be discovered or surreptitiously read by others.  
Using the REDCap system, questions are presented in a standardized form that does not vary from 
participant to participant, thereby reducing one source of experimental error common in the structured interview 
format. Further, the hardware records data directly into a data base, eliminating data entry labor and errors.  

12 
 
Post SAH-C 
Assessment 
3-Month Follow-
up
Informed Consent Procedures Completed  
Baseline Eligibility Assessment  
(N = 170)* 
Randomization 
(N = 140)*
ST 
n = 70 
SAH-C 
n = 70
Post ST 
Assessment 
3-Month Follow-up 
Assessments
The REDCap survey will consist of a demographic 
questionnaire, a Partner Contact form, the PTSD Checklist 
(PCL)81, the Alcohol Use Disorders Identification Test 
(AUDIT)82, the Childhood Trauma Questionnaire (CTQ)83, a 
suicidality measure, the Revised Conflict Tactics Scale-2 
(CTS-2),44 the Multidimensional Measure of Emotional 
Abuse (MMEA)80, the Dyadic Adjustment Scale (DAS)69, an 
ongoing intervention questionnaire, and a Post-intervention 
Satisfaction assessment. 
During baseline assessment, the demographics 
questionnaire, partner contact form, CTS-2 (time one), DAS, 
MMEA, PCL, AUDIT, ongoing intervention assessment, the 
suicidality measure, and CTQ will be given to the 
participants. At the post-intervention assessment, the partner 
contact form, CTS-2 post-intervention, DAS, MMEA, PCL, 
AUDIT, ongoing intervention assessment, the suicidality 
measure, and post-intervention satisfaction measures will be 
given. At the 3-month follow up, partner contact, the CTS-2 
post-intervention, DAS, MMEA, AUDIT, ongoing 
intervention assessment, the suicidality measure, and PCL 
will be assessed. 
The PCL is widely used as an assessment for screening 
individuals for PTSD and monitoring change across time. 
This questionnaire includes a list of potential responses an 
individual may have following an extremely stressful 
experience81. 
The AUDIT is a widely used screening tool to assess 
alcohol consumption and alcohol-related behaviors 
developed by the World Health Organization (WHO)82. 
The CTQ is a self-report measure reflecting on childhood abuse and neglect. The five subscales include 
emotional, physical, and sexual abuse as well as emotional and physical neglect (Emotional, Physical, and 
Sexual) and two assessing neglect (Emotional and Physical)83. 
The ongoing intervention questionnaire has been adapted from the United States Army Medical Command 
(MEDCOM) behavioral health intake form. The two questions asked request participants to explain the types of 
services they currently receive (i.e., alcohol and drug, community behavioral health, chaplains, etc.) and the 
type of therapy they are attending (i.e., individual, couples, family, or group). 
The suicidality measure is comprised of items from other scales. Items 1-4 are from the Depression 
Symptom Index-Suicidality Subscale by Metalsky & Joiner84, 1997; 5-6 created by Joiner and Gutierrez, 7-8 
from the Beck Scale for Suicide Ideation by Beck & Steer, 199185, 9-11 from the Beck Hopelessness Scale by 
Beck, Weissman, Lester, & Trexler, 197286, and 12-16 from the Interpersonal Needs Questionnaire by Van 
Orden et al., 201287. This assessment examines thoughts about killing oneself, the number of suicide attempts 
since the last suicide risk assessment, wish to live/die, and feelings of belongingness within relationships. This 
suicide assessment was recommended by Centers for Disease Control suicide researchers, is currently being 
used within DoD, and derives from 5 different validated assessments.  
Figure 9.  
*The N here is for the entire sample; we expect that 
20% will not be eligible for payment due to active 
military status. 

13 
 
The CTS-2 is the most widely used measure of IPA, with excellent internal consistency reliability, content 
validity, and construct validity.44,66 The measure assesses physical, psychological, and sexual aggression in 
intimate relationships. Respondents report on the frequency of each item for themselves and their partners. 
Combined partner reports are used to reduce IPA underreporting.  
Because the CTS-2 assesses a fairly limited number of psychologically abusive behaviors, the 
Multidimensional Measure of Emotional Abuse (MMEA) will also be administered to assess psychological 
IPA.96  
The DAS is appropriate for use with both married and cohabitating couples. In addition to a global 
satisfaction score, this 32-item measure consists of four subscales: Dyadic Consensus, Affectional Expression, 
Dyadic Satisfaction, and Dyadic Cohesion. Several studies provide evidence for this measure’s strong 
psychometric properties.67-69  
 
The post-intervention satisfaction questionnaire asks questions to determine barriers and facilitators of the 
program. This information will be used to make adjustments to the program if necessary. 
 
The partner contact form consists of a single item assessing the frequency of contact with the participant’s 
partner. 
 
In addition to the self-report questionnaires, a collateral contact form will be completed by each individual 
to ensure research staff will be able to contact the individual if they move away prior to the final time point. The 
form includes contact information for themselves as well as up to three others that research staff can contact if 
there is difficulty getting in contact with the participants. 
 
Intervention and Integrity Measure Refinement 
 
To facilitate the rapid integration of the information into the refinement of the intervention and materials, 
meeting summaries will be content analyzed using a rapid coding technique based on methods of Sobo et al.70,71  
Based on Stakeholder Advisory Board recommendations and an examination of the pilot data, refinements 
will be made to the SAH-C manual. As a final working version becomes available, intervention integrity 
measures will be refined based on changes to the manual and psychoeducational intervention integrity ratings 
(5) Phase 2: Randomized Trial/Pre-Implementation Phase 
(a) Study Design 
The refined intervention manual and integrity measures from Phase 1 will be tested in Phase 2 in a 
randomized trial. Figure 9 illustrates the study design, procedures, and schedule of assessments planned for 
Phase 2. This choice in study design is analogous to that used in our prior CDC trial within a VA setting and is 
consistent with recommendations about the appropriate progression of control conditions when determining the 
efficacy of any intervention.73 
Participants for Phase 2 will be 140 service members and their partners. The same recruitment procedures 
employed for Phase 1 will be used for Phase 2. Informed consent procedures will be almost identical to those 
described for Phase 1 in Section D.2.3., with the exceptions that they will be notified that they will participate in 
one of two possible interventions.  
As in Phase 1, all assessments will remain confidential and will be stored separately from one another. Each 
assessment will also entail the provision of information regarding safety planning and IPA resources.  

14 
 
(b) Assignment to Groups 
Random assignment will be completed after study enrollment using computer-generated random numbers. 
Assignment to conditions will be conducted using urn randomization methods to balance conditions on case 
severity. Urn randomization alters the probability of assignment to study conditions based on imbalances that 
resulted from prior random assignments.74 This methodology allows for random assignment of each case, and 
maintains the possibility that each individual will be assigned to either condition, while at the same time 
reducing the chance of imbalances in prognostic factors that can threaten the validity of small-sample clinical 
trials. 
(c) Interventions 
In total, 28 intervention groups will be conducted (14 for each condition), with five couples per group. 
Please see Section 2.c. for an initial outline of the SAH-C intervention. The SP intervention, used in our prior 
trial, is based on the work of Jennings76 and on Yalom’s77 primary therapeutic factors for group intervention. 
This intervention involves minimal facilitator-directed intervention beyond encouragement of a mutually 
supportive environment and focus on relationship issues. In ST, the provider will allow group members to set 
the session agenda and address themes and topics that spontaneously emerge in the group interaction. The 
provider will emphasize a collaborative group norm and refrain from using active skills-training interventions. 
The provider will be 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 interventions used in SAH-C.  
(d) Intervention Integrity 
Intervention integrity for SAH-C will be monitored using the intervention integrity measures used during 
Phase 1, as outlined in Section D.2.5. The same procedure will be used to measure intervention integrity for the 
SP condition, utilizing the modified SP codes developed in our previous trial. A framework of adaptations and 
modifications to evidence-based interventions78 will be used to complement the integrity measure and identify 
any adaptations that the trained psychoeducational facilitator makes within session to address potential 
challenges or participant needs. Intervention integrity and adaptation data will be examined as implementation 
outcomes and will also be integrated with qualitative data to understand challenges to delivering the 
intervention with an adequate level of integrity and perceptions of the effectiveness of any adaptations that are 
made. 
(e) Additional Intervention and Early Termination 
Participants may receive additional types of intervention during this trial. Any additional intervention will 
be monitored for descriptive purposes. Study participants may be terminated from the group if they become 
actively suicidal or homicidal or fail to attend three consecutive scheduled meetings without a reason deemed 
appropriate by their providers. All participants who are terminated early will continue to be followed for all 
subsequent assessments.  
(f) Feasibility 
In order to enhance recruitment and achieve our target recruitment goals, we will seek approval from the 
Medical Treatment Facility Commander and the Garrison Commander. We will then attend all hands meetings 
in order to brief the troops on this research. All necessary permissions from Medical and Line Commanders will 
be obtained in order to accomplish this research. Preliminary conversations have already commenced with these 
officers, who have expressed their willingness to meet with us to find the best way to implement the study once 
the grant has been awarded. 

15 
 
There are currently 383 referrals annually to the Family Advocacy Program at Madigan Army Medical 
Center that do not meet the criteria for domestic abuse, but still require help in working through the various 
challenges associated with solving differences about money, children, sex, and friends. In addition, there are 4 
M&FTs who work full time providing services to couples who have not yet come to the attention of the Family 
Advocacy Program. These providers average around 210 couples per year each. Thus, there is a pool of more 
than 1,600 couples who could be referred for SAH-C during the recruitment period, which would help us easily 
meet our recruitment goal. 
(g) Attrition 
We expect relatively low attrition since we are only including participants if they indicate that they plan to 
remain on base for the next six months and given previous rates of attrition obtained by members of the study 
team. To limit attrition, the research coordinator will contact participants to schedule their in-person 
assessments. We have planned for a 12% attrition rate. Reasons for attrition will be assessed as potential 
barriers to implementation.  
Participants (service members and partners) will separately receive remuneration of a $50 Visa Gift Card or 
a $50 check sent to their address for completion of each assessment. Due to military compensation restrictions, 
and to ensure no conflict, if the service member is active duty, they may only be compensated if they fill out 
their surveys while on off-duty or on leave status. 
 

16 
 
(h) Intervention after Completion of Trial 
Following the completion of the final assessment, all participants assigned to the SP condition will be 
offered the opportunity to participate in a SAH-C group. This participation would be entirely voluntary and 
would involve no further assessment or remuneration. 
(6) Measures 
(a) Outcome Measures 
Outcome assessments are identical to those from Phase 1, though the assessment window for Phase 2 
assessments refers to the prior three months. Data collected will include demographics questionnaire, partner 
contact form, PCL, AUDIT, Post-Intervention satisfaction, suicidality measure, MMEA80,  CTS244, ongoing 
intervention questionnaire, and DAS69.  
(b) Intervention Compliance Measure 
Session Attendance will be measured as the total number of group sessions attended by each client. 
(7) Stakeholder Meetings 
Stakeholder meetings will be held to discuss study performance and needs of the study, such as discussions 
related to study recruitment, barriers to participation, and dissemination of research findings. 
 
(c) Intent-to-Treat (ITT) versus “Adequate Dose” Analyses 
 
An ITT philosophy will be strictly adopted. Experts in clinical trials have noted that no consensus exists 
about how missing data should be handled in ITT analyses, and different imputation approaches result in 
various potential biases. Thus, there is no single definition of ITT, and the phrase carries different meanings for 
different researchers.87,88 Therefore, every effort will be made to collect complete outcome data for all 
randomized participants, regardless of their intervention completion. As discussed in section D.3.7., 
measurement losses are expected to be relatively small due primarily to the use of tracking procedures, as well 
as the relatively short follow-up assessment periods.  
 
Analyses will first be conducted on the ITT sample, and then on the subset of participants who are 
considered to have received an “adequate dose” of the group intervention over the course of the study. We 
intend to focus on a comparison of those who had an adequate dose versus completed the intervention, because 
the group sessions will continue in spite of a couple’s non-attendance. This approach is consistent with prior 
group interventions.89 It is recognized that the ITT and adequate dose analyses address different questions, and 
only the ITT analyses permit strong inferences. However, there is important information to be gained in looking 
at the data both ways. 
 
(d) Primary Data Analyses  
 
Formal data analyses will be conducted only on those subjects recruited during Phase 2 of the project, as 
this is the only phase that includes random assignment. Differences between the SAH-C groups and SP groups 
on the frequency of physical and psychological IPA and relationship satisfaction (Aim 1) will be examined with 
random-effects regression models, using Hierarchical Linear Modeling (HLM5).90 Random-effects regression 
models provide more flexibility in modeling missing data than general linear models. They do not require data 
to be missing completely at random, but only missing at random (that is, the probability of missingness is 

17 
 
assumed to be a function of observed covariates and previously measured outcomes, but not unobserved 
outcomes). Based on such considerations, this type of an approach has been recommended for analyzing 
outcomes in prevention trials as it is generally more powerful than traditional repeated measures analyses of 
variance.91 In the current project it is of interest to model person-specific effects (i.e., time course for each 
participant), as well as the variation of responses between individuals. In addition, because of the suspected 
intraclass correlation between individuals nested within intervention groups, couples, and perhaps intervention 
site, these variables will be treated as fixed effects in the analyses. Time will be modeled as a random effect, 
and condition (SAH-C and ST) will be a fixed effect. Change in intervention outcomes over time and differences 
between the conditions over time (intervention by time interactions) will be examined. The primary effect size 
for the study will be derived from the random regression analyses, and specifically the intervention by time 
interaction, which will compare the two groups across intervention and follow ups. There are covariates that are 
a priori hypothesized to be associated with intervention outcomes, including socioeconomic status and 
education, and these will be included in follow-up analyses to significantly reduce error variance.  
 
 
(e) Exploratory Analyses  
 
Differences between the two group conditions in participant intervention compliance (Aim 2) will be 
explored by examining condition differences in session attendance using ANOVAs.  
 
 
(f) Qualitative Analytic Strategy and Data Integration  
Both intervention integrity and adaptation will be assessed. Descriptive statistics will be examined. Findings 
will be linked with interview data to facilitate understanding of reasons for, and perceived benefits of, any 
adaptations that are made to SAH-C within session, as well as to understand any barriers to, or facilitators of, 
intervention integrity. To examine Subaims 3.1 and 3.2, we are embedding qualitative methods within the study 
and connecting them to quantitative data (e.g., intervention credibility and satisfaction measures, study 
outcomes, reasons for attrition, homework compliance and therapeutic alliance) for the purpose of expansion 
and development. Established procedures to enhance validity will be used, including development of an audit 
trail documenting analytical decisions. All data will be checked for accuracy and entered into NVivo qualitative 
data management software. All coding decisions will be noted for further review. Rater agreement will be 
assessed through a second rater coding a subset of the data, and agreement will be reported. We will also use a 
check-coding model where the primary coder will code and recode the same material to ensure there is over a 
90% consistency.  
We will use a theory-driven approach to explore the relationship between the findings and the CFIR 
framework. The goals, objectives and key research questions will guide all aspects of the qualitative analyses. 
Using content analysis, we will identify analytical categories to describe and explain observations. Our work 
will occur in five stages, outlined in the Mays et al.92 approach to qualitative analysis: 1) Familiarization, 2) 
Identifying a Thematic Framework, 3) Indexing, 4) Charting, and 5) Mapping and Interpretation. In stage 2, 
codes will be derived deductively by identifying categories at the beginning of the research (e.g., elements of 
the CFIR framework) and inductively by identifying those that emerge gradually from the data. We will work 
from a list of research questions (e.g., What provider, participant, and setting-level factors might explain 
outcomes if outcomes are inconsistent with prior research? What are potential barriers and facilitators to future 
deployment? What adaptations might be needed to SAH-C for successful future deployment in routine care 
military settings?). We will develop a codebook with operational definitions of each code. Using constant 
comparison, we will update the coding model to reflect further refinement. In the charting and mapping phases, 
we will integrate the qualitative and quantitative data for expansion, development, and convergence, identify 
themes, and look for the commonalities and variations in themes and findings related to training, feasibility, 
acceptability, and intervention integrity-related issues. Data integration will assist a fine-grained understanding 
of processes and characteristics that may influence effectiveness and implementation outcomes. 

18 
 
Consistent with the REP process, findings will be presented to the Stakeholder Advisory Board at the end of 
the study, and will guide decisions regarding next steps for intervention refinement if needed, or for broader 
implementation. If, for example, findings indicate effectiveness of SAH-C, we will use findings regarding 
modifiable barriers and facilitator that can be leveraged to facilitate broader implementation and to guide the 
selection of appropriate implementation strategies and models for use in future research. In this case, a future 
study might be a Type-III Hybrid study, which would allow the testing of an implementation model for military 
settings. If, on the other hand, findings suggest that effectiveness is lower than in previous research, we will use 
qualitative findings to determine whether intervention-related contextual variables may have contributed to 
these findings, and determine appropriate next steps for research accordingly. 
(g) Power Analysis 
 
Power analyses were based on the main hypotheses that SAH-C would reduce the level of IPA to a greater 
degree than the SP condition by the 3-month follow-up assessments. Estimates affecting power (e.g., effect size, 
intra-class correlations, attrition) were derived from our prior CDC funded study.  
 
Our first consideration in estimating the necessary sample size for detecting differential change over time in 
SAH-C versus SP in terms of IPA incidence was the expected incidence rate of IPA during the follow-up period. 
Our sample is at high risk for such incidence as defined by the presence of high levels of marital distress. While 
there is no prospective military data available that directly speaks to such incidence rates, available estimates 
suggest a 33% one-year prevalence of IPA among trauma exposed service members.93 Conservatively, it would 
be expected that during the current project, approximately 16% of cases of IPA would emerge (half of the one 
year prevalence). However, inclusion of only couples with high levels of marital distress will increase this 
estimated incidence rate. Accordingly, we expect an increase of 10% in the incidence rate. Together, we based 
power analyses on an estimated 26% one-year incidence rate. Our second consideration involved expected 
sample attrition. Based on our prior trial and the specific plan for data capture outlined for the project, we 
estimate that about 15% of participants will provide no follow-up assessment data. However, power analyses 
were conducted based on the conservative estimate of 20% assessment dropout. Consistent with an ITT 
approach, regardless of intervention dropout, we will assess participants randomized into the trial. Thus, 
dropout from measurement versus intervention is of greatest concern. Our third consideration involved expected 
within-subjects correlations. The within-subjects correlation was estimated as the average correlation observed 
in our previous trial for pre-intervention, post-intervention, and follow-up data on reports of physical and 
psychological IPA on the Revised Conflict Tactics Scale (CTS-2).44 These correlations ranged from .53 to .90. 
We also considered the expected intra-class (group) correlation, which was approximately .05. Finally, 
consistent with recommendations,94 we considered the intra-class (dyadic) correlation among couples. We did 
not incorporate an estimate of such correlations into power analyses because of our proposed use of a composite 
measure of IPA, which results in a single index of IPA, thereby eliminating intra-dyad correlations. Together, 
we assumed an intra-class correlation of .38 for power analyses. Our fifth consideration involved the expected 
effect size of the SAH-C relative to ST. Our prior work suggested an ITT effect size of d = 1.01. A conservative 
estimate of a mean effect size of d = .5 for the SAH-C in terms of reduction of IPA incidence was utilized for 
the power analysis.  
 
Each of these considerations was used to calculate the needed sample size for testing the main hypotheses in 
the proposed project. Power analyses were conducted for the main hypothesis tests involving IPA perpetration 
and were conducted using the GEESIZE Macro in SAS Proc Mixed according to recommendations for 
estimating sample sizes needed in repeated measures experiments.95 Together, assuming (1) 26% incidence of 
IPA in the control condition, (2) 20% overall attrition, (3) .70 within-subjects correlation, (6) d = .5, (5) two-
tailed, and (6) p < .05, the proposed total N of 280 (140 couples) will provide ample power (> .9) to detect 
differences in IPA frequency across experimental conditions. 

19 
 
(8) Human Studies Section 
(a) Risk to Subjects 
Human Subjects Involvement and Characteristics 
The study population consists of service members attached to an installation who may be at risk for intimate 
partner aggression (IPA) and their intimate partners. The participants will be 150 service members (10 in Phase 
1; 140 in Phase 2) and their partners who will provide data on IPA. The research team has conducted several 
intervention studies with military samples. There are currently 383 referrals annually to the Family Advocacy 
Program at Madigan Army Medical Center that do not meet the criteria for domestic abuse, but still require help 
in working through the various challenges associated with solving differences about money, children, sex, and 
friends. In addition, there are 4 M&FTs who work full time providing services to couples who have not yet 
come to the attention of the Family Advocacy Program, Madigan Army Medical Center. These providers 
average around 210 couples per year each. Thus, there is a pool of more than 1,600 couples who could be 
referred for SAH-C during the recruitment period, which would help us easily meet our recruitment goal. 
Inclusion/Exclusion Criteria  
Inclusion criteria are as follows: (a) couples (heterosexual and same-sex dyads) must be in an intimate 
relationship; (b) participants and their partners must be over the age of 18, due to our emphasis on adult IPA, 
and so that all participants will be legally able to provide consent without parental involvement; (c) both 
members of the couple report no occurrence of physical IPA in the past 3 months; (d) at least one member of 
the couple reports at or below a score of 100 on the Dyadic Adjustment Scale (DAS), a cutoff score used to 
distinguish relationship distress, or they report the presence of psychological aggression in the past three 
months; and (e) both members of the couple provide research consent. Pregnant women are eligible to 
participate in this study. Research indicates that pregnant women may be at increased risk for intimate partner 
victimization. Thus, violence prevention interventions may be particularly applicable and important for this 
group. Potential participants will be excluded on the basis of reading difficulties that preclude valid completion 
of the assessment instruments. 
Gender Inclusion  
The couples-based interventions studied make it likely that equal numbers of men and women will 
participate. However, we will make no exclusions related to gender/gender identity, and same-sex couples are 
also eligible for participation.  
 
Minority Inclusion  
Across the study sites, 70% of potential participants are Caucasian, 20% are African American, and 10% are 
of another ethnicity.  
(b) Sources of Materials   
Data will be obtained from subjects from self-report measures completed through the online data collection 
tool, REDCap. Data will not be collected from routine medical care. All data gathered and analyzed will be 
obtained for this specific study. Study participation will not be documented in participants’ electronic medical 
records.  

20 
 
(c) Potential Risks  
Given that all participants will be in a program designed to improve relationships and prevent IPA, the 
added risks are those associated with the research assessments. All participants will be encouraged to discuss 
any painful issues that arise during the initial assessment. Those who do not receive intervention will be 
provided with referrals for counseling during the assessments as well as information on safety and resources for 
victims of abuse, such as 24-hour hotline numbers and shelter/legal services information. All participants who 
complete the Supportive Prevention group intervention will also have the option to participate in the Strength at 
Home-Couples’ intervention. 
AEs/SAEs will be reported according to VABHS IRB SOP by our on-site study coordinator. Reporting will 
be directed to Dr. Taft, who will ensure this is reported to the VABHS IRB. 
A second risk involves the possibility that material discussed during research assessments will become the 
topic of a violent conflict. To minimize this risk, all assessments will be conducted separately with partners. 
Additionally, the loss of confidentiality by another group member is a risk. To minimize this risk we discuss 
that group members will use only their first names and they agree to not discuss what is said in the group with 
others outside of the group.  
(9) Adequacy of Protection from Risks  
(a) Recruitment and Informed Consent 
Recruitment will occur through referrals made by providers at Madigan Army Medical Center who they feel 
may be eligible for and may benefit from participating in this research study. Referrals will come from the 
Family Advocacy Program (FAP), Embedded Behavioral Health, Chaplain services, Military and Family Life 
Counselor Program (MFLC), couples retreats, other program and prevention facilities, and through the posting 
of fliers and brochures in public areas and media advertising to promote the program and to be more inclusive. 
We will not disclose willingness to participate to anyone else in the service members’ unit or in the U.S. Armed 
forces other than research regulatory bodies. We will also omit the witness signature to protect confidentiality. 
Finally, only the investigators or the Boston without compensation (WOC) project coordinator may obtain 
consent from potential participants. Study staff will be available at all times to oversee this process and respond 
to questions. Two copies of each consent form will be completed. Study volunteers will be given a copy of the 
consent form for their records. The investigators will keep the other. The original paper copies of the ICFs will 
be stored on site in a locked filing cabinet in a secure data storage room during the project and will then be 
securely shipped to the Boston VA via a trackable shipping method (e.g., FedEx). To ensure confidentiality, 
ICFs will ultimately be stored in a locked filing cabinet in a secure data storage room at the Boston VA. 
 
Informed consent  
The consent process will be conducted by program staff at the study site. Informed consent will be 
conducted with each member of the dyad in separate rooms. No study procedures will occur prior to participants 
giving informed consent.  
For the consent procedure, each individual will meet one-on-one briefly with the study staff member to 
indicate his/her willingness to participate in the study. The study staff member will review the study procedures 
and have the individual sign the form if he/she would like to participate.  

21 
 
Screening procedures.  
All appropriate service members aged 18 or older, with partners over the age of 18, reporting no occurrence 
of physical IPA over the prior 3 months in their relationship will be invited with their partners to participate in a 
screening to determine appropriateness for group intervention and assess study eligibility. Members of the 
couple will arrive together but be screened separately to ensure confidentiality and safety. Both members of the 
couple will be administered the DAS to assess relationship distress, partner contact frequency, the MMEA for 
emotional abuse, the PCL to screen for PTSD, the AUDIT to screen for alcohol use, the CTQ for child abuse 
and neglect history, the CTS-2 to assess lifetime history of IPA in their current relationship, the suicidality 
measure, and the demographics questionnaire. If either participant fails to meet study eligibility requirements, 
the couple’s participation will end. If IPA is reported by either partner, the trained psychoeducational facilitator 
will separately inform them that they are not eligible for this study, and will assess the victim or victims’ 
perceptions of safety, discuss safety planning with the victim(s) (e.g., packing a small bag with a change of 
clothes and important papers in the event that s/he needs to escape), and will provide them with local contact 
information for Victim Advocacy services. Victims will be educated by the Victim Advocate about reporting 
options which include restricted reporting.  
  In the event a participant endorses suicidal ideation, the facilitator will conduct safety planning and offer a 
referral to FAP for additional assistance. If there is imminent threat, the facilitator will inform FAP to conduct a 
formal suicide assessment or accompany the participant to the emergency room. Additionally, if they have a 
counselor we will direct them to contact their counselor immediately. 
(b) Protection Against Risk  
Given that all participants will be in a program designed to improve relationships and prevent IPA, the 
added risks are those associated with the research assessments. All participants will be encouraged to discuss 
any painful issues that arise during the initial assessment. Those who do not receive intervention will be 
provided with referrals for counseling during the assessments as well as information on safety and resources for 
victims of abuse, such as 24-hour hotline numbers and shelter/legal services information. All participants who 
complete the Supportive Prevention group intervention will also have the option to participate in the Strength at 
Home-Couples’ intervention. 
A second risk involves the possibility that material discussed during assessments will become the topic of a 
violent conflict. To minimize this risk, all assessments will be conducted separately with partners.  
All identifying information (e.g., signed consent forms) will be stored separately from the research 
questionnaires. Separate locked, secure files will be used to store study materials for each participant, and 
couple’s files will be kept in separate storage areas to ensure confidentiality and safety. Identity masking subject 
numbers assigned to each participant will be the only means by which collected information is labeled. Each 
participant will have his or her own assigned number. Subject numbers will reflect the link between 
participating members of the couple. The only list that will link the names of the participants with their subject 
numbers will be kept in a secure, password-protected computer account accessible only to the on-site study 
staff. Study results will be presented and/or published in a fashion to ensure that participants cannot be 
identified. 
Data collected through the REDCap system will be encrypted and unidentifiable to REDCap staff. It will be 
accessed only by the study staff at Joint Base Lewis-McChord and Boston VA Healthcare System.  
 (10) Potential Benefit of the Proposed Research to the Subject and Others 

22 
 
The risks associated with the project are deemed to be justified on several grounds. First, there may be 
benefits associated with the research assessment, particularly for those reporting relationship problems and 
potential IPA, who will have an opportunity to discuss their situation with a trained psychoeducational 
facilitator. The facilitator will be prepared to complete a safety plan with the victim, provide support, and give 
information about local hotlines and shelter/legal services. Second, all participants will be scheduled to receive 
a program designed to prevent aggressive behavior. Finally, the findings are likely to benefit others through the 
possible enhancement of relationships and prevention of IPA in the future. 
(11) Importance of the Knowledge to be Gained 
There is no currently available evidence-based intervention for military couples to prevent negative 
trajectories that may include IPV from developing after deployment or upon exposure to trauma. The Strength 
at Home-Couples’ (SAH-C) program was designed to fill this gap in services and assist in preventing IPA in 
those couples who may be at risk for relationship problems. Through a recently completed randomized 
controlled trial funded by the Centers for Disease Control, we have shown SAH-C to be effective in preventing 
both physical and psychological IPV relative to those receiving a Supportive Prevention intervention among 
veterans and service members within the Department of Veterans Affairs. Before we disseminate SAH-C on a 
large scale on military installations, it would be important to examine its efficacy in this particular setting and to 
identify any potential barriers and facilitators for implementation. Potential short-term impacts from the current 
study would be to demonstrate best clinical practices in reducing IPV risk and preventing IPV in military dyads. 
Long term, study results could assist in changing the way we manage and prevent IPV, not only in military 
settings, but also beyond the military context since trauma is linked with violence in civilians in addition to 
military members.   
(12) Resources 
(a) Research Space 
The Principal Investigator is a staff psychologist in the National Center for PTSD at the Boston VA Medical 
Center. He has an office and research lab space at the Jamaica Plain Campus of the Boston VA. 
Study staff will be provided an office space and a conference room on Joint Base Lewis-McChord to recruit, 
assess participants, and hold groups. 
 (b) Other Research Resources 
Joint Base Lewis-McChord maintains its own computer support staff for hardware and software computer 
assistance.  
The software to be used in this study is already in place for all lab studies, and no additional licenses will be 
required. 
(13) Publications from previous funding period N/A 
(14) References cited 
See below.  
 
 
 

23 
 
 
 

24 
 
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