Evaluation of a Brief Marriage Intervention for Internal Behavioral Health Consultants in Military Primary Care

The most challenging community problems faced by senior military leaders are closely linked
to the quality of marriage relationships. These include family violence, spouse maltreatment,
and suicide. Half (51%) of the service members who either completed or attempted suicide from
2008 to 2010 had a history of a failed intimate relationship, and for nearly one-third (30%)
this failure had occurred within 30 days of the self-harm event. Relationship distress not
only affects marriages but is also associated with depression, substance abuse, work role
impairment and lowered children's health. Despite the potential high costs of chronic marital
distress, very few couples seek therapy. In a recent Air Force study, only 6% of Airmen in
distressed relationships reported making use of couple counseling after returning from
deployment. Indeed, distressed couples wait an average of 6 years before seeking help, at
which point their relationship likely has deteriorated dramatically.

Thus, there is a substantial need in the military for early detection and preventative care
for deteriorating couples before serious and irreversible relationship damage has occurred.
There are currently no widely available means to fill this need. Mild-to-moderately
distressed couples may view therapy as reserved for only the most severely distressed
couples, and thus delay seeking treatment until its efficacy is seriously diminished by the
chronicity and severity of the accumulated relationship dysfunction.

The Marriage Checkup (MC) addresses this issue by providing a less-threatening option for
couples to seek early preventative care before they have begun to identify as distressed.
Intended to be the relationship health equivalent of the annual physical or dental checkup,
the MC is a 4 to 5 hour assessment and feedback intervention. This brief intervention
includes assessment of the couple's relationship history, strengths, and concerns and
provides individualized feedback to the couple with a list of options addressing the couple's
primary concerns. Studies conducted with civilian samples have shown that couples receiving
MC demonstrate significant and lasting improvement across a range of marital health
variables. In addition, MC has been shown to attract couples across the distress continuum
and be perceived by couples as more accessible than traditional therapy.

In recognition of the limited reach and potential stigma of tertiary mental health treatment,
the military services and the Department of Veterans Affairs have implemented collaborative
care models in primary care. In a collaborative care model, mental health providers are
embedded into the primary care setting and serve as integrated behavioral health consultants
(IBHCs) to the medical providers. The IBHC provides brief, focused assessments and
interventions for patients referred by their primary care provider. Marital problems are a
common reason for primary care providers to refer patients to IBHCs, yet there has been no
effort toward development of marital interventions suitable for primary care. MC's design as
a brief "check-up" model for marriage help appeared particularly well-suited to primary care.
Therefore, the investigators conducted a pilot study to adapt MC for use with military
couples in Air Force primary care clinics (FWR20120054H).

In our pilot study the original MC was adapted for military couples and fit into the
fast-paced environment of primary care. Military specific content for the assessment tools in
the Marriage Checkup were developed. In addition, the team developed and piloted a protocol
to use when only one member of the couple is available to come in for a Marriage Checkup,
given the likelihood that some partners seeking an MC may have a partner who is currently
deployed or otherwise unable/unwilling to participate in an in-person checkup. Finally, the
Marriage Checkup was streamlined to fit within a Primary Care setting. More specifically, it
was re-formatted into three 30-minute sessions. Session 1 consisted of the couple's
relationship history and each partner's primary strengths, Session 2 focused on each
partner's primary concern, and Session 3 is dedicated to feedback for the couple. IBHCs
working in primary care were then trained to offer the intervention within a
quasi-experimental research design in which pre-post changes were evaluated within subjects.

To date, twenty-two couples and one individual (N = 45; at least one partner in each couple
was active duty) at two primary care sites have completed the MC. A multilevel modeling
analysis indicated statistically significant pre-post changes for all study variables at both
two weeks and two months, with effect sizes in the moderate range. Relationship satisfaction
(B = .54, p = .003, B = .55, p = .004), distress (B = .75, p < .001, B = .58, p = .003) and
intimacy (B = .43, p < .017, B = .47, p = .014) were significantly improved. In addition,
couples completed a questionnaire measuring their level of satisfaction with the MC
intervention itself. The scale ranged from 1(not at all) to 5 (very much), and across the
questions the average response was 4.33 immediately post checkup and 4.05 at the one-month
follow-up, indicating that couples were satisfied with their Marriage Checkup experience. The
results of the pilot study provide preliminary evidence suggesting that the MC can be
effectively adapted to a military population, and successfully used by behavioral health
consultants (BHCs) working in an integrated primary care clinic.

The overall purpose of the proposed study is to build on pilot study findings by conducting a
randomized trial of the military-adapted Marriage Checkup (MC) delivered in primary care by
Integrated Behavioral Health Consultants (IBHCs). The primary outcomes of interest are
marriage health (e.g., greater satisfaction, deeper intimacy) and community reach (e.g.,
attracts couples at-risk for marital deterioration who otherwise would not be seeking
treatment). There are three specific objectives of the study, the first being to conduct a
randomized trial comparing MC for use in military primary care clinics to a wait list control
condition. Second, examine the effects of MC participation on relationship health at one
month and six months post-treatment follow-up. Lastly, to determine whether the MC is
successful at reaching couples at risk for marital deterioration who would otherwise be
unlikely to seek traditional couple counseling.

This study will investigate two research hypotheses. The first hypothesis being that Military
couples who participate in the Marriage Checkup (MC) for primary care will demonstrate
positive relationship health trajectories for intimacy, acceptance, and relationship
satisfaction over the course of six months when compared to couples in a wait-list control
condition. A randomized control trial with 215 civilian couples demonstrated significant
increases in relationship satisfaction, intimacy, and acceptance both in the short term and
at two-year follow-up for treatment couples compared to no-treatment control couples.
Emerging evidence further suggests that the primary mediator of improvements in marital
health is the effect of the MC on increasing the level of intimate connection between
spouses. In addition, the MC worked to affect both distal (i.e., depression) and specific
(i.e., time together, sexual satisfaction and communication) outcomes. The second hypothesis
is that the MC will attract military couples at-risk for marital deterioration who are
otherwise not seeking relationship treatment. The MC is designed to significantly lower the
barriers to couple help seeking. The MC is very brief and is advertised as an informational
marital health service rather than therapy, intended for all couples who are interested in
learning more about their strengths and areas of concern. The MC has been shown to attract a
broad range of couples across the range of satisfaction from relationally satisfied to
severely distressed and has been shown to successfully attract couples who would not
otherwise seek any kind of relationship intervention.

The randomized trial will be conducted at four military primary care clinics. Three sites
will be Wilford Hall Ambulatory Services Center (WHASC) in San Antonio, Texas, 359th Medical
Operations Squadron (359 MDOS) in San Antonio, Texas, and Malcolm Grow Medical Clinics and
Surgery Center (MGMCSC), Joint Base Andrews, in Maryland. The remaining site will be
recommended by the Air Force Chief of Behavioral Health Optimization (co-investigator Maj Liz
Najera).

Individuals and couples who express an interest in participating in the study will be
scheduled by the on-site study coordinator with the IBHC to receive a more thorough
explanation of the study purpose and requirements of participation. Potential participants
will have the opportunity to ask questions about the study prior to making a decision to
participate. Potential participants will be told that the MC involves three appointments with
the IBHC within a four week period and completion of take-home relationship questionnaires to
aid the BHC in assessing their relationship. At the third IBHC appointment the participants
will receive feedback on the clinical questionnaires and interview results and be given a
list of possible strategies for improving their relationship that has been tailored to their
unique situation. For the purposes of the research, potential participants will be informed
that they will be contacted approximately one month and six months later and asked to log
onto a study website to re-complete surveys about their relationship. They will also complete
surveys that ask their opinion of the MC including what they thought was most helpful and how
it could be improved further.

This first contact will also include the standard brief clinical screening conducted by the
IBHC for all referrals. During this screening the IBHC will also assess for the presence of
any study exclusion factors. If at the conclusion of this first IBHC contact the potential
participant expresses interest in participating and meets the inclusion and exclusion
criteria, they will then meet with the Research Assistant to review and complete the informed
consent documents for study participation and the baseline questionnaires.

The study will use a randomized two-group research design in which participants are randomly
assigned after signing the informed consent document to either receive the MC right away or
be placed on a 7-month wait list condition. All participants will complete study measures at
baseline, eight weeks (1 month post-treatment for those assigned first to the MC condition)
and 28 weeks (six months post-treatment for those assigned first to the MC condition).
Participants assigned to the 7-month wait-list condition will be offered the MC at the
completion of the 6-month follow-up measures.

Inclusion Criteria:

- Potential participants will be active duty and/or their active duty or Department of
Defense (DoD) beneficiary spouses (adults >= 18 years old) who present to the IBHC in
primary care with relationship concerns or questions following referral from their
primary care manager or in response to study advertisements. Potential participants
will be eligible for enrollment whether both partners are participating in-person or
only one partner. Study participants do not have to be married; enrollment is open to
active duty or who are not married but in committed romantic partnerships

Exclusion Criteria:

- Exclusion criteria will mirror clinical practice for patients normally not seen in
primary care behavioral health, i.e., patients greater than mild risk for self-harm,
patients with current alcohol dependence, psychotic disorder, significant dissociative
disorder, or moderate or severe brain injury. Civilians along with potential
participants that cannot understand, speak or read English will be excluded.