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Easing Reintegration: Telephone Support Groups forSpouses of Returning Iraq and Afghanistan ServiceMembersLinda Olivia Nichols a , Jennifer Martindale-Adams b , Marshall J. Graney c , Jeffrey Zuber b

& Robert Burns da Veterans Affairs Medical Center and Departments of Preventive Medicine and InternalMedicine , University of Tennessee Health Science Centerb Department of Preventive Medicine , University of Tennessee Health Science Center andVeterans Affairs Medical Centerc Veterans Affairs Medical Center and Department of Preventive Medicine , University ofTennessee Health Science Centerd Departments of Preventive and Internal Medicine , University of Tennessee Health ScienceCenter and Geriatrics Group of MemphisPublished online: 17 Oct 2013.

To cite this article: Linda Olivia Nichols , Jennifer Martindale-Adams , Marshall J. Graney , Jeffrey Zuber & Robert Burns(2013) Easing Reintegration: Telephone Support Groups for Spouses of Returning Iraq and Afghanistan Service Members, HealthCommunication, 28:8, 767-777, DOI: 10.1080/10410236.2013.800439

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Health Communication, 28: 767–777, 2013Copyright © Taylor & Francis Group, LLCISSN: 1041-0236 print / 1532-7027 onlineDOI: 10.1080/10410236.2013.800439

Easing Reintegration: Telephone Support Groups for Spousesof Returning Iraq and Afghanistan Service Members

Linda Olivia NicholsVeterans Affairs Medical Center and

Departments of Preventive Medicine and Internal MedicineUniversity of Tennessee Health Science Center

Jennifer Martindale-AdamsDepartment of Preventive Medicine

University of Tennessee Health Science Center andVeterans Affairs Medical Center

Marshall J. GraneyVeterans Affairs Medical Center andDepartment of Preventive Medicine

University of Tennessee Health Science Center

Jeffrey ZuberDepartment of Preventive Medicine

University of Tennessee Health Science Center andVeterans Affairs Medical Center

Robert BurnsDepartments of Preventive and Internal MedicineUniversity of Tennessee Health Science Center and

Geriatrics Group of Memphis

Spouses of returning Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (OperationEnduring Freedom, OEF) military service members report increased depression and anxietypost deployment as they work to reintegrate the family and service member. Reconnectingthe family, renegotiating roles that have shifted, reestablishing communication patterns, anddealing with mental health concerns are all tasks that spouses must undertake as part ofreintegration. We tested telephone support groups focusing on helping spouses with these basicreintegration tasks. Year-long telephone support groups focused on education, skills building(communication skills, problem solving training, cognitive behavioral techniques, stressmanagement), and support. Spouse depression and anxiety were decreased and perceivedsocial support was increased during the course of the study. In subgroup analyses, spouses withhusbands whose injuries caused care difficulties had a positive response to the intervention.However, they were more likely to be depressed, be anxious, and have less social support com-pared to participants who had husbands who had no injury or whose injury did not cause care

Correspondence should be addressed to Linda Olivia Nichols, PhD, Veterans Affairs Medical Center (11-H), 1030 Jefferson Avenue, Memphis, TN 38104,USA. E-mail: linda.nichols@va.gov

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difficulty. Study findings suggest that this well-established, high-access intervention can helpimprove quality of life for military spouses who are struggling with reintegration of the servicemember and family.

Military deployment can negatively affect marriages.Although deployment does not necessarily lead to divorce(Karney & Crown, 2011), combat troops who have beendeployed to Iraq report increased marital dissatisfaction,intention to divorce, and spouse abuse, particularly at12 months post deployment (Hoge, Castro, & Eaton, 2006).At 6 months post deployment, service member concernsabout interpersonal conflicts rise dramatically (Milliken,Auchterlonie, & Hoge, 2007). Approximately 17 to 30% ofreturning Iraq war veterans suffer from depression, anxiety,and posttraumatic stress disorder (PTSD) symptoms (Hogeet al., 2004; Hoge, Auchterlonie, & Milliken, 2006), andthese problems continue or increase during the first year postdeployment (Hoge, Auchterlonie, & Milliken, 2006).

Spouses of active-duty service members who have beendeployed to Iraq and Afghanistan also show mental healthdiagnoses of depression, anxiety, sleep disorders, and acutestress reaction and adjustment disorders (Mansfield et al.,2010), with rates similar to those of service members (Eatonet al., 2008). Spouses are more likely than service members(21.7% vs. 6.2%) to report that stress or emotional problemsimpact their work or other activities (Hoge, Castro, & Eaton,2006). National Guard spouses are also at risk, with 34%,compared to 40% of National Guard members, screeningpositive for mental health problems (Gorman, Blow, Ames,& Reed, 2011).

Reintegration difficulties can contribute to mental healthproblems and marital concerns. Renegotiating roles andresponsibilities that have changed during deployment canbe a particular source of conflict and stress (Blow et al.,2012; Drummet, Coleman, & Cable, 2003; Faber, Willerton,Clymer, MacDermid, & Weiss, 2008). Family membersreport difficulty resuming previous patterns of roles andresponsibilities, determining how to negotiate new rolesand responsibilities, and giving up roles taken on duringdeployment (Knobloch & Theiss, 2011; Sayers, Farrow,Ross, & Oslin, 2009). For significant others and familiesof service members with PTSD symptoms, family function-ing is likely to be even more impaired (Dekel & Monson,2010).

To support military families with reintegration, recom-mendations have been made to provide evidence-based,longer term support that includes strategies on how to dealwith deployments and reunions (Booth, Wechsler Segal,& Bell, 2007). Resources to assist military families withreintegration tasks have included counseling, online training,weekend retreats, and other programs (Lester et al., 2011).However, many military families do not use resources thatare available, perhaps because the resources are not in a formthat families feel comfortable with or because they do notaddress the particular stressors that families are experiencing

(Di Nola, 2008). Work and child care are the most commonbarriers to accessing care (Hoge, Castro, & Eaton, 2006).Because they are not on base, Reserve and Guard families areless likely to have access to military resources, may not haveother unit members in the same town, and therefore may nothave support from other military spouses, which is an impor-tant resource for military wives (Blow et al., 2012; Gormanet al., 2011; Gottman, Gottman, & Atkins, 2011).

To meet the needs of spouses, while being sensitiveto the lack of local resources, we developed a telephonesupport group intervention, funded through the DefenseHealth Program (DHP), managed by the U.S. Army MedicalResearch and Materiel Command. Our goal was to developan intervention that would be widely accessible to mili-tary spouses and would provide ongoing assistance postdeployment.

Telephone groups were chosen because they are a low-cost, distance-neutral intervention that uses established tech-nology. They circumvent resource obstacles such as lackof local services, access, and travel and provide manyof the advantages of face-to-face support groups, such asinteraction, information, social support, and skills build-ing. Participants can access the groups wherever there is atelephone, at home or at work. In dementia caregiving tele-phone support groups, participants from various ethnicitiesreport good satisfaction and little difficulty in managing thetechnology (Bank, Argüelles, Rubert, Eisdorfer, & Czaja,2006; Martindale-Adams, Nichols, Burns, & Malone, 2002).Results have included improvements in mental health status,self-efficacy, and social support (Marziali & Garcia, 2011).Of particular importance is the opportunity for mutual sup-port, which is generally not a component of modalities suchas online training. Support from other unit wives is the majortype of social support that has been shown to buffer the stressof a husband’s absence (Rosen & Moghadam, 1990).

The telephone support intervention’s strategies to amelio-rate difficulties faced by military families can be understoodthrough a theoretical model of stress and coping (Lazarus& Launier, 1978). Stress is a major concern for militaryspouses (Drummet et al., 2003). Coping with stress caninclude both action-oriented management of environmentaldemands and intrapersonal efforts to manage an individual’sinternal responses (cognitive and emotional) to these envi-ronmental demands (Lazarus & Launier, 1978). Individualsevaluate whether environmental stressors/demands pose apotential threat and whether they have coping capabilities.Both of these mechanisms have been found to be impor-tant for mediating stressors for military families (Faber et al.,2008; MacDermid, Samper, Schwarz, Nishida, & Nyaronga,2008). If individuals perceive demands as threatening andcoping resources as inadequate they will experience stress.

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The support groups taught strategies such as cognitive/moodmanagement, communication skills (active listening), prob-lem solving training, and stress reduction techniques to helpin appraisal of demands.

Resources and options available to the stressed personcan be drawn from the environment (Folkman, Schaeffer, &Lazarus, 1979), and these resources shape coping activity.Information on resources, skills to access resources suc-cessfully, support, and mutual problem solving from othergroup members were features of the groups that helpedspouses shape coping activity (Folkman et al., 1979). Action-oriented coping depends in part upon information and skillsdirected toward diminishing, tolerating, or mastering situa-tional demands. A major component of the support groupsdesigned to diminish or master demands was problem-solving skills and the ability to practice these skills withongoing feedback from others. The second component ofstress, internal responses of the stressed individual, as wellas techniques to tolerate demands that could not be changed,was targeted through cognitive behavioral skills and supportfrom others (Folkman et al., 1979).

Using this theoretical framework, the support groups weremulticomponent, including (a) the components of caregivinginterventions that have been shown to be successful, (b)education, support, and practical skills building, includingproblem-solving training such as determining antecedentsand consequences, (c) communication skills such as theuse of active listening strategies, (d) stress reduction skillssuch as deep breathing and engaging in pleasant events,and (e) cognitive/mood management (Belle et al., 2006;Gottman et al, 2011; Schulz et al., 2003). With a strongtheoretical framework and components common to suc-cessful caregiving interventions, this pilot study with anuncontrolled pre- and postintervention evaluation examinedtelephone groups that focused on reintegration tasks forspouses/significant others of service members.

METHODS

Participants

To be eligible for the study, participants had to have beenmarried to or living as married with a service member whohad deployed to Iraq or Afghanistan and was at least 1 monthpost deployment. Per the Memphis Veterans Affairs (VA)Medical Center Institutional Review Board, which oversawthe study, each service member had to give assent for his/herspouse to participate and this assent had to be reported to thestudy team at the time of spouse consent.

Participants were recruited in several ways, includingthrough the study website, brochures, e-mails, and refer-rals from military family advocates and Veterans HealthAdministration clinicians. In addition, just as general recruit-ment ended 26 participants were enrolled directly through

the Wounded Warrior Project (WWP), which serves fam-ily and caregivers of service members/veterans living withphysical and/or mental health conditions. These latter par-ticipants were in telephone support groups with other WWPmembers, and some of them knew each other, at least from aweekend encounter.

Intervention

There were 14 telephone groups, each led by a trainedmaster’s-level mental health professional. Each of thegroups met 12 times during 1 year. The groups were closed,with the same participants. Most groups had 5 or 6 members;three WWP groups had 6 or 10 members. Meeting timesfor the groups were selected by the participants for theirconvenience; most met in the evening. Anonymity andconfidentiality were stressed, both for participants and foranyone they mentioned (e.g., my husband’s commander).The 1-hour sessions were semistructured conference callswith education, support, and practical skills building asshown in Table 1.

Groups focused on practical suggestions to help spouses“normalize” their experiences in a safe environment.Treatment implementation (delivery, receipt, and enactment)was assessed through review of structured, standardizedgroup-leader notes. Delivery focused on whether each com-ponent of the intervention (e.g., didactic information) wasdelivered. Treatment implementation receipt was measuredthrough the amount of interaction and active learning (e.g.,role play, self talk, and modeling of appropriate behavior)

TABLE 1Group Session Components

ComponentTime

(minutes) Description

Welcome 5 Introduction to session, signalbreath relaxation exercise tosegue and help focus onsession

Check in and review ofstrategies from last call

15 Status since last call; review ofstrategies tried; minimizingbarriers to implementingstrategies

Didactic topic presentation 15 Information on thepredetermined topic

Practice and discussion ofways to implementstrategies from presentation

20 Discussion by participantsabout their experience withtopic area and how they canimplement; practice use oftechniques; identification ofbarriers to implementingstrategies

Closure 5 Overview; commitment;reminder of next date andtopic, signal breathrelaxation exercise

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exhibited by spouses during the session. Spouses wouldmake a commitment at the end of each session to selectand practice at least one strategy or skill between sessions(Najavits, 2002). To determine enactment, each spouse wasqueried at the beginning of the next session about the last ses-sion commitment, whether it had been tried, and whether itworked. Barriers to enacting the commitment were problemsolved by the entire group.

Intervention content was informed by the SpouseBattlemind concept, which was originally developed by theArmy to help soldiers and their spouses transition fromcombat to home life (Riviere, Clark, Cox, Kendall-Robbins,& Castro, 2007). For our program, each of the lettersof the Battlemind rubric was expanded into a semistruc-tured hour-long session with didactic information, trainingin problem-solving skills and cognitive restructuring, andsupport components that were designed to reduce or elimi-nate reunion and reintegration difficulties and build familyresilience (Black & Lobo, 2008). As shown in Table 2,sessions focused on reintegration tasks such as managingstress, identifying mental health issues, and learning com-munication skills (Kelly, Fincham, & Beach, 2003) to assistin problem solving, role negotiation, conflict management,reestablishing relationships and intimacy, and accessingsocial support and resources.

Group sessions used a spouse workbook with mate-rial related to each topic, including exercises. In addition,the workbook has red-flag topics, potentially dangerous orunsafe situations and behaviors, including abuse and addic-tions, child abuse, depression, domestic violence, grief,stress and reintegration, suicide risk, and anger. Spouseswere referred to these sections if appropriate during thesupport groups.

Measures

All data were collected by telephone with response cardssent to the participant to make answering more efficient. Datacollections, which took approximately 30 minutes, were atbaseline and at 6 and 12 months. The same research associateperformed all data collection for a participant. Service mem-ber demographics, collected from spouse report, includedemployment, military branch, rank, current military status,Veterans Affairs (VA) services, number of deployments,time since and length of last deployment, and injury sta-tus. Spouse participant demographics included age, gender,years married, children, race/ethnicity, education, employ-ment status, and household income. Outcome measuresincluded depression, anxiety, quality of marriage, socialsupport, family coping, and family communication.

The Patient Health Questionnaire (PHQ-9) was used toassess depression. The PHQ-9 has nine items (e.g., “feel-ing down, depressed, or hopeless”) based on the Diagnosticand Statistical Manual of Mental Disorders, 4th edition(DSM-IV) depression diagnostic criteria that are scored from

0 (not at all) to 3 (nearly every day). Scores are summedto characterize depression as minimal (0 to 4), mild (5 to9), moderate (10 to 14), moderately severe (15 to 19), orhigh/severe (20 to 27). Major depressive syndrome is sug-gested if five or more items or the first two items (littleinterest and feeling depressed, also known as the PHQ-2) are reported positive (at least “more than half the days”)(Kroenke, Spitzer, & Williams, 2001).

The Generalized Anxiety Disorder seven-item scale(GAD-7) was used to assess anxiety. The GAD-7 is a seven-item screening measure for anxiety disorders, with a focuson the symptoms of generalized anxiety disorder based onDSM–IV–TR diagnostic criteria, such as “not being able tostop or control worrying.” Participants report frequency ofdistress due to anxiety symptoms over the past 2 weeks ona scale ranging from 0 (not at all) to 3 (nearly every day)for an overall score of 0 to 21. A cut point of 10 has demon-strated good sensitivity (0.89) and specificity (0.82) in thedetection of generalized anxiety disorder. The measure hasshown good internal consistency reliability at 0.92 (Spitzer,Kroenke, Williams, & Löwe, 2006).

The Quality of Marriage Index (QMI) (Norton, 1983) is ashort and simple measure of global relationship satisfaction.A 7-point scale from 1 (very strongly disagree) to 7 (verystrongly agree) is used for rating five of the six QMI items(e.g., “our marriage is strong”), with the last QMI item (“thedegree of happiness, everything considered, in your mar-riage”) rated on a 10-point scale. Total scores range from 6 to45, with higher scores reflecting greater relationship satisfac-tion. The measure has high internal consistency (Cronbach’salpha coefficient for both women and men = .97) and excel-lent convergent and discriminant validity (Heyman, Sayers,& Bellack, 1994).

Spouse social support was measured using the SocialSupport Index (SSI) (McCubbin, Patterson, & Glynn, 1996),which has been used with military families, has been shownto be an important predictor of family resilience, and is pos-itively correlated with families’ confidence in coping. Thereare 17 questions focusing on family (e.g., “members of myfamily make an effort to show their love and affection forme”) and community support (e.g., “people can depend oneach other in this community”). The questions are scoredon a 5-point scale from 0 (strongly disagree) to 4 (stronglyagree) and items are summed after reverse scoring to 0 to68 with higher scores indicating greater social support. TheSSI has good internal consistency with a Cronbach’s alphaof .82 and test–retest correlation of .83 and good concurrentvalidity.

Family coping ability, from spouse self-report, was mea-sured with the Family Crisis Oriented Personal EvaluationScales (F-COPES), which has been used with military fami-lies. The F-COPES has 30 items to identify family problem-solving and behavioral strategies in difficult or problematicsituations, such as “facing problems ‘head-on’ and trying toget solutions right away.” There are five subscales: acquiring

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TABLE 2Sessions, Topics, and Content for Spouse Intervention Sessions

Session Content

Introduction1 Note: “Red Flag” behaviors discussed at each session

along with resources to address specific concernsIntroductions; format of support group; expectations; transition from combat to home;

normalize transition difficulties, discuss adaptation as goal; overview of interventionand participant workbook; techniques to be used during each session; cognitiverestructuring techniques to be used during each session.

BATTLEMIND Sessions2 Bonds (social support) Coping skills aimed at social reintegration; spouse (SP) and service member (SM)

sources of support during deployment; strategies to keep those sources whileincreasing positive family/couple time; problem-solving training (e.g.,operationalizing goals); techniques for gradual community reentry for SM; ways SPcan support SM during readjustment to home.

3 Adding and subtracting family roles Skills for negotiating family roles; loss of roles by SM and taking on by SP duringdeployment; expectations of roles by each post deployment; acknowledgment andencouragement of roles that SM and SP shared during deployment with focus onstrengths of couple and family members; effective negotiation methods to resetroles/expectations of family members during post-deployment adjustment (e.g.,identifying alternative roles).

4 Taking control Levels of control and stress/anger management; awareness of escalating body signals(breathing, heart rate, etc.); changes since deployment; time out; anger management;relaxation methods to manage stress through use of self awareness.

5 Talking it out Changes with injury/illness in SM ability to communicate; how to deal withexpectations of others and self post combat; active listening skills; strategies forhealthy conflict resolution (e.g., forgiveness).

6 Loyalty and commitment SM and SP commitment to relationship; recommitment to relationship to strengthensupport for each other during times of stress; understand dynamics of couples inrelationships; importance of commitment, appreciation, and honesty for optimumfunctioning as individuals, couple and family.

7 Emotional balance Skills and strategies for coping with emotions and intimacy; recognition of importanceof fidelity and trust in relationships; emotional grounding for SP and SM; timing ofreturn to intimacy and unrealistic expectations; strategies for communicatingemotional needs as a couple (e.g., mirroring, “I” statements).

8 Mental health and readiness Recognition of need for mental health assistance for SP, SM, or children; combat stressreactions and dangerous behaviors; PTSD/TBI/depression; resilience-buildingstrategies; Where to find local and national resources if assistance needed to helpwith adjustment issues and concerns.

9 Independence (and interdependence) Changes in SP and SM’s independence during deployment; recognition and support ofboth individual and couple independence and interdependence; healthy andunhealthy relationships.

10 Navigating the military/VA/community system Resources available; assertive, passive, and aggressive communication; verbal andnonverbal (e.g., calm voice, eye contact), assertive communication skills; situationsneeding assistance from family, friends, and community; rehearse asking for help.

11 Denial of self (self-sacrifice) Ways SPs and SMs can express appreciation for sacrifices; readjustment strategies(e.g., being patient); plan for the future.

Termination session12 Moving forward Review topics and skills learned; discuss gains, next steps, coping with problems;

identify areas needing continued attention/cues for family members needing help.

social support; reframing (redefining stressful events to makethem more manageable); seeking spiritual support; mobiliz-ing family to acquire and accept help; and passive appraisal(ability to accept problematic issues). All items are scoredfrom 1 (strongly disagree) to 5 (strongly agree), and afterappropriate reverse scoring, subscales are summed to anoverall score from 29 to 145. The F-COPES has good inter-nal consistency with a Cronbach’s alpha of .86. Individualsubscales have alphas from .63 to .83 and test–restest cor-relations from 0.61 to 0.95. The scale has good factorial

validity and good concurrent validity (McCubbin, Olson, &Larsen, 1996).

The quality of family communication is a determinant ofhow families manage tension and strain and develop goodfamily functioning. The 10-item Family Problem SolvingCommunication scale (FPSC) was developed to examinefamily stress and resiliency and evaluates positive and nega-tive aspects of communication that families use to cope withstress and difficulties, for example, “we talk things throughtill we reach a solution.” Each item is scored on a 4-point

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scale from false (0) to true (3). A total score from 0 to30 and two subscale scores (affirming and incendiary com-munication) can be computed. The FPSC has good internalconsistency with a Cronbach’s alpha of .89 for the total scaleand alphas of .86 and .78 for the respective subscales. Test–retest correlation is 0.86 and the scale has good concurrentvalidity (McCubbin, McCubbin, & Thompson, 1996).

Data Analysis

In this study of telephone support, each participant served asher own control and all participants enrolled were includedin analysis, regardless of number of sessions attended. Dataanalysis for outcomes used mixed-effects linear models toanalyze individuals’ baseline and follow-up scores to esti-mate the fixed effect parameter of change over time. Eachoutcome measure was treated as independent of the oth-ers. The distributional properties for all outcome measureswere inspected to determine appropriateness for the anal-ysis methods utilized. Because mixed-effects models anal-ysis accommodates missing data without loss of subjects,no data imputation strategy was necessary. At each timepoint, the analysis model uses those data that are avail-able. Subgroup analysis utilized the same mixed-effectslinear models methodology. Baseline demographic and clin-ical characteristics were compared between those whohad data at all follow-up points and those who did not,using chi-squared tests or independent-samples t-tests, asappropriate.

Our power analysis called for a minimum of 60 partici-pants; we estimated that with 15% attrition the study wouldhave statistical power of 0.80 or better to detect an effect sizeof d = 0.40 (Cohen, 1988). Those p values less than or equalto .05 were considered statistically significant, and thosebetween .05 and .10 were considered to document trends thatapproached, but did not attain, statistical significance.

Effect size, estimated as mean change from baseline to12 months relative to estimated population standard devia-tion (Cohen, 1988), was used as an estimate of the findings’substantive magnitude. For statistically significant compar-isons, an effect size (d) of at least 0.2 SD improvementwas considered noteworthy (Cohen, 1988), consistent witheffect sizes reported for psychosocial interventions, whichare generally small (d = 0.2) to medium (d = 0.5) (Sorensen,Pinquart, & Duberstein, 2002).

RESULTS

Participants

Of 107 spouses screened, 86 were enrolled in 14 groups.Seventeen enrolled spouses (19.8%) were missing at leastone follow-up data point. There were two significant baselinedifferences between these spouses and those who provided

data at both follow-up points. “Missing data” spouses hadmore children (2.0 vs. 1.4) and worse general health (2.4 vs.1.8). For the variables examined for service members, therewere no significant baseline differences between the servicemembers of spouses who were missing data and those whowere not.

Although husbands were welcome, none were recruited,so all participants were wives. Spouses were 37.4 (SD =9.0) years old and had been married 10.4 (SD = 8.2) yearswith 1.5 (SD = 1.2) children. They were predominantlywhite/Caucasian (84.9%); 10.5% were Black/AfricanAmerican. Latino/Hispanic ethnicity was 10.5%. More thanhalf (57.0%) were employed, education level was 14.3(SD = 2.4) years, and household income was $4881 (SD =$2703) per month.

For their husbands, 47.8% were Guard or Reserve, 77.9%were affiliated with the Army, and 61.6% were noncommis-sioned officers. Almost two-thirds (65.1%) were employed.They had, on average, 2.6 (SD = 2.8) deployments totalwith the last deployment lasting 11.6 (SD = 5.4) months.The husbands had been back from deployment 28.6 (SD =21.6) months. Almost two-thirds (64%) had been injuredduring deployment and 59.3% were receiving VA services.

About one-fourth (22.1%) of participants attended nine ormore sessions and about one fourth (25.6%) attended threeor fewer sessions. Half (50%) attended at least six sessions.

Outcomes

During the course of the study there were statistically signifi-cant improvements in depression, anxiety and social support,as shown in Table 3. There was no significant improvementin marriage quality, family coping, or family communica-tion. For the three statistically significant outcome measures,effect size (d) was 0.33 for depression, 0.40 for anxiety, and0.17 for social support.

Examining Spouses Dealing With Care Difficulties

Participants were asked whether the service member hadbeen injured during deployment, whether the injury or illnesshad caused any difficulties in care, and the type of difficul-ties. Similar to what has been found in the general populationof individuals returning from Iraq and Afghanistan, the mostcommon medical conditions mentioned were traumatic braininjury (TBI), PTSD, and orthopedic problems such as kneeand back injuries. The types of care difficulties included gen-eral care burden on the spouse due to problems associatedwith memory loss and decreased mobility.

We had initially separated the sample into WWP par-ticipants and non-WWP participants for analysis. However,because of the large number of participants reporting caredifficulties associated with injury/illness of the servicemember, we used reported care difficulties to stratify thesample to increase the generalizability and applicability of

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TABLE 3Outcomes Over Time for Study Participants

Variable

Baseline,M ± SD

(n = 86)a

6 Months,M ± SD(n = 77)

12 Months,M ± SD(n = 70)

Timep Valueb dc

Depression (0–27) 8.9 ± 5.9 7.4 ± 5.6 6.9 ± 5.7 .003 .33Anxiety (0–21) 8.9 ± 5.7 6.7 ± 5.1 6.7 ± 5.6 <.001 .40Quality marriage (6–45) 32.7 ± 8.0 31.6 ± 9.9 31.9 ± 9.8 .26 .10Social support (0–68) 44.0 ± 8.6 46.0 ± 10.2 45.5 ± 10.1 .04 .17Coping (29–145) 104.3 ± 13.8 104.7 ± 13.7 105.7 ± 14.5 .20 .10Family communication (0–30) 19.9 ± 6.2 20.9 ± 6.4 20.9 ± 6.2 .10 .16

Note. Degrees of freedom = (2, 147) for depression and coping, (2, 148) for anxiety, (2, 149) for quality marriage, (2,151) for social support, (2, 74) for family communication. All denominator degrees of freedom are rounded Satterthwaiteapproximations.

an = 85 for coping and family communication outcomes.bThe p values from repeated-measures mixed-effects linear model analyses.cCohen’s d effect sizes calculated using baseline and 12-month data only.

analysis. There were 48 spouses (including 24 WWP) whoreported an injury that caused care difficulties, comparedto 38 spouses who reported either no injury or no injurythat caused care difficulties. The analysis of the 26 WWPparticipants compared to the 60 non-WWP participants wasremarkably similar to the analysis reported in the follow-ing of the injury/care difficulty versus no injury/no caredifficulty participants.

When baseline demographics for the two subgroupswere compared, fewer of the injury/difficulty spouses wereemployed, with similar findings for their husbands. Thehusbands of spouses with care difficulties had also beenback a longer time compared to no injury/no difficultyhusbands (3 years vs. 1.5 years), and were more likely tobe discharged from the military and, therefore, using VAservices.

From the subgroup mixed-effects linear model analysesshown in Table 4, during the course of the study there werestatistically significant group differences between these twosubgroups of spouses in depression, anxiety, and social sup-port, with a trend toward a significant difference in quality ofmarriage, with injury/difficulty spouses reporting worse out-comes. Statistically significant improvements over time werefound for depression, anxiety, and social support. There wasa significant group by time interaction for anxiety. Within-group analyses reveal significant improvements over timein anxiety and depression for the injury/difficulty group.These significant findings document that the injury/difficultyspouse group had an amelioration of anxiety and depressionduring the course of the study.

For the outcomes of depression, anxiety, quality of mar-riage, social support, family coping, and family communi-cation during the 12 months of the study, only for familycoping did injury/difficulty spouses’ scores ever reach thelevel of the no injury/no difficulty spouses. Figure 1 illus-trates this pattern with values for anxiety during the studyfor the two subgroups.

DISCUSSION

The purpose of this pilot study was to demonstrate feasibilityand effectiveness of a telephone support group interven-tion for spouses of returning Iraq and Afghanistan servicemembers. From baseline to follow-up, spouses reported sig-nificantly improved depression, anxiety, and social support,with effect sizes for depression and anxiety between smalland medium. These findings suggest that telephone supportgroups are a viable means of providing information, support,and skills to military spouses. Although telephone supportgroups are not the only resources available for militaryspouses (Gottman et al., 2011; Lester et al., 2011; Stanley,Allen, Markman, Rhoades, & Prentice, 2010), they are sim-ple to implement and eliminate many access concerns offace-to-face interventions, particularly for rural participants.

There were several features of the telephone supportgroups that are part of successful caregiving interventionsthat we believe were important in our findings. The inter-vention was multicomponent, including cognitive behavioralskills building and support from others, both of which havebeen shown to target internal responses of stressed individ-uals (Folkman et al., 1979). Multiple domains of caregivingrisk, such as emotional and physical well-being, were tar-geted. Caregiving risks are individualized, and interventionsthat address one area of risk may not be effective for all par-ticipants (Belle et al., 2006; Schulz, Gallagher-Thompson,Haley, & Czaja, 2000; Schulz et al., 2003; Sorenson et al.,2002). Each session incorporated practice in the skills taught(Belle et al., 2003; Czaja, Schulz, Lee, & Belle, 2003).Trained group leaders guided discussion and practice andkept the groups on track and on task (Martindale-Adamset al., 2002). The intervention was standardized with thespouse workbook and scripts and talking points for the groupleader but was also individualized through the commitmentsmade by each participant that were related to her ownconcerns (Schulz et al., 2003).

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TABLE 4Outcomes for Injury/Difficulty and No Injury/No Difficulty Participants

VariableInjury/DifficultyNo Injury/No Difficulty

Baseline,M ± SD

(n = 48)a

(n = 38)

6 Months,M ± SD(n = 43)(n = 34)

12 Months,M ± SD(n = 38)(n = 32)

Groupp Valueb

Timep Valueb

Group × Timep Valueb dc

Depression (0–27) .003 .005 .14 .35d

Injury/difficulty 10.9 ± 5.8 8.7 ± 5.8 8.1 ± 5.7 .001 .48No injury/no difficulty 6.4 ± 5.1 5.6 ± 4.8 5.6 ± 5.4 .67 .16

Anxiety (0–21) .001 <.001 .009 .39d

Injury/difficulty 11.3 ± 5.5 7.9 ± 5.3 8.1 ± 5.9 <.001 .57No injury/no difficulty 6.0 ± 4.5 5.3 ± 4.7 4.9 ± 4.7 .43 .24

Quality marriage (6–45) .08 .28 .55 .25d

Injury/difficulty 31.5 ± 7.9 30.5 ± 9.8 29.7 ± 9.6 .35 .23No injury/no difficulty 34.2 ± 8.1 32.9 ± 10.0 34.4 ± 9.6 .42 .03

Social support (0–68) .03 .04 .91 .03d

Injury/difficulty 42.0 ± 8.7 44.3 ± 11.0 43.6 ± 10.7 .10 .18No injury/no difficulty 46.5 ± 7.9 48.3 ± 8.7 47.8 ± 8.9 .35 .16

Coping (29–145) .51 .18 .26 .15d

Injury/difficulty 103.3 ± 15.9 105.2 ± 13.9 103.8 ± 15.1 .36 .03No injury/no difficulty 105.5 ± 10.9 104.1 ± 13.7 108.0 ± 13.7 .17 .23

Family communication (0–30) .28 .11 .89 .06d

Injury/difficulty 19.1 ± 6.5 20.3 ± 6.5 20.0 ± 5.8 .15 .13No injury/no difficulty 20.8 ± 5.7 21.6 ± 6.4 22.0 ± 6.5 .54 .21

Note. Group effects: degrees of freedom = (1, 82) for depression and anxiety, (1, 85) for quality marriage, (1, 86) for socialsupport, (1, 83) for coping and family communication. Time and group × time effects: degrees of freedom = (2, 145) for depression,anxiety, and coping, (2, 147) for quality marriage, (2, 149) for social support, (2, 73) for family communication. All denominatordegrees of freedom are rounded Satterthwaite approximations.

an = 47 for coping and family communication outcomes.bThe p values from repeated-measures mixed-effects linear model analyses.cCohen’s d effect sizes calculated using baseline and 12-month data only.dGroup by time interaction effect size.

FIGURE 1 Anxiety change over time for spouses.

There were some surprising findings. The lack of asignificant finding for coping was unexpected, as spousecommitments reflected that they were using the skills theylearned. The emphasis on family coping in our measure andthe emphasis on individual coping/problem solving skills inour intervention may explain this lack of significant findings.The lack of change in marriage quality and family commu-nication may also indicate that for meaningful change to

family system variables to occur, an intervention would needto target both partners.

Recruitment initially targeted only Guard and Reservespouses with the idea that they would have limited accessto resources for military families. However, active-dutyspouses eventually made up half the sample, suggesting thattelephone support groups are a viable and useful meansof providing information, support, and skills to militaryspouses, regardless of whether they are near to resources.

As originally conceptualized, the study targeted spousesof newly returned service members during the first yearpost deployment, when reintegration and mental health dif-ficulties have been found to increase. In fact, the length oftime post deployment ranged from 1 month to 80 months,with the average time post deployment greater than 2 years.Clearly, for some families, reintegration tasks continue toprovide challenges and concerns several years after deploy-ment. This could indicate that our sample was more troubledthan other military spouses but we do not think this is thecase. A 2010 study examined electronic medical-record datafor all outpatient medical visits for 3 years (2003 to 2006),by 250,000 wives of active-duty Army personnel who eitherreceived care at a U.S. military treatment facility or usedmilitary medical insurance for a visit at a nonmilitary health

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TELEPHONE SUPPORT FOR MILITARY WIVES 775

care facility. Although time post deployment was not avail-able, 19.1% of wives had a depressive disorder diagnosisand 10.8% an anxiety diagnosis. A total of 30.5% had somemental health diagnosis (Mansfield et al., 2010).

The intervention focus was on basic reintegration tasks,such as negotiation of roles. When we examined spouseswho were also struggling with a husband’s illness or injurythat caused care difficulties, these spouses were more bur-dened, with greater depression and anxiety and less socialsupport and poorer quality marriage than spouses who didnot report an injury or an injury that caused care difficul-ties. Despite their added burden of care coupled with thechallenges of reintegration and the fact that the interventionwas not targeted to dealing with injury, illness, or caregiving,these spouses improved over the course of the study.

However, despite this response, for the outcomes ofdepression, anxiety, quality of marriage, social support, fam-ily coping, and family communication during the 12 monthsof the study, the reported scores for the injury/difficultyspouses did not appear to reach the level of the no injury/nodifficulty spouses, except for the family coping score. Thesefindings suggest that the burden of care caused by living witha husband with an injury levied a toll on these wives thatcould not be completely relieved.

The busy lives led by military spouses had been oneof our initial impetuses for developing telephone supportgroups. Work, school, household duties, children, and carefor aging parents or a husband who may have been injuredare all excellent reasons why spouses cannot travel to a sitefor an intervention. However, although the telephone sup-port groups were at convenient times chosen by the spousesand did not necessitate leaving home, spouses’ scheduleschanged with the seasons and with children’s schedules, andanother family or work commitment could take precedence.When this occurred, spouses wanted additional opportunitiesto participate in the groups. In addition to additional ses-sions, because the sessions were monthly, when spouses hadto miss a session, they went 60 days without a session andthe support they valued. In project evaluation, they stronglysuggested that sessions occur more frequently. In additionto busy lives, there are other explanations why spouses didnot attend all sessions. Many rapid responders experiencereduced depression early in therapy or after the first ses-sion, with those with first-session gains doing particularlywell (Busch, Kanter, Landes, & Kohlenberg, 2006). We can-not discount that those who did not continue to attend mayhave received what they needed.

Some limitations should be mentioned. Because this wasa pilot feasibility study and not a randomized controlledtrial, our findings could be unrelated to the interventionand a function of time alone. However, the participantswho were caring for husbands with injuries or conditionsthat caused care difficulties suggest that time alone is notresponsible. Their husbands had been back from deploy-ment twice as long as participants who were not coping

with care difficulties. To provide the full scientific rigor ofa randomized controlled trial to test the intervention, a trialtesting telephone support, online sessions, and usual care isnow underway, funded through the Defense Health Program(DHP) and managed by the U.S. Army Medical Researchand Materiel Command.

For this pilot study, sample size was a limitation that lim-its generalizability. However, the sample was diverse, withrepresentation from different ages, branches of the military,and injury level of service members, which supports gener-alizability. Some of the Wounded Warrior Project spousesknew each other from participating in a weekend retreat, andsome corresponded online with each other outside the group.This could have influenced the outcomes positively for theseparticipants.

Implications

The positive results from the study—with spouses improvingin depression, anxiety, and social support—have implica-tions for clinical care and for public policy.

Clinically, although resources to help with deploymentand reintegration concerns are available, spouses and ser-vice members do not always use them, particularly forGuard, Reserve, and veteran spouses who are not near amilitary installation. In this sample, only 12.8% of spouseshad received pre-deployment 1-hour Battlemind training andonly 17.4% received this training post deployment, although27.9% of their husbands had received the post-deploymentBattlemind training.

For clinicians, our findings suggest a need to includethe spouse when treating a service member or veteran.Spouses are a critical support for the returned service mem-ber. For example, for National Guard members with alcoholmisuse, for those who receive services, spouses are mostcommonly credited as the reason the veteran sought care(Burnett-Zeigler et al., 2011).

Conversely, it is important to remember that military andveteran spouses are dealing with their own challenges fromdeployment and reintegration. Military spouses are as likelyto report mental health needs as their service members, andare more likely to seek care (Gorman et al., 2011). Whenspouses do seek care for stress or emotional problems, care isusually sought from a primary care provider (Hoge, Castro,& Eaton, 2006). Military and veteran spouses may need spe-cial attention from their primary care providers and mentalhealth providers. Spouses in this pilot study voiced a desireto have more focus on their concerns and issues in additionto their role as a support for their service members.

In the area of public policy, Public Law111–163 Caregivers and Veterans Omnibus Health ServicesAct of 2010 was signed May 2010. The act allows theDepartment of Veterans Affairs (VA) to provide benefits tocaregivers of veterans. In part because of the enthusiasmof the study participants, the VA is rolling out telephone

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support groups that are based on this model and studythrough the Spouse Telephone Support (STS) program forspouses of Iraq and Afghanistan veterans. Staff membersfrom VA Medical Centers are being trained and certifiedin delivering the support group intervention. Training,group-leader materials, spouse workbooks, and coaching areprovided by the VA’s Caregiver Support Program throughthe Caregiver Center at the Memphis VA Medical Center.

The STS multicomponent intervention continues to incor-porate those elements that have been shown to improvecaregivers’ well-being (Belle et al., 2006; Gottman et al,2011; Schulz et al., 2003): education, support, and practicalskills building, including problem-solving skills, commu-nication skills, stress reduction skills, and cognitive/moodmanagement. However, the lessons learned from this pilotstudy have informed the design of the STS groups. For exam-ple, to reflect increased emphasis on the spouse, the sessionsdo not follow the the pilot study Battlemind rubric (whichhas been discontinued by the Army) but sharpen the focus onbuilding the spouse’s resilience and strengths, through tasksrelated to communication and conflict management, relation-ships, role negotiation, intimacy, mental health issues, andresources.

As the STS program is being rolled out in VA MedicalCenters across the country, it is being evaluated to determinewhether the outcomes remain positive. While the materialand structure remain the same for each group, the program isdesigned to be flexible to meet the needs of the spouses whoare at each facility. During the pilot, spouses wanted addi-tional opportunities to participate in the groups. In projectevaluation, spouses strongly suggested that sessions occurmore frequently. Therefore, STS group sessions occur every2 weeks instead of monthly and they repeat for spouses whomust miss a session. Some medical centers are implement-ing the program with spouses who may know each other, andsome may provide face-to-face groups rather than telephonegroups. The goal remains the same—to provide a forum forspouses’ concerns and to help spouses better manage thechallenges of reintegration. As one spouse reported about theprogram, “I was able to get feedback and suggestions fromthe group leader and the other participants and an objec-tive perspective on issues too difficult for me to handle bymyself.”

ACKNOWLEDGMENTS

Disclaimer: The views expressed in this article are thoseof the authors and do not reflect the official policy orpositions of the U.S. Department of Veterans Affairs, theU.S. Department of the Army, the U.S. Department ofDefense, or the U.S. government. This research was sup-ported through the Defense Health Program (DHP), man-aged by the U.S. Army Medical Research and MaterielCommand, through the Congressionally Directed Medical

Research Program (CDMRP) and the Department of theArmy Medical Research Acquisition Activity (W81XWH-08-2-0195). Our thanks to Dr. Katharine Nassauer and COLCarl Castro for their support. The study was also supported inpart by the Office of Research and Development, Departmentof Veterans Affairs, and the Memphis VA Medical Center.Special thanks to all those who worked on the project: GroupLeaders Patricia Miller, MA, and Denise Brown, MS, were ahuge part of the success of the project. Sarah Kennedy, MA,Celeste Bursi, MSSW, and Barbara Higgins, MA, made surethat the data were accurate and worked hard to make surethat busy spouses were contacted at times that were con-venient. Drs. Meghan McDevitt-Murphy, Lyndon Riviere,Karin Thompson, and Kathleen M. Wright were invaluablein study development. Our heartfelt gratitude to the spouseswho participated, who managed their concerns with graceand dignity, and who taught us so much about being part ofa military family.

REFERENCES

Bank, A. L., Argüelles, S., Rubert, M., Eisdorfer, C., & Czaja, S. J.(2006). The value of telephone support groups among ethnically diversecaregivers of persons with dementia. Gerontologist, 46, 134–138.

Belle, S., Burgio, L., Burns, R., Coon, D., Czaja, S., Gallagher-Thompson,D., . . . Zhang, S. for the REACH II Investigators. (2006). Enhancingthe quality of life of Hispanic/Latino, Black/African American, andWhite/Caucasian dementia caregivers: The REACH II randomized con-trolled trial. Annals of Internal Medicine, 145, 727–738.

Black, K., & Lobo, M. (2008). A conceptual review of family resiliencefactors. Journal of Family Nursing, 1, 33–55.

Blow, A., MacInnes, M., Hamel, J., Ames, B., Onaga, E., Holtrop, K., . . .

Smith, S. (2012). National Guard service members returning home afterdeployment: The case for increased community support. Administrationand Policy in Mental Health and Mental Health Services Research, 39,383–393.

Booth, B., Wechsler Segal, M., & Bell, D. B. (2007). What we knowabout Army families: 2007 Update. Caliber Company. Retrieved fromhttp://www.mwrbrandcentral.com/HOMEPAGE/Graphics/Research/whatweknow2007

Burnett-Zeigler, I., Ilgen, M., Valenstein, M., Zivin, K., Gorman, L., Blow,A., . . . Chermack, S. (2011). Prevalence and correlates of alcohol misuseamong returning Afghanistan and Iraq Veterans. Addictive Behaviors, 36,801–806.

Busch, A. M., Kanter, J. W., Landes, S. J., & Kohlenberg, R. J. (2006).Sudden gains and outcome: A broader temporal analysis of cognitivetherapy for depression. Behavior Therapy, 37, 61–68.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences. 2nded. Hillsdale, NJ: Lawrence Erlbaum Associates.

Czaja, S. J., Schulz, R., Lee, C. C., & Belle, S. H., for the REACHInvestigators. (2003). A methodology for describing and decompos-ing complex psychosocial and behavioral interventions. Psychology andAging, 18, 385–395.

Dekel, R., & Monson, C. M. (2010). Military-related post-traumatic stressdisorder and family relations: Current knowledge and future directions.Aggression and Violent Behavior, 15, 303–309.

Di Nola, G. M. (2008). Stressors afflicting families during military deploy-ment. Military Medicine, 173(5), v–vii.

Drummet, A. R., Coleman, M., & Cable, S. (2003). Military families understress: Implications for family life education. Family Relations, 52, 279–287.

Dow

nloa

ded

by [

Uni

vers

ity o

f Il

linoi

s C

hica

go]

at 1

8:38

15

Nov

embe

r 20

14

TELEPHONE SUPPORT FOR MILITARY WIVES 777

Eaton, K. M., Hoge, C. W., Messer, S. C., Whitt, A. A., Cabrora, O. A.,McGurk, D., . . . Castro, C. A. (2008). Prevalence of mental health prob-lems, treatment need, and barriers to care among primary care-seekingspouses of military service members involved in Iraq and Afghanistandeployments. Military Medicine, 173, 1051–1056.

Faber, A. J., Willerton, E., Clymer, S. R., MacDermid, S. M., & Weiss, H.M. (2008). Ambiguous absence, ambiguous presence: A qualitative studyof military reserve families in wartime. Journal of Family Psychology, 22,222–230.

Folkman, S., Schaeffer, C., & Lazarus, R. (1979). Cognitive processes asmediators of stress and coping. In V. Hamilton & D. Warburton (Eds.),Human stress and cognition (pp. 265–298). Chichester, UK: John Wileyand Sons.

Gorman, L. A., Blow, A. J., Ames, B. D., & Reed, P. L. (2011). NationalGuard families after combat: Mental health, use of mental health services,and perceived treatment barriers. Psychiatric Services, 62, 28–34.

Gottman, J. M., Gottman, J. S., & Atkins, C. L. (2011). The compre-hensive soldier fitness program: Family skills component. AmericanPsychologist, 66, 52–57.

Heyman, R. E., Sayers, S. L., & Bellack, A. S. (1994). Global marital sat-isfaction versus marital adjustment: An empirical comparison of threemeasures. Journal of Family Psychology, 8, 432–446.

Hoge C. W., Auchterlonie J. L., & Milliken C. S. (2006). Mental healthproblems, use of mental health services, and attrition from military ser-vice after returning from deployment to Iraq or Afghanistan. Journal ofthe American Medical Association, 295, 1023–1032.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., &Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mentalhealth problems, and barriers to care. New England Journal of Medicine,351, 13–22.

Hoge, C., Castro, C., & Eaton, K. (2006). Impact of combat duty inIraq and Afghanistan on family functioning: Findings from the WalterReed Army Institute of Research Land Combat Study. Human Factorsand Medicine Panel Symposium (HFM-134) on Human Dimensions inMilitary Operations. Military Leaders’ Strategies for Addressing Stressand Psychological Support. Retrieved from http://www.socialwork.vcu.edu/pdfs/Impact_of_Combat_Duty.pdf

Karney, B. R., & Crown, J. S. (2011). Does deployment keep military mar-riages together or break them apart? Evidence from Afghanistan and Iraq.In S. MacDermid Wadsworth and D. Riggs, (Eds.), Risk and resilience inU.S. military families (pp. 23–45). New York, NY: Springer.

Kelly, A. B., Fincham, F. D., & Beach, S. R. H. (2003). Communicationskills in couples: A review and discussion of emerging perspectives. InJ. O. Greene & B. R. Burleson (Eds), Handbook of communication andsocial interaction skills (pp. 723–751). Mahwah, NJ: Lawrence ErlbaumAssociates.

Knobloch, L. K., & Theiss, J. A. (2011). Depressive symptoms and mecha-nisms of relational turbulence as predictors of relationship satisfactionamong returning service members. Journal of Family Psychology, 25,470–478.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validityof a brief depression severity measure. Journal of General InternalMedicine, 16, 606–613.

Lazarus, E. B., & Launier, R. (1978). Stress-related transactions betweenpersons and environment. In L. Pervin & M. Lewis (Eds.), Perspectivesin international psychology (pp. 287–325). New York, NY: Plenum Press.

Lester, P., Mogil, C., Saltzman, W., Woodward, K., Nash, W., Leskin,G., . . . Beardslee, W. (2011). Families overcoming under stress:Implementing family-centered prevention for military families facingwartime deployments and combat operational stress. Military Medicine,176, 19–25.

MacDermid, S. M., Samper, R., Schwarz, R., Nishida, J., & Nyaronga,D. (2008). Understanding and promoting resilience in military fam-ilies. Military Family Research Institute, Purdue University, WestLafayette, IN.

Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey,J. P., & Engel, C. C. (2010). Deployment and the use of mental healthservices among U.S. Army wives. New England Journal of Medicine,362, 101–109.

Martindale-Adams, J., Nichols, L., Burns, R., & Malone, C. (2002).Telephone support groups: A lifeline for isolated Alzheimer’s diseasecaregivers. Alzheimer’s Care Quarterly, 3, 181–189.

Marziali, E., & Garcia, L. J. (2011). Dementia caregivers’ responses to2 Internet-based intervention programs. American Journal of Alzheimer’sDisease and Other Dementias, 26, 36–43.

McCubbin, H., Olson, D., & Larsen, A. (1996). Family crisis orientedpersonal scales (F-COPES). In H. I. McCubbin, A. I. Thompson,& M. A. McCubbin (Eds.), Family assessment: Resiliency, copingand adaptation—Inventories for research and practice (pp. 455–507).Madison, WI: University of Wisconsin System.

McCubbin, H. I., Patterson, J., and Glynn, T. (1996). Social support index(SSI). In H. I. McCubbin, A. I. Thompson, & M. A. McCubbin (Eds.),Family assessment: Resiliency, coping and adaptation—Inventories forresearch and practice (pp. 357–389). Madison, WI: University ofWisconsin System.

McCubbin, M. A., McCubbin, H. I., & Thompson, A. (1996). Family prob-lem solving communication (FPSC). In H. I. McCubbin, A. I. Thompson,& M. A. McCubbin (Eds.), Family assessment: Resiliency, copingand adaptation—Inventories for research and practice (pp. 639–686).Madison, WI: University of Wisconsin System.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinalassessment of mental health problems among active and reserve com-ponent soldiers returning from the Iraq war. Journal of the AmericanMedical Association, 298, 2141–2148.

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD andsubstance abuse. New York, NY: Guilford.

Norton, R. (1983). Measuring marital quality: A critical look at the depen-dent variable. Journal of Marriage and the Family, 45, 141–151.

Rosen, L., & Moghadam, L. (1990). Matching the support to the stressor:Implications for the buffering hypothesis. Military Psychology, 2, 193–204.

Riviere, L. A., Clark, J. C., Cox, A. L., Kendall-Robbins, A., & Castro,C. A. (2007, August). Spouse Battlemind training: Elements andstrengths. In C. A. Castro (Chair), The Battlemind training system:Supporting soldiers throughout the deployment cycle. Symposium con-ducted at the meeting of the American Psychological Association, SanFrancisco, CA.

Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009).Family problems among recently returned military veterans referredfor a mental health evaluation. Journal of Clinical Psychiatry, 70,163–170.

Schulz, R., Burgio, L., Burns, R., Eisdorfer, C., Gallagher-Thompson,D., Gitlin, L. N., & Mahoney, D. F. (2003). Resources for enhancingAlzheimer’s caregiver health (REACH): Overview, site-specific out-comes, and future directions. Gerontologist, 43, 514–520.

Schulz, R., Gallagher-Thompson, D., Haley, W., & Czaja, S. (2000).Understanding the interventions process: A theoretical/conceptualframework for intervention approaches to caregiving. In R. Schulz (Ed.),Handbook on dementia caregiving: Evidence-based interventions forfamily caregivers (pp. 33–60). New York, NY: Springer.

Sorensen, S., Pinquart, M., & Duberstein, P. (2002). How effective are inter-ventions with caregivers? An updated meta-analysis. The Gerontologist,42, 356–372.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief mea-sure for assessing Generalized Anxiety Disorder: The GAD-7. Archivesof Internal Medicine; 166, 1092–1097.

Stanley, S. M., Allen, E. S., Markman, H. J., Rhoades, G. K., & Prentice,D. (2010). Decreasing divorce in Army couples: Results from a random-ized clinical trial of PREP for Strong Bonds. Journal of Couple andRelationship Therapy, 9, 149–160.

Dow

nloa

ded

by [

Uni

vers

ity o

f Il

linoi

s C

hica

go]

at 1

8:38

15

Nov

embe

r 20

14