Background
U.S. military service members with alcohol misuse are a vulnerable population with a high unmet need for intervention efforts [
1]. Alcohol misuse occurs before more severe sub-classifications of an alcohol use disorder and can be quantified as at-risk or heavy drinking (more than 3 drinks/day or 7 drinks/week for women; more than 4 drinks/day or 14 drinks/week for men) [
2,
3]. Approximately 40 percent of the nearly 775,000 married service members in the U.S. Armed Forces report heavy drinking [
4]—a rate over twice that of the 13 percent of married civilians reporting heavy drinking [
5]. For the service member, alcohol misuse is associated with numerous occupational, relational, and personal consequences (e.g., fitness for duty, absenteeism, comorbid depression and anxiety [
1,
6,
7]). For the family of these service members, alcohol misuse is correlated with poor marital quality, greater rates of infidelity and separation/divorce, intimate partner violence, and child maltreatment [
8,
9], and alcohol is involved in approximately one-quarter of emotional and physical abuse incidents in this population [
10].
Current military policies that mandate reporting to commanding officers may prevent service members from seeking specialty care services for alcohol use disorders. Service members and their partners are often reluctant to seek out services due to the lack of confidentiality and negative repercussions associated with seeking care for alcohol misuse in the military (e.g., appearing on their record [
11,
12]). Indeed, guardsmen report that their greatest concern with seeking care for alcohol misuse is fear it would appear on their record [
11]. Military reporting policies [
1,
13], which may require health care providers to report alcohol use disorder diagnoses to an individual’s commanding officer, may not only prohibit treatment-seeking, but may also escalate problematic drinking patterns and potentially impact operational readiness for the service member and their unit [
1]. These prohibitive barriers have made the prevention and early intervention of alcohol misuse among service members a difficult challenge to overcome.
Although alcohol misuse can weigh heavily on service members’ relationships, spouses or partners of service members can also be an important catalyst for motivating service members to seek treatment. Spouses/partners are in close proximity to and spend significant time with the service member; they are also motivated and typically want to help their partner reduce drinking to improve their relationship as well as to alleviate their own struggles resulting from their partner’s drinking [
14,
15]. The concerned partner (CP) may be more likely to recognize warning signs of misuse, compared to the service members, who may be more resistant to admitting at-risk drinking issues [
16,
17]. Service members with alcohol misuse report encouragement from partners as the most prevalent facilitator of pursuing care [
11], and individuals changing drinking patterns most often cite partner support as the most helpful mechanism in supporting change [
18]. Accessible prevention-focused programs for the CP can encourage help-seeking among service members, alleviate mental health symptoms of partners, and increase relationship satisfaction [
19‐
21]. CPs can encourage their partners to seek help to prevent the progression to dependence. CPs also can seek help for themselves to develop boundaries, coping, positive communication skills, and an awareness of how their behavior may be reinforcing the drinker’s continued problematic use (e.g., calling in sick for them after a night of heavy drinking [
22‐
24]). If the relationship is strained by the alcohol misuse, a CP-focused intervention could present an opportunity to improve the quality of the relationship and the perceived support both the CP and the service member experience.
Many existing couples-based interventions in nonmilitary cohorts focus on partners with already-established alcohol use disorders, but they are labor-intensive and are delivered face to face [
25‐
27]. Other less intensive CP interventions have traditionally been based on the 12-step approach (e.g., Al-Anon) or the Johnson intervention (i.e., confronting the family members during a structured, often surprise, group session; [
28,
29]). Al-Anon is a 12-step worldwide support group for relatives and friends of individuals with alcohol problems. These intervention approaches focus on the CP’s well-being and “loving detachment” from their loved one’s drinking [
30]. Another approach, the Community Reinforcement and Family Training (CRAFT) intervention [
24], supports CPs in making positive changes in their own lives (e.g., engaging in pleasurable activities, seeking support), while teaching them to effectively communicate with their partner so the partner might consider seeking treatment. CPs engaged with the CRAFT model first learn how to change their own lifestyle and take care of their own needs. They receive feedback about enabling behaviors that may unintentionally reinforce continued abuse of alcohol by their partner; they establish new communication skills to interact with their loved ones to help them consider change; and they learn how to change the environment of their partner to create a nonsubstance using lifestyle that is more rewarding than one focused on using alcohol [
20,
24,
31].
While CRAFT, the Johnson intervention, and Al-Anon all have been associated with significant improvements in depression, anger, relationship satisfaction, and family conflict among CPs, CRAFT consistently has been shown to increase engagement in alcohol-focused treatment two to three times more than these other comparison interventions [
19‐
21]. While efficacious, CRAFT is typically conducted face to face, which somewhat limits the number and extent of individuals that can be reached using the approach. Specifically, for military CPs, a face-to-face intervention may not be an option due to such barriers as confidentiality, concerns within the military behavioral health system, and frequent moves due to deployment. Thus, more accessible programs based on empirically supported interventions such as CRAFT are needed to reach this at-risk population in their homes—confidentially and on their own time—to help avoid more serious alcohol problems from developing.
Web-based interventions (WBIs) are emerging practical mechanisms for reaching individuals struggling with substance use who may experience barriers to care. WBIs have been increasingly used for alcohol misuse because of decreased stigma compared to formal treatment programs; they also can safeguard anonymity and privacy and are geared toward self-guided pacing [
32,
33]. WBIs can extend the reach and impact of existing preventive interventions. That is, they can assist those at the beginning stages of alcohol misuse to help prevent development of long-term problems or dependence. Although there have been several alcohol-related WBIs developed for alcohol misuse among younger populations, all have been individually focused on the person with misuse; most involve a nonmilitary college population, and none are directed to the CP [
34‐
36]. Additionally, most existing web-based approaches that target couples are conjoint and focus on general relationship satisfaction, not alcohol misuse [
37]. Currently, no WBI model exists to help CPs prevent alcohol misuse among their service member family members, so this study represents an important service need of the military community.
There is preliminary evidence that web-based approaches for use by CPs would be well-accepted and accessible to the underserved population of CPs and substance-using partners. Specifically, Rychtarik and colleagues [
38] assessed interest in and accessibility to a coping skills program designed for female CPs of people with problem drinking. The majority of women (66%) had never sought help for their partner’s alcohol misuse (nor had their partners) and over three-quarters (77%) reported either preferring an online intervention of this type or rated it equally preferential to face-to-face formats (77%). It is possible that a web program tailored specifically for CPs of service members may be acceptable and even preferred over a face-to-face intervention.
In the current randomized controlled pilot study, Partners Connect, we will adapt CRAFT as a WBI for CPs living with service members who have alcohol misuse problems and evaluate the WBI compared to delayed-WBI at 3-month follow-up. Based on feedback from this study, we will develop a follow-on WBI module for use by the service members themselves. We will utilize the evidence-based CRAFT approach to serve as a model for intervention content, and the WBI will consist of four modules designed to be completed at the CP’s own pace. This study represents the first WBI for concerned military partners that targets service member alcohol misuse. It is self-sustainable and flexible, and thus expected to extend the reach and impact of existing preventive interventions. This study will fill an important gap in the alcohol misuse prevention literature and also help establish evidence that service members are willing to seek care and reduce drinking when their CPs are given resources to help them.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KCO, ERP, TT, and KG conceptualized the study and obtained funding. KCO has overall responsibility for the execution of the WBI intervention, data collection, analyses, and reporting. KCO and ERP conducted literature searches and provided summaries of previous research studies. ERP will assist with the design and evaluation of the WBI. TT will perform quantitative data analyses. KG will assist with the design of Phase 3. SSH contributed to the draft of the manuscript and will assist with study coordination, data collection, and qualitative data analyses. All authors read and approved the final manuscript.