The Impact of Couple Therapy on Service Utilization among Military Veterans: The Moderating Roles of Pretreatment Service Utilization and Premature Termination

• Author: Brian D. Doss,Joshua W. Madsen,Lianne M. Tomfohr‐Madsen
• Published date: 01 September 2017
• DOI: http://doi.org/10.1111/famp.12234
• Date: 01 September 2017

The Impact of Couple Therapy on Service Utilization

among Military Veterans: The Moderating Roles of

Pretreatment Service Utilization and Premature

Termination

JOSHUA W. MADSEN*

LIANNE M. TOMFOHR-MADSEN

†

BRIAN D. DOSS

‡

Couple therapy reduces relational and individual distress and may affect utilization of

other health services, particularly among higher service utilizers. Although average

decreases in service utilization are predicted among recipients of couple therapy , low utiliz-

ers of services may appropriately increase use. The relationship between couple therapy

and service utilization was examined among a sample of 179 U.S. military veterans who

received treatment in Veterans Affairs (VA) specialty couple therapy clinics. Consistent

with hypotheses, overall mental and physical health visits decreased from the 12 months

preceding couple therapy to the 12 months following treatment. Moderator analyses

showed that decreases were greatest among individuals who were rated by their therapist

as having completed a full course of couple therapy, suggesting that change was attributa-

ble to intervention. Pretreatment service utilization also moderated observed change—

higher utilizers’ use of services decreased substantially, whereas lower uti lizers’ slightly

increased. Cost analyses revealed that the estimated per person mean cost in our sample

decreased by $930.33 in the year following compared to the year prior to couple therapy, as

per 2008 VA cost data. As service utilization data were only available for one partner and

only for 1 year posttherapy, the true magnitude of this effect may be underestimated. Our

findings are relevant to policy makers as they demonstrate that couple therapy reduces

average service utilization and associated costs and addresses calls for analyses of cost

effectiveness of systemic interventions.

Keywords: Couple Therapy; Service Utilization; Medical Offset; Cost Effectiveness;

Military Veterans

Fam Proc 56:620–635, 2017

Decades of empirical investigation paint a favorable picture of the efficacy and

effectiveness of couple therapy. The efficacy of couple-based interventions has been

*Department of Psychology, University of Calgary, Calgary, AB, Canada.

†

Departments of Psychology and Pediatrics, Alberta Children’s Hospital Research Institute, University of Cal-

gary, Calgary, AB, Canada.

‡

Department of Psychology, University of Miami, Coral Gables, FL.

Correspondence concerning this article should be addressed to Joshua W. Madsen, Department of

Psychology, University of Calgary, 2500 University Dr. NW, Calgary, Canada T2N 1N4. E-mail:

jmadsen@ucalgary.ca

This work was supported by the generous donors of the Alberta Children’s Hospital Foundation (L. T.)

and a Provost Research Award from the University of Miami (B. D.). We would also like to thank the veter-

ans and their partners who made this study possible.

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Family Process, Vol. 56, No. 3, 2017 ©2016 Family Process Institute

doi: 10.1111/famp.12234

observed across numerous outcome variables, including relationship satisfaction (e.g.,

Shadish & Baldwin, 2003), family climate (Lundblad & Hansson, 2006), and child adjust-

ment (Gattis, Simpson, & Christensen, 2008). The effects of couple therapy on relationship

functioning tend to be large (e.g., Shadish & Baldwin, 2003) and durable for a sizeable pro-

portion of couples (e.g., Christensen, Atkins, Baucom, & Yi, 2010; Shadish & Baldwin,

2003). Moreover, significant relationship discord does not tend to remit spontaneously,

but does so reliably with couple therapy (Baucom, Hahlweg, & Kuschel, 2003). However, a

nontrivial percentage of couples prematurely discontinue couple therapy (e.g., Hahlweg &

Klann, 1997), do not experience clinically significant improvement during the cou rse of

treatment (e.g., Lebow, Chambers, Christensen, & Johnson, 2012), and divorce even in

the years following administration of well-established, evidence-based therapies (e.g.,

Christensen et al., 2010).

Notwithstanding these limitations and areas of continued growth for the field, there

can be little doubt that couple therapy has, on average, a reliable and positive impact on

relationship functioning. As such, studies of efficacy, effectiveness, and availab ility of cou-

ple therapy could benefit from more attention to economic evaluation of this health service

(Drummond, Sculpher, Torrance, O’Brien, & Stoddart, 2005).

The effects of relationship distress extend beyond an individual’s romantic relationship.

Relationship distress has repeatedly been found to be associated cross-sectionally and lon-

gitudinally with psychopathology (for reviews, see Whisman, 2013; Whisman & Bauco m,

2012), including among veteran samples (e.g., Sayers, Farrow, Ross, & Oslin, 2009; Taft,

Watkins, Stafford, Street, & Monson, 2011). As such, it is not surprising that (a) higher

mental health service utilization has been observed among individuals reporting relation-

ship discord in a community sample (Schonbrun & Whisman, 2010), and that (b) a number

of studies have demonstrated that couple-based interventions are also capable of amelio-

rating individual psychopathology (for reviews, see Baucom, Whisman, & Paprocki, 2012;

Lebow et al., 2012; Snyder, Castellani, & Whisman, 2006), and can be a particularly

potent means of doing so. For example, meta-analytic findings have provided evidence of

superior outcomes for behaviorally oriented couple-based interventions for substance use

disorders as compared to individual therapy (Powers, Vedel, & Emmelkamp, 2008). In

addition, individual therapy has diminished effectiveness for a number of disorders in the

presence of co-occurring relationship discord (for reviews, see Baucom, Belus, Ad elman,

Fischer, & Paprocki, 2014; Baucom et al., 2012). In our own study of veterans in treat-

ment-as-usual couple therapy, improvements in psychological distress among men medi-

ated the effect of treatment on subsequent relationship satisfaction (Doss, Mitchell,

Georgia, Biesen, & Rowe, 2015). In summary, relationship problems are associated cross-

sectionally and longitudinally with individual mental health problems and greater use of

mental health services; therefore, couple therapy may reduce mental health visits by alle-

viating individual distress.

Relationship distress is also associated with poorer physical health. In a recent meta-

analysis representing 50 years of research, Robles, Slatcher, Trombello, and McGinn

(2014) found that better marital quality was associated with better health, as reflected in

a reduced risk of mortality and more adaptive physiological processes. Relationship con-

structs have been shown to affect physical health via a variety of physiological pathways

(Jaremka, Glaser, Malarkey, & Kiecolt-Glaser, 2013; Robles & Kiecolt-Glaser, 2003)—

these processes may explain serious health outcomes observed among individuals in dis-

tressed relationships (e.g., Troxel, Matthews, Gallo, & Kuller, 2005; Whisman & Uebe-

lacker, 2012). More positive relationship functioning may also confer health benefits via

other mechanisms. For example, a communal approach to coping with heart failure in one

spouse within marital dyads has been shown to be associated with better health outcomes

Fam. Proc., Vol. 56, September, 2017

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