Introduction

Family violence, encompassing both intimate partner violence (IPV) and child maltreatment (CM), is a considerable public health issue affecting a large subset of the U.S. population. One in every four women and one in ten men experience sexual or physical violence or stalking in the context of an intimate relationship (Center for Disease Control and Prevention (CDC), 2022b). Similarly, approximately one in every seven children experience child abuse or neglect each year (CDC, 2022a). The Department of Defense (DoD) (2021) defines child abuse as “the physical or sexual abuse, emotional abuse, or neglect of a child by… a caregiver…under circumstances indicating the child’s welfare is harmed or threatened” (p.18). Domestic abuse is defined as “domestic violence, or a pattern of behavior resulting in emotional/psychological abuse, economic control, and/or interference with personal liberty” (DoD, 2021, p. 39). The definition of domestic abuse extends to current and former married partners, partners who share a child, and current or former intimate partners who share or have shared a domicile (DoD, 2021). These different experiences of violence occurring within the family appear to be interrelated, such that the experience of one form of family violence may increase the likelihood of other forms of violence in the home (Chan et al., 2021). Recent research has also suggested that lockdowns and social distancing meant to control the COVID-19 pandemic have contributed to an increase in IPV and potentially CM in the United States (Kaukinen, 2020; Rapp et al., 2021; Rossi et al., 2020; Viero et al., 2021).

Military families may be exposed to unique risk factors for experiencing family violence. Elements of the deployment cycle as well as the physical and mental health consequences of military service may be associated with elevated risk for CM and IPV (Hisle-Gorman et al., 2019; Park et al., 2021; Sullivan et al., 2022; Taylor et al., 2016). Military and Veteran families experience a unique set of stressors. During military service, these stressors can include frequent relocation, long work hours, separation from loved ones for training or deployments, exposure to combat and associated physical and mental health consequences (Sullivan et al., 2020). Among Veteran families, these stressors can include coping with Post Traumatic Stress Disorder (PTSD), finding and maintaining employment, navigating care within the VA health system, as well as what it means to be a Veteran family (Creech & Misca, 2017; Kintzle & Castro, 2018; Wadsworth et al., 2013).

Meta-analytic findings suggest that the prevalence of IPV among military samples is approximately 26%, though prevalence varied by gender and military status (e.g., Active Duty vs. Veteran), which is slightly higher than the national average for “contact” sexual violence and slightly lower than the national average for “severe” violence in an individual’s lifetime (Kwan et al., 2020). Regarding child maltreatment, the U.S. military’s Family Advocacy Program (FAP), which is tasked with prevention, detection, and response to violence among Active Duty families, reported a unique child victim rate of 4.3 per 1000 in 2021, which is lower than the national average (CDC, 2022a; DoD, 2022). Considering the adverse psychological, social and economic outcomes associated with family violence (e.g., Chan et al., 2021), interventions to address violence among military families are critical to preventing and ameliorating these experiences and their sequelae.

Interventions to address family violence that are specific to military and Veteran populations are critical to military family wellbeing as they address the unique military context as well as military stressors. Considering the unique set of stressors and context experienced by military/Veteran families, it is critical to consider the availability of effective treatment options, which target both the prevention of family violence and intervention for families experiencing IPV, CM, or both. Though a number of these programs exist, to our knowledge, there has been no systematic effort to describe and evaluate these interventions. The present review aims to address this gap in the literature.

To address this issue, the present study employs systematic review methods to explore the following research question (s): (1) What military family violence interventions are reported on in the peer-reviewed literature? (2) What are the characteristics of these interventions? (3) How effective are these interventions?

Methods

Based on evidence that suggests librarian or information specialist co-authorship in systematic reviews are correlated with higher quality search strategies (Rethlefsen et al., 2015), the research team invited a librarian from one of their academic institutions to participate in the review process and be a co-author on this paper. In addition to helping develop the review’s search strategies, the librarian participated in the composition of a detailed protocol explaining the review methods, questions, context, definitions, search strategy, inclusion/exclusion criteria, quality appraisal, data extraction and synthesis. This protocol was submitted to PROSPERO (the International Prospective Register of Systematic Reviews). Due to the COVID-19 pandemic, the PROSPERO team of peer reviewers were unable to conduct its usual checking of submitted protocols. Although the protocol was not approved, the submission can be accessed under the registration code CRD42022296207] (Table 1).

Table 1 Search terms
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With the librarian, the research team identified the databases APA PsycNET, PubMed, Social Services Abstracts, and the ProQuest Military Collection to conduct their searches in December 2021. To ensure our search was most up to date, another search was conducted on September 24th, 2022 spanning literature published between December 2021 to September 2022. The initial search strategy focused on four broad and inclusive concepts (1. Family roles/identities, 2. Military context, 3. Relational health, and 4. Intervention methods). Since this initial search revealed several military focused family-based interventions (i.e., Post Traumatic Stress Disorder, Traumatic Brain Injury, etc.), the study team decided to focus on interventions that addressed family violence. Eligible sources included peer-reviewed literature only, that met the following inclusion criteria including: (1) empirical research article, (2) U.S. military sample, (3) reported an outcome at the family level, (4) published after 2001 (to focus on post-9/11 era of military families), (5) published in English, and (6) reported a measure of violence. Pharmacological interventions were excluded (see Fig. 1).

Fig. 1
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Systematic review flow diagram

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The four databases returned a total of 3,666 research citations, of which 196 were identified as duplicates according to the systematic review management application Covidence (Covidence Systematic Review Software, 2022). The review process included four steps. First, two research team members (CK, WW) independently screened the 2,751 research citations based on predetermined inclusion criteria (described above). Second, disagreements were resolved by a third investigator tasked to screen the research citations (JD). Overall agreement during the screening process was over 80% with a Cohen’s Kappa ranging from 0.5 to 0.7 demonstrating adequate consensus among the team members. Third, data that was extracted from the remaining 15 studies included authors, year, program name, military status (Veteran or Active Duty), number of intervention sessions, mode of delivery, retention rates, targets for intervention, violence outcomes assessed, effect sizes, research design and reporting participant(s) (see Tables 2 and 3). Lastly, the final list of sources were determined, and the PRISMA checklist was referenced to extract main findings and collate them to describe study characteristics and intervention characteristics to comment on the intervention components and effectiveness of the studies.

Table 2 Studies included in systematic review on military family Intimate Partner Violence (IPV) interventions
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Table 3 Overview of intimate partner violence interventions for military families
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Results

Fifteen studies evaluated thirteen interventions that address either IPV or CM, including different modalities of the same intervention (Tables 2 and 3). For example, the Strength at Home intervention had five papers that examined three modalities represented in this review (couples, men’s program, parenting). About half of the studies evaluated interventions for Veterans and/or their partners (n = 7), one study was for both Veterans and Active Duty service members and/or their partners (n = 1), four were solely for Active Duty service members and/or their partners and families (n = 4), two studies were for Veterans alone (n = 2), and one study addressed a system-level intervention (n = 1). Only three studies examined child-level outcomes (child sexual abuse, child neglect, and child’s psychosocial functioning) using data drawn from parent self-reports (Creech et al., 2022; Slep et al., 2021, 2022; see Table 3). For studies including Veterans and their partners (n = 7), sample sizes ranged from N = 10 to N = 246 (M = 86; SD = 77) with retention rates ranging from 21 to 100% across various treatment modalities. In studies including Active Duty service members and their partners and/or families that reported retention and individual outcomes (see Table 3; n = 3), sample sizes ranged from N = 102 to N = 147 (M = 119; SD = 25) with retention rates ranging from 45 to 100%. In the two studies including individual Veteran alone, sample sizes ranged from N = 21 to N = 131 (M = 76; SD = 77), with retention rates ranging from 62 to 73%. One study included a sample that was both Veteran and Active Duty service members and their partners; this study was all virtual with a retention rate of 57% (see Table 3).

Study Characteristics & Outcomes

Table 2 shows the characteristics and violence outcomes assessed for all studies included in this review. Of these 15 studies, five utilized the randomized control study design (Baddeley & Pennebaker, 2011; Salivar et al., 2020; Slep et al., 2021; Taft et al., 2016a, b, 2021), five case-controlled (Creech et al., 2018; Nowlan et al., 2017; Schaffer, 2015; Taft et al., 2013, 2014), one non-experimental retrospective case study design (Kaye et al., 2022), two pilot trials (Creech et al., 2022; Khalifian et al., 2022), and two quasi-experimental study designs (Anderson et al., 2013; Slep et al., 2022). Among these 15 studies, 6 utilized non-randomized comparison groups.

Thirteen out of fifteen studies utilized validated measures including the Anger Management Scale (AMS), CDC National Intimate Partner and Sexual Violence Survey, Conflict Tactics Scale (CTS) and the Revised CTS (CTS2), Multidimensional Measure of Emotional Abuse (MMEA), Family Maltreatment Measure (FM) Domestic Violence/Abuse Screen (DV/AS). The remaining studies utilized participant self-report to record the frequency of yelling and physical violence between military spouses in addition to other forms of partner abuse (emotional or sexual) (Baddeley & Pennebaker, 2011; Slep et al., 2022). One study (Kaye et al., 2022) utilized case files and family reports to identify factors that contribute to family violence revictimization. Most studies, all randomized or case-controlled, conducted a range of follow-up timelines from 1 to 12 months post-intervention. The most common follow up procedure was 6 and 12 month follow-up assessments post-intervention.

Two studies (Kaye et al., 2022; Slep et al., 2022) examined FAP case files to understand family violence (both child maltreatment and partner abuse) utilizing different approaches—evaluation of a system-level intervention to reduce recidivism and a large-scale, retrospective case study analysis to understand individual, family, community, and treatment factors associated with family violence revictimization.

While most studies included racial/ethnic and gender information of participants, none focused on these important minority groups. Another important minority group that was not reported on in these interventions were non-heterosexual relationships.

Intervention Characteristics

Table 3 presents all IPV and CM interventions evaluated in the reviewed studies. Across all modalities, the average length of sessions was 93.8 min (SD = 53.0) and the average number of sessions was 9.5 (SD = 3.4) when excluding one intervention which took place during a one and a half day training (NORTH STAR) and the Army Family Advocacy Program (FAP) where the number of sessions varied considerably (Slep et al., 2021; Smith Slep et al., 2022). Overarching themes of the studies included a shared focus on communication skills (38%; n = 6), psychoeducation on IPV and reactions to trauma (33%; n = 5), understanding anger (20%; n = 3), conflict management (20%; n = 3), and developing cognitive strategies (47%; n = 7). 47% (n = 7) of studies reported effect sizes of their primary outcomes while the remaining studies reported pre-post results, including some form of violence assessment.

Several studies reported on the environment necessary for successfully implementing their IPV intervention. For example, Slep and colleagues showed that a supportive program environment was necessary to see significant positive intervention outcomes (Slep et al., 2021). Creech and colleagues described four different implementation strategies to improve treatment success: (1) requiring sites and clinicians to apply to receive the IPV training, (2) assigning pre-training activities through pre-training calls, (3) beginning outreach before training, (4) team-based implementation in which all clinicians assist with referrals and outreach (Creech et al., 2018). Taft and colleagues discussed how implementation efforts are needed on bases that house Active Duty military couples in addition to medical settings (Taft et al., 2016a). Lastly, Slep and colleagues demonstrated that implementing a systems level intervention, the Field-tested Assessment, Intervention-planning, and Response (FAIR), including training in assessment and computerized decision-making tools, decreased child maltreatment and intimate partner violence recidivism within the Army community (Slep et al., 2022).

Intervention Outcomes

All studies reported positive intervention outcomes, which ranged from improved anger management skills, including reduced yelling (Anderson et al., 2013; Baddeley & Pennebaker, 2011), reductions in physical and psychological IPV (Creech et al., 2018; Nowlan et al., 2017; Schaffer, 2015; Slep et al., 2021; Taft et al., 2013, 2014, 2016a, 2021), decreases in parenting practices that could potentially become violent (Creech et al., 2022), improvement in overall couples functioning (Salivar et al., 2020), and increased relationship satisfaction (Anderson et al., 2013; Khalifian et al., 2022). This is encouraging as a variety of treatment modalities, including group-based (Anderson et al., 2013; Creech et al., 2018, 2022; Taft et al., 2013, 2014), individual (Schaffer, 2015; Slep et al., 2021), couples-based (Baddeley & Pennebaker, 2011; Nowlan et al., 2017; Salivar et al., 2020; Taft et al., 2014, 2016a, b, 2021; Khalifian et al., 2022), in-person (Baddeley & Pennebaker, 2011; Creech et al., 2018; Nowlan et al., 2017; Schaffer, 2015; Slep et al., 2021; Taft et al., 2013, 2014, 2016a, b, 2021), and virtual or self-paced workbook or adaptable treatments (Anderson et al., 2013; Khalifian et al., 2022; Salivar et al., 2020) were all shown to be effective. Only two studies examined the impact of an IPV intervention on child maltreatment. One study found that a “light touch” day and a half training (called New Orientation for Reducing Threats to Health from Secretive-Problems That Affect Readiness (NORTH STAR) for base leadership led to reliable reductions in suicidality, child physical abuse, and partner emotional abuse (Slep et al., 2021).

Intervention Effectiveness

While all studies reported positive outcomes, their effect sizes ranged from small to large (Anderson et al., 2013; Baddeley & Pennebaker, 2011; Creech et al., 2018; Salivar et al., 2020; Nowlan et al., 2017; Schaffer, 2015; Slep et al., 2021; Taft et al., 2013; Creech et al., 2022; see Table 2). The Strength at Home intervention was especially effective, consistently demonstrating medium to large effect sizes over time across different studies, settings and modalities, with a substantial improvement in both physical and psychological IPV (Creech et al., 2018, 2022; Taft et al., 2013, 2014, 2016b, 2021) compared to treatment as usual. NORTH STAR (Slep et al., 2021) and Treatment as Usual Couples Therapy offered within the Veterans Administration Medical Centers (Nowlan et al., 2017) showed medium effect sizes. The Brief Expressive Writing Intervention (Baddeley & Pennebaker, 2011) showed a small effect size and the Our Relationship and Relationship Enhancement Program showed little to no effect (Salivar et al., 2020). It is important to note that the majority of these effect sizes were from non-randomized control trials (n = 9). Without randomization and a comparison group it is hard to rule out other causes for the reduction in IPV.

Regardless of modality, the reported long-term treatment outcomes were for the most part sustained at four months post treatment (Baddeley & Pennebaker, 2011; Salivar et al., 2020; Taft et al., 2013, 2014, 2016b), with some that showed sustained improvements for up to a year post intervention (Creech et al., 2018; Taft et al., 2016a, 2021) and one that showed sustained improvements for 18 months after the intervention (Nowlan et al., 2017).

Discussion

This systematic review assessed the availability of effective treatment options, which target both the prevention of violence and intervention for those experiencing IPV, CM, or both. Specifically, this paper reviews military violence interventions reported in the peer-reviewed literature and describes the characteristics and effectiveness of these interventions. This study had three main findings: (1) The majority of interventions were for Veterans and/or their partners rather than active service personnel; (2) All interventions reported positive outcomes in the reduction of self-reported IPV, with the majority of these outcomes maintained overtime; (3) While we intended to assess military family-level interventions that targeted IPV and CM, we only found two studies that targeted or included CM.

Accessibility of IPV Interventions

The majority of the programs were designed for Veterans and/or their partners Creech et al., 2018; Khalifian et al., 2022; Nowlan et al., 2017; Schaffer, 2015; (Taft et al., 2014, 2016a, b, 2021), followed by Active Duty service members and/or their partners (Anderson et al., 2013; Baddeley & Pennebaker, 2011; Kaye et al., 2022; Slep et al., 2021), and only two interventions that included either Active Duty or Veteran and/or their partners (Salivar et al., 2020; Taft et al., 2013). When Salivar and colleagues assessed the OurRelationship and ePREP (Prevention and Relationship Enhancement Program) programs, they compared military couples to civilian couples and found that civilian couples had a higher completion rate compared to military couples (Salivar et al., 2020). Elements of the deployment cycle and regular changes in duty station which require families to move frequently could make it hard to attend regular appointments (Sullivan et al., 2021a; Wadsworth et al., 2016). Future research should focus on how to best engage military couples in treatment as they cope with the demands of military life. A potential avenue could be virtual treatment, in which some studies in this review found success (Anderson et al., 2013). For example, the OurRelationship intervention that was reviewed in this study was found to be an effective virtual treatment (Anderson et al., 2013). However, this systematic review also shows that Active Duty service members and their partners had overall higher retention rates than Veterans and their partners. This could be due to Veterans not being close to a medical center that offers couples-based treatment, while Active Duty couples typically live closer to military bases where services are offered. Future research could explore the difference in retention rates online vs. in-person modalities of the treatment.

Several studies in this review discussed environmental characteristics that supported the implementation of IPV interventions. Across studies, these results suggest that inner contextual (i.e., organizational climate/culture, local leadership support) factors are keys to support the implementation of IPV interventions (Aarons et al., 2011; Damschroder et al., 2022; Moullin et al., 2019; Kaye et al., 2022; Slep et al., 2022). For example, site level individual adopter characteristics, i.e., organizational climate and culture, such as requirements for clinicians to apply to receive IPV training, recruiting on military bases that house military couples, and supportive implementation environments led to more successful implementation (Creech et al., 2018; Slep et al., 2021; Taft et al., 2016b). Furthermore, another study found that clinician characteristics such as the willingness of clinicians to assist with referrals to specific IPV services and outreach supported the roll out of an IPV intervention within the Veterans Health Administration healthcare system (Creech et al., 2018). Collectively, these results highlight the importance of understanding the inner context, specifically the climate and culture as well as clinician characteristics, before implementing an IPV intervention.

The Positive Impact of Couples IPV Interventions

Findings revealed that all ten IPV interventions demonstrated positive outcomes for both Active Duty and Veteran couples. Regardless of modality, the reported long-term treatment outcomes were mostly sustained at four month post treatment, with some that showed sustained improvements for up to a year post intervention (Creech et al., 2018; Nowlan et al., 2017; Taft et al., 2016a, 2021). An area of future research could be to investigate the long-term outcome differences for different treatment modalities. For example, research could explore if a couples-based treatment has more of a sustained impact compared to group or individual based treatment, or if in-person or virtual treatment has more of an impact over time. The latter will be particularly important to address in the wake of the COVID-19 pandemic as many health interventions have been adapted to virtual delivery for safety reasons (Rauschenberg et al., 2021).

Child Wellbeing

While the majority of treatment outcomes focused on the individual or couple, NORTH STAR, Strength at Home Parenting, and Family Advocacy Programs were the only studies to assess child maltreatment as an outcome from the parent’s perspective (Creech et al., 2022; Slep et al., 2021, 2022). Two studies do not report on the types of interventions used to address child maltreatment, only reporting it as an outcome alongside other familial and community risk factors (e.g., hazardous drinking, financial difficulty, prior family violence, and IPV; Slep et al., 2021, 2022). A limitation of the other interventions found in this review was that they did not report how many of these individuals or couples had children in the home. Research shows that IPV in the home can greatly impact the wellbeing of children and their long term health (see Chan et al., 2021 for meta-analysis). Furthermore, the current research shows military families may have unique risk factors, including a high prevalence of PTSD, for experiencing family violence (Hisle-Gorman et al., 2019; Sullivan et al., 2016, 2021, 2022). For example, the Strength at Home intervention was adapted to provide parenting skills to Veterans diagnosed with PTSD to improve parent-child functioning, including reducing child maltreatment (Creech et al., 2022).

This review highlights the lack of peer-reviewed publications on military family interventions specifically designed to treat CM, a critical gap in the military family violence in the home intervention literature. This is particularly crucial for the Active Duty military community where witnessing IPV is defined as child maltreatment by the FAP (DoD, 2022). The Veterans Affairs hospital does not include child maltreatment in their IPV definition (Intimate Partner Violence Assistance Program (IPVAP), 2021). Future research should focus on documenting if children are in the home where IPV occurs in order to know the magnitude of the problem among Veterans.

Strengths & Limitations

This study is the first review to examine family-based violence interventions within the military population. This review was registered through PROSPERO and a librarian was consulted and included in this manuscript to ensure higher quality search strategies. This review included only peer-reviewed literature to ensure the empirical rigor of sources included in this review, though this choice likely excluded grey literature. This systematic review was limited to information available through the four databases used for searching. A broader search may lead to the identification of further articles. Additionally, this search was limited to the past 20 years focusing on post-9/11 era of military families, therefore excluding potential military family programs in past era. For example, we know this excluded the Wexler “STOP” program as it was published before 2001 (Dunford, 2000). However, by focusing our search on the post-9/11 era, these findings are most applicable to current military and Veteran families.

While it was this studies’ intent to assess interventions focused on violence in the home, minimal child maltreatment interventions appeared in our search. This indicates a gap in the literature about the support – and the effectiveness of such support – available to military families. Furthermore, while one study evaluates the FAP program (Kaye et al., 2022) as a whole, this systematic review did not find any empirical research on the specific programs or interventions offered in the FAP program. The majority of these findings were from non-randomized studies and therefore limited because they cannot rule out other factors that could be leading to the reduction in IPV. Finally, a major limitation of this systematic review is that we did not find any interventions that focused on racial/ethnic/gender minorities or non-heterosexual relationships. Future research on IPV interventions should focus on these minority populations.

Conclusions

This review documents that numerous IPV treatment interventions have demonstrated effectiveness to various degrees at reducing various self-reported types of violence in military families. Future research should explore how different treatment modalities (e.g., couples, individual, group, in-person, online) could affect long-term IPV treatment outcomes. Additionally, future research should consider whether treatment modalities (e.g., couples, individual, group, in-person, online) has an impact on retention rates; this is particularly important for Veterans who may not live close to where services are provided. Lastly, more research should focus on how to best document if children are in the household when delivering IPV treatments/programs for military families to help understand the magnitude for potential child maltreatment.