The longitudinal effects of military spouses' concern and behaviors over partner drinking on relationship functioning

Alcohol 76 (2019) 29e36

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The longitudinal effects of military spouses' concern and behaviors over partner drinking on relationship functioning Lindsey M. Rodriguez a, *, Clayton Neighbors b, Karen Chan Osilla c, Thomas E. Trail c a

University of South Florida, St. Petersburg, St. Petersburg, FL, United States University of Houston, Houston, TX, United States c RAND Corporation, Santa Monica, CA, United States b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 23 December 2017 Received in revised form 11 June 2018 Accepted 11 July 2018

Among those in close relationships, the perception that one's partner has a drinking problem is more strongly related to detriments in relationship quality than are the actual rates of the partner's drinking. The current study extends this work by examining the effects of this perception on relationship functioning longitudinally and whether this association is mediated by changes in how one behaves in response to their partner's drinking. Spouses and partners of military service members who were concerned about their partner's drinking (n ¼ 234) completed a baseline survey and a follow-up assessment five months later. Structural equation modeling was used to prospectively examine the association between concern about partner drinking and relationship functioning (i.e., relationship quality, conflict, communication patterns), and the mediated effect of regulation strategies. Results suggested that changes in participant concern were related to changes in relationship functioning, and these changes were mediated by changes in punishment and rewarding sobriety regulation strategies. This research suggests that concern about partner drinking is linked with poorer relationship functioning partly because of the increased use of punishment and the decreased use of rewarding sobriety. © 2018 Elsevier Inc. All rights reserved.

Keywords: Couples Relationship Alcohol use Problem drinking Perception Service members CRAFT

Introduction

Alcohol use and committed relationships

Among those in romantic relationships, the role alcohol plays can be positive, providing an outlet for couples to socialize together and build intimacy, or negative, serving as a source of stress, conflict, and potential aggression. Once crossing the threshold into problematic misuse, drinking can be a serious and legitimate cause of concern in relationships. Misuse of alcohol and other substances is the third most common cited reason for divorce (Amato & Previti, 2003). Moreover, one of the criteria in the DSM-V for an alcohol use disorder is whether the person's drinking has caused trouble with family or friends (American Psychiatric Association, 2013). Thus, concern about a romantic partner's drinking is an important factor in the complex dynamic between alcohol use and relationship processes.

There is a growing body of literature demonstrating that alcohol misuse not only has detrimental effects among those who drink heavily, but also negatively affects their loved ones. Spouses of individuals who misuse alcohol report higher rates of depression, anxiety, and somatic concerns and higher rates of relationship dissatisfaction and distress, emotional and physical abuse, and divorce (Collins, Ellickson, & Klein, 2007; Cranford, Floyd, Schulenberg, & Zucker, 2011; Cronkite & Moos, 1984; Dawson, Grant, Chou, & Stinson, 2007; Fischer & Wiersma, 2012; Halford, Bouma, Kelly, & Young, 1999; Leonard & Senchak, 1993, 1996; Moos, Finney, & Cronkite, 1990; Rodriguez, Neighbors, & Knee, 2014; Van Hasselt, Morrison, & Bellack, 1985). Greater alcohol use is also associated with less effective communication strategies between spouses (Marshal, 2003; Williamson et al., 2015). Alcohol misuse negatively affects other family members, especially children in the household. Families with parents who misuse alcohol experience more conflict than those with parents who drink less (Moos & Moos, 1984), and participating in spouse-focused alcohol

* Corresponding author. University of South Florida, St. Petersburg, 140 7th St., St. Petersburg, FL 33701, United States. E-mail address: [email protected] (L.M. Rodriguez). https://doi.org/10.1016/j.alcohol.2018.07.004 0741-8329/© 2018 Elsevier Inc. All rights reserved.

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L.M. Rodriguez et al. / Alcohol 76 (2019) 29e36

interventions is associated with reduced family conflict over time (Miller, Meyers, & Tonigan, 1999). Thus, alcohol misuse has the potential to be a source of strain in families and efforts to understand how to support spouses of those who drink problematically can benefit those who drink, their partner, and their family relationships.

subsequent drinking and concerned partners reported higher relationship satisfaction. This preliminary research underscores the significant potential for influence that concerned partner regulating strategies can have on their partner's drinking and the quality of their relationship. The current study is the first to examine the longitudinal effects of this association in a sample of concerned military spouses and partners.

Concern about partner drinking Alcohol use in the military Perceptions about others' behaviors exert a powerful influence in relationships. Concern about partner drinking (CPD) represents stress, uncertainty, and anxiety that results from a partner's drinking (Rodriguez, DiBello, & Neighbors, 2013; Rodriguez, Øverup, & Neighbors, 2013). More complex and profound than simply whether they are concerned about their partner, CPD can be both all-encompassing and cognitively depleting for the concerned partner, and include difficulties such as persistently worrying about the partner, whether and to what extent the partner is currently or will be intoxicated, and distrust about the partner's ability to stay sober, maintain everyday household tasks, or to not become verbally or physically abusive. Together, this uncertainty and anxiety can place a substantial strain on the relationship. CPD has been shown to have negative implications for relationship well-being, more so than the partner's drinking itself (Rodriguez, Øverup, et al., 2013; Rodriguez & Neighbors, 2015). In this way, perceptions exert a stronger influence on relationship well-being than reality (i.e., partner drinking quantity and frequency), and this concern about partner drinking is strongly associated with poorer relationship functioning (Rodriguez, Øverup, et al., 2013) and an increased likelihood of divorce several years later (Amato & Rogers, 1997). However, existing research is limited to community and college samples of partners with generally relatively low levels of concern. More research is needed to hone in on the specific effects of this concern in a targeted sample of concerned partners who are seeking help e both for themselves in managing their concern and for their partner in hopes of reducing the drinking. In the present research, we consider the impact of the CPD on family conflict, communication patterns, and relationship quality, beyond how much the partner drinks, in a sample of partners who are explicitly concerned about their partner's drinking. We also consider the concerned partner's behavioral responses to partner drinking as potential mechanisms underlying these associations. The role of behavioral regulation strategies A natural consequence of being concerned about a partner's drinking is to engage in behaviors aimed at reducing the partner's drinking. Four kinds of partner-regulating behaviors have been identified in the literature: punishing partner drinking (e.g., expressing anger, threatening), rewarding partner sobriety (e.g., suggesting activities that do not involve drinking, positively reinforcing sobriety), rewarding partner drinking (e.g., bringing alcohol home, drinking with the partner), and withdrawal from partner when drinking (e.g., leaving the residence, avoiding the partner; Love, Longabaugh, Clifford, Beattie, & Leaslee, 1993). Previous work has shown that when partners evince more concern about their partner's drinking, they are more likely to use both punishing drinking and rewarding sobriety strategies (Rodriguez, DiBello et al., 2013). Specifically, when a concerned partner uses punishing strategies, the drinking partner is more likely to subsequently drink heavily and the concerned partner is more likely to report poorer relationship satisfaction (Rodriguez, 2016; Rodriguez, DiBello et al., 2013; Rodriguez, DiBello, & Wickham, 2016). This link was inverse when the concerned partner rewarded their partner's sobriety, such that their drinking partner reported less

Given the prevalence of alcohol misuse in the military, there is growing concern about the mental health and drinking of military spouses (Booth et al., 2007; Eaton et al., 2008). Approximately 40% of the nearly 775,000 married service members in the U.S. report heavy drinking (i.e., 7þ/14 þ drinks per week for women/men; Bray et al., 2008; National Institute on Alcohol Abuse and Alcoholism, 2005; U.S. Preventive Services Task Force, 2004); this is more than three times higher than that of married civilians (13%; Paul, Grubaugh, Frueh, Ellis, & Egede, 2011). Military spouses in relationships with a heavy drinking service member report high levels of depressive symptoms and social impairment (Erbes, Meis, Polusny, & Arbisi, 2012), and an increased risk for domestic violence (Sayers, Farrow, Ross, & Oslin, 2009). Military spouses may also be at risk of heavy drinking themselves due to partner concordance in health behaviors, including alcohol use and misuse (e.g., Cornelius, Desrosiers, & Kershaw, 2016; Holway, Umberson, & Thomeer, 2017; €nn, Salvatore, Sundquist, & Sundquist, 2018; Leonard & Kendler, Lo Mudar, 2003; Windle & Windle, 2018). Thus, efforts to improve the mental health and relationship functioning among military spouses are sorely needed. Current research The current study is a secondary data analysis of a randomized clinical trial evaluating a web-based intervention, Partners Connect, for CPs concerned about their partner's drinking [blinded for review]. The larger trial found significant intervention effects on reducing CP anxiety and increasing social support compared to CPs randomized to a waitlist control group at 5-month follow-up [blinded for review]. We utilize the same baseline sample from the larger study to examine the effects of CPD longitudinally and whether the association between changes in CPD and reduced relationship quality over time is mediated by changes in how one behaves in response to their partner's drinking. The current research fills at least two gaps in the literature. First, although previous work has examined CPD in community and college samples, no research has evaluated how this concern might present itself in a targeted sample of military spouses (or civilian helpseeking samples) who are seeking help in dealing with their service member partner's drinking. Second, evaluating the ways in which CPD and maladaptive regulation strategies co-vary together is important to identify in order to tailor more effective intervention efforts for the concerned spouse, with potential downstream effects on the partner's drinking. We examine outcomes of experiencing CPD: relationship quality, family conflict, and communication patterns (i.e., demand/withdraw, criticize/defend, positive interactions). Then, we evaluate how the influence of CPD on changes in relationship functioning are explained by different types of behavioral regulation responses to partner drinking. Hypotheses We expect that CPD will be associated with reduced relationship functioning (i.e., poorer relationship quality and positive interactions, greater family conflict, demand/withdraw, and criticize/

L.M. Rodriguez et al. / Alcohol 76 (2019) 29e36

defend patterns). We do not expect perceived partner drinking to be associated with these outcomes because perceived partner drinking has not been related to relationship functioning after controlling for CPD in prior research (e.g., Rodriguez, DiBello et al., 2013; Rodriguez & Neighbors, 2015). We further expect that CPD will be related to greater use of punishing, rewarding sobriety, and withdrawal regulatory behaviors and reduced use of rewarding drinking behaviors. We also hypothesize, based on previous research, that punishing partners for drinking will be negatively related to changes in relationship functioning and that rewarding partners for their sobriety will be positively related to changes in relationship functioning. Finally, we expect that CPD will be related to poorer relationship functioning via specific regulatory behaviors. Based on previous work with social control and regulation (Craddock, vanDellen, Novak, & Ranby, 2015; Rodriguez, DiBello et al., 2013; Rodriguez et al., 2016), we expect CPD to be linked with poorer relationship quality through higher punishment and lower rewarding sobriety strategies. Method Participants and procedure Participants were 234 concerned partners (CPs) that included spouses and unmarried partners of military personnel who were interested in participating in a web-based brief intervention designed to help improve self-care and teach positive strategies regarding alcohol use when communicating concern to their partner. Inclusion criteria for participation included that CPs needed to: (1) be at least 18 years old; (2) be in a romantic relationship with their partner; (3) be living with their partner; (4) not be in the military currently themselves; (5) have a computer, mobile, phone, or tablet with Internet access; (6) have no plans to separate from their partner in the next 60 days; (7) indicate at least a value of “3” on scale from “1 not at all” to “7 very much” for the degree to which they felt their partner had an alcohol problem; (8) indicate they believed they would be in no danger if their partner found out about their participation in the study; (9) indicate no general concerns they would be physically hurt by their partner; and (10) be willing to try an online program focused on communicating with their partner about his/her drinking. CPs (n ¼ 483) were recruited via Facebook (Osilla, Pedersen et al., 2018). Eligible CPs (n ¼ 312; 65%) were randomized to the Partners Connect web-based intervention or a waitlist control condition. Intervention details may be found in Osilla, Trail et al. (2018). All CPs completed a baseline survey and another follow-up survey 5 months later. Attrition did not differ by follow-up status when examining our primary outcomes, and the most common reason for lost-to-follow-up was inability to schedule and contact the participant. Analyses are based on the 234 CPs who completed the 5month follow-up. These CPs were 95% female, 71% Caucasian, 9% multiracial, 6% African American, and 4% Hispanic. Participants were, on average, 32 years old (SD ¼ 6.5 years) and 89% of CPs were married to their current partner. About 1% of the sample (n ¼ 3) reported being in same-sex relationships. More than three quarters (77%) had children. Participants reported that 62% of their partners were on active duty, 8% were on Reserves/Guard, and 28% were Separated/Retired. Measures Demographics CPs answered questions about their age, gender, race/ethnicity, and the presence of children who live with them at least half of the time.

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Concern about partner drinking Concern about partner drinking was assessed with the Thinking about Your Partner's Drinking scale (Rodriguez, DiBello et al., 2013). This concern presents itself when the partner's drinking becomes a source of strain on the relationship and it represents worry, anxiety, potential resentment, uncertainty, anger, and a desire to reduce the partner's drinking. This measure includes 25 items (e.g., my partner's drinking is a source of strain in our relationship, I wish my partner wouldn't drink so many drinks, sometimes my partner scares me with how much he or she drinks) rated on a 1 (strongly disagree) to 7 (strongly agree) Likert-type response scale. Items were averaged to create a composite (aT2 ¼ .98). Perceived partner drinking Collateral reports of alcohol data have been validated (Meyers, Miller, Hill, & Tonigan, 1998; Meyers, Miller, Smith, & Tonigan, 2002; Miller et al., 1999; Roozen, de Waart, & van der Kroft, 2010). CPs completed the Drinking Norms Rating Form (DNRF) to assess perceptions of their partners’ total drinks per week in the previous 30 days (Baer, Stacy, & Larimer, 1991). We also assessed the number of perceived partner heavy drinking episodes (HDEs) in the previous 30 days by asking participants how frequently they thought their partner had five or more drinks on one occasion. Scores could range from 0 to 30. Participant drinking We also included heavy drinking episodes by the concerned partners as a covariate. Participants were asked how many times during the previous 30 days they drank four or more drinks on one occasion. Scores could range from 0 to 30. Regulation strategies The Spouse Behavior Questionnaire (SBQ; Love, Longabaugh, Clifford, Beattie, & Peaslee, 1993) was used to assess different behavioral responses to their partner's drinking. The SBQ comprises four subscales: punishment (e.g., try to stop your partner's drinking by getting angry; aT2 ¼ .90), rewarding sobriety (e.g., do things your partner likes when he/she was not drinking; aT2 ¼ .93), rewarding drinking (e.g., bring alcoholic beverages home; aT2 ¼ .57), and withdrawal (e.g., keep out of your partner's way when he/she was drunk; aT2 ¼ .76). Each subscale was created by taking the mean of the items representing that subscale. Relationship functioning We created a relationship functioning variable for baseline and follow-up time points, which comprised a factor score from measures of relationship quality, family conflict, and three communication subscales. Relationship quality The CPs' perceptions of relationship quality were measured using the 6-item Quality of Marriage Index (QMI; (Norton, 1983)). CPs rated items (e.g., our relationship is strong) on a scale from 1 (strongly disagree) to 10 (strongly agree) and scores were calculated by summing the six items (range 6e60; aT2 ¼ .98). The QMI has been used in previous studies of military couples (Doss et al., 2012; Skopp et al., 2011). Family conflict Family environment quality was assessed using the conflict subscale from the Family Environment Scale (FES; (Moos & Moos, 1986)). The 9-item subscale measured anger and conflict among family members. CPs rated items (e.g., we fight a lot in our family) on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). Four

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of the items were reverse-scored and all items were summed so that higher scores reflected more conflict (aT2 ¼ .77). Communication Communication patterns were assessed with the Communication Patterns Questionnaire (CPQ; Futris, Campbell, Nielsen, & Burwell, 2010). CPs reported how likely 11 statements were to happen when discussing issues or problems in their relationship on a 1 (very unlikely) to 10 (very likely) scale. Three patterns of interactions were scored: positive interactions (e.g., both partners express feelings to each other; aT2 ¼ .89), demand/withdraw patterns (e.g., you try to start a discussion while your partner tries to avoid a discussion; aT2 ¼ .67), and criticize/defend patterns (e.g., both partners blame, accuse, or criticize each other; aT2 ¼ .82). Analysis plan Analyses were conducted using structural equation path n & Muthe n, 2017). Relationship modeling in Mplus 8.0 (Muthe functioning was specified from factor scores of relationship quality, family conflict, and communication (i.e., positive interactions, demand/withdraw, and criticize/defend patterns) measures. Factor scores (Devlieger, Mayer, & Rosseel, 2016) were used rather than latent variables with multiple indicators to reduce the number of parameters estimated relative to the sample size. Factor scores for each time point were created by using a confirmatory factor analysis with relationship quality, family conflict, and the three communication subscales (i.e., positive interactions, demand/ withdraw patterns, and criticize/defend patterns). Results from the confirmatory factor analysis provided loadings for each indicator, and regression on the new variable yielded the factor scores, which were saved and included in the models. We included perceived partner drinking (both drinks per week and heavy drinking episodes), CP heavy drinking episodes, intervention condition, the presence of children in the home, and all study variables at baseline as covariates. Concern about partner drinking was specified as an exogenous variable with a direct pathway to relationship functioning and indirect pathways through regulation strategies. We were primarily interested in whether changes in regulation strategies mediated associations between changes in CPD and changes in relationship functioning. In other words, as concern about the partner's drinking changes over time, how is that related to how they change their behaviors related to the partner's drinking, and how is that in turn related to their communication, conflict, and

relationship quality? To test this question, we examined the association of Time 2 CPD on Time 2 relationship functioning via Time 2 regulation strategies, controlling for each respective baseline measure. In this way, we examine how changes in CPD relate to changes in relationship functioning, and whether these links occur at least in part due to changes in regulation strategies. Because analyses with Time 2 variables control for Time 1 variables, we were functionally examining assessments of change. For example, in the model presented in Fig. 2, CPD at Time 2 is the residual of CPD at Time 1, which captures the change in the variable between baseline and follow-up. Thus, paths from a Time 2 variable to another Time 2 variable represent how changes in one variable are related to changes in another. The conceptual model is presented in Fig. 1 and the statistical model is presented in Fig. 2. Based on Kline's (2015) recommendation, overall model fit was evaluated with five fit indicators: the chi-square test for model fit, the Root Mean Square Error of Approximation (RMSEA; Steiger, 1990), the Comparative Fit Index (CFI; Bentler, 1990), the TuckerLewis Index (TLI; Bentler, 1990), and the Standardized Root Mean Square Residual (SRMR). Mediation hypotheses were evaluated via bootstrapped bias-corrected confidence intervals, specified with 1000 bootstraps. For the c2 test, a c2/df ratio <3 is a standard threshold for acceptable fit (Kline, 2015); for the RMSEA, values less than .05 indicate good fit and values as high as .08 represent acceptable fit (Browne & Cudeck, 1993; Steiger, 1990); for the CFI and TLI, values greater than .90 and .95 reflect acceptable and good model fit, respectively (Hu & Bentler, 1999); and for the SRMR, values less than .08 indicate good model fit (Hu & Bentler, 1999). Results Preliminary associations Descriptive statistics and zero-order correlations are presented in Tables 1 and 2 for Time 1 and 2 study variables, respectively. On a 1 to 7 scale, CPs reported an average concern about partner drinking (CPD) score of 5.04 (SD ¼ 1.34) at baseline and 4.27 (SD ¼ 1.74) at follow-up. CPs reported that their partners drank, on average, approximately 27 drinks per week (SD ¼ 19.26) at baseline and 18.5 drinks per week (SD ¼ 18.91) at follow-up. They perceived that their partners experienced approximately 10.8 (SD ¼ 9.2) and 6.9 (SD ¼ 9.2) heavy drinking episodes in the previous month at each time point, with themselves experiencing 2.6 (SD ¼ 3.2) and 2.1 (SD ¼ 3.0) heavy drinking episodes. Although intervention

Fig. 1. Hypothesized mediation model.

L.M. Rodriguez et al. / Alcohol 76 (2019) 29e36

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Table 1 Descriptive statistics and zero-order correlations among all study variables at Time 1.

1. CPD 2. Punishment 3. Reward P Sobriety 4. Reward P Drinking 5. Withdrawal 6. Relationship Funct 7. Perceived P DPW 8. Perceived P HDE 9. Concerned P HDE Mean Standard Deviation Range

1.

2.

3.

4.

5.

6.

7.

8.

9.

– .63*** .20** .24*** .40*** .37*** .34*** .38*** .12y 5.04 1.34 1e7

– .25*** .19** .46*** .41*** .19** .21** .02 10.94 3.82 5e20

– .17* .12y .16* .02 .08 .15* 22.47 5.14 9e32

– .21** .02 .09 .04 .29*** 5.55 1.99 3e12

– .33*** .10 .14* .14* 6.85 2.58 4e16

– .06 .09 .08 9.14 3.47 0e16.83

– .81*** .13y 26.94 19.26 0e100

– .12y 10.80 9.22 0e30

– 2.64 3.23 0e22

Note. CPD ¼ Concern about partner drinking. Funct ¼ Functioning factor score. P ¼ Partner. DPW ¼ Drinks per week. HDE ¼ Heavy drinking episodes. yp < .10; *p < .05; **p < .01; ***p < .001.

Table 2 Descriptive statistics and zero-order correlations among all study variables at Time 2.

1. CPD 2. Punishment 3. Reward P Sobriety 4. Reward P Drinking 5. Withdrawal 6. Relationship Funct 7. Perceived P DPW 8. Perceived P HDE 9. Concerned P HDE Mean Standard Deviation Range

1.

2.

3.

4.

5.

6.

7.

8.

9.

– .65*** .19** .01 .45*** .51*** .46*** .44*** .03 4.27 1.74 1e7

– .02 .10 .48*** .47*** .27*** .29*** .08 8.48 3.75 5e20

– .01 .02 .38*** .28*** .21** .24*** 22.00 6.48 8e32

– .12y .04 .13* .06 .28*** 5.12 1.83 3e10

– .32*** .18* .16* .09 6.38 2.69 4e16

– .20** .17* .12y 8.65 3.95 0e19.88

– .82*** .06 18.47 18.91 0e100

– .06 6.93 9.23 0e30

– 2.09 3.03 0e20

Note. CPD ¼ Concern about partner drinking. Funct ¼ Functioning factor score. P ¼ Partner. DPW ¼ Drinks per week. HDE ¼ Heavy drinking episodes. yp < .10; *p < .05; **p < .01; ***p < .001.

condition was included as a covariate, it was not significant in the context of the model presented here. As shown in Tables 1 and 2, CPD was significantly correlated with all study variables except rewarding a partner's drinking and own heavy drinking episodes at follow-up. Specifically, higher CPD was related to greater perceived partner drinking, punishment, and withdrawal regulation strategies. CPD was also significantly related to lower rewarding partner sobriety strategies and relationship functioning. Punishment and withdrawal were significantly related to poorer relationship functioning, whereas rewarding partner sobriety was related to better relationship functioning. Rewarding partner drinking was not related to relationship functioning.

Table 3 Estimates of indirect effects and 95% confidence intervals for associations between changes in CPD and relationship functioning through regulation strategies. Effects CPD / Regulation Strategies Total effect Total indirect effect Specific indirect effect Via punishment Via rewarding sobriety Via rewarding drinking Via withdrawal Direct effect

ab

SE (ab)

95% LLCI

/ Relationship Functioning 1.073 .155 .744 .461 .105 .269 .255 .124 .003 .085 .612

.079 .050 .012 .053 .175

.114 .043 .036 .012 .254

95% ULCI 1.358 .686 .419 .244 .014 .201 .948

Note. ab ¼ Product of a path  b path coefficients; SE ¼ Standard error; LLCI ¼ Lower level confidence interval; ULCI ¼ Upper level confidence interval. 95% confidence intervals are bias-corrected bootstrapped confidence intervals based on 1000 bootstraps.

CPD linked to relationship functioning via regulation strategies Concern about partner drinking and relationship functioning Our first hypothesis was that changes in CPD would be related to reductions in relationship functioning at follow-up. We expected this pattern to emerge after controlling for perceived partner drinking and covariates (i.e., intervention condition and the presence of children). We did not expect perceived partner drinking to be significantly related to relationship functioning when CPD was included in the model. In other words, we expected perceptions of drinking as problematic e not perceived amount of alcohol e to be the factor meaningfully linked with relationship functioning. We examined relationship functioning at Time 2 as a function of CPD at Time 2, with each controlling for respective Time 1 variables and covariates. This model fit the data well, c2/df ¼ 2.15; RMSEA ¼ .071, 95% CI [.050, .092], CFI ¼ .930, TLI ¼ .905, SRMR ¼ .050. Results suggested a strong, negative association between changes in CPD and changes in relationship functioning, b ¼ 1.077, p < .001. Conversely, as hypothesized, changes in perceived partner drinking were not related to changes in relationship functioning (drinks per week b ¼ .001, p ¼ .996, and heavy drinking episodes b ¼ .008, p ¼ .823). Mediation via regulation strategies Our second hypothesis was that perceiving the partner's drinking as a problem would be related to increased use of certain CP regulatory behaviors at follow-up. Results from the path model including covariates, perceived partner drinks per week, CPD, and regulation strategies are presented with standardized estimates in Fig. 2. Overall, the model fit the data well, c2/df ¼ 1.61;

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Fig. 2. Results from the mediation model. Standardized coefficients are presented. T1 ¼ Time 1 (baseline). T2 ¼ Time 2 (5-month follow-up). PP ¼ Perceived Partner. CP ¼ Concerned Partner. DPW ¼ Drinks per week. HDE ¼ Heavy drinking episodes. Paths were also specified from Time 1 to Time 2 for PP DPW, PP HDEs, and CP HDEs; however, these are not included here for parsimony. yp < .10; *p < .05; **p < .01; ***p < .001.

RMSEA ¼ .052, 95% CI [.038, .064], CFI ¼ .932, TLI ¼ .909, SRMR ¼ .069. Indeed, changes in CPD were positively associated with the use of punishment, b ¼ 1.196, p < .001, and withdrawal, b ¼ .605, p < .001. Changes were also negatively related to rewarding partner sobriety, b ¼ .748, p ¼ .005, and unrelated to rewarding partner drinking, b ¼ .021, p ¼ .755. Our third hypothesis was that certain regulation strategies would be differentially related to changes in relationship functioning. We expected punishment and potentially withdrawal to be negatively related e and rewarding sobriety to be positively related e to changes in relationship functioning. As can be seen in Fig. 2, in examining predictors of changes in relationship functioning, changes in punishment were significantly negatively related to changes in relationship functioning. Further, as expected, changes in rewarding sobriety were positively related to changes in functioning at follow-up. Changes in rewarding drinking and withdrawal from the partner were not related to changes in functioning. Although CPs' own heavy drinking episodes were related to poorer functioning, perceived partner drinking and heavy drinking episodes, intervention condition, and presence of children were also unrelated to changes in relationship functioning (p's > .45). Finally, we hypothesized that changes in partner regulation strategies would mediate the association between CPD and relationship functioning. Results from mediation analyses with 95% bias-corrected bootstrapped confidence intervals for the indirect effects are presented in Table 3. As expected, changes in punishment and rewarding sobriety mediated the association between changes in CPD and changes in relationship functioning. In other words, when concerns about a partner's drinking increased over time, participants used more punishing strategies, which was, in turn, negatively associated with changes in relationship functioning. On the contrary, when partners experienced decreases in concern about partner drinking, they used more frequent positively reinforcing strategies, and thereby reported better relationship

functioning. Changes in rewarding drinking and withdrawal from the partner while drinking did not emerge as mediators. Discussion Military spouses often experience considerable problems associated with their partner's drinking. In this research, military spouses sought participation in a research study because they experienced concern about their partner's drinking (CPD) behavior. This concern is a complex psychological construct that emerges when a partner's drinking becomes a source of strain on the relationship, and it depicts the CP's levels of worry, anxiety, potential resentment, uncertainty, anger, and desire to reduce the partner's drinking. This research is the first study to examine the associations between CPD and CP regulation strategies in a sample of concerned partners, and is the first to longitudinally examine the underlying mechanisms in changes in CPD over time. Consistent with prior research (e.g., Rodriguez & Neighbors, 2015), we found that CPD was a better predictor of poorer relationship functioning (including relationship quality, family conflict, and communication patterns) than perceived partner drinking, and was also linked with behavioral regulation strategies: higher use of punishing and withdrawal behaviors and lower use of rewarding sobriety behaviors. In other words, when partners experienced more concern about their partner's drinking, they tended to engage in more punishing and withdrawing behaviors and fewer behaviors related to rewarding sobriety. Longitudinally, punishing partners for drinking was negatively associated with relationship functioning, and rewarding partners for their sobriety was positively related to relationship functioning. Finally, regulation strategies (punishment and rewarding sobriety) mediated the association between CPD and relationship outcomes. Specifically, CPs who had increases in CPD scores over time reported greater use of punishment regulation,

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which was in turn related to poorer relationship functioning. CPs with decreases in CPD scores over time reported using more positively reinforcing strategies such as rewarding partner sobriety, and thereby reported better relationship functioning and conflict resolution. These results suggest the powerful effect of CPD on how CPs interact with their partner, and the direct impact of changes in CPD on regulation strategies and relationship quality, communication, and conflict. Implications CPD is a complex construct that not only describes a CP's concern, but also encompasses levels of worry and maladaptive intra- and interpersonal functioning associated with their partner's drinking. Decreases in CPD may be an important target of future screening and intervention efforts, and our research shows that decreases in CPD contribute to changes in regulation behaviors over time, which strengthens relationship outcomes. As for clinical implications of this research, our research lends support for benefits of decreasing CPD. Therapeutic interventions such as the Community Reinforcement and Family Training (CRAFT) and Alcohol Behavioral Couple Therapy (ABCT) teach CPs self-care to cope with their partner's drinking effectively and skills for interacting with a partner who may be reluctant to seek treatment (McCrady et al., 2016; Meyers, Smith, & Lash, 2005; Smith & Meyers, 2007). Second, future intervention work may focus on decreasing maladaptive regulation strategies, such as punishing, and increasing positive reinforcement, such as rewarding sobriety. Future interventions with CPs may focus on positive communication strategies, interactive role-plays, and problem solving/emotion regulation when negative interactions ensue. Finally, examining the individual items of the CPD may guide treatment planning with the CP. For example, if a CP strongly agrees that “Sometimes my partner scares me with how much he or she drinks”, a clinician may decide to further assess the CP's safety and discuss a safety plan with him/ her. If a CP strongly agrees to “I wish there were more I could do to make my partner drink less”, a clinician may explore how their partner's drinking is affecting the CP's mental health and/or capitalize on the CP's motivation to learn more effective communication strategies.

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about partner drinking and changes in relationship functioning, because only two timepoints of data were collected, variables were assessed at the same timepoints and are not in a temporal order for mediation. Future research would benefit from investigating these constructs with several timepoints to evaluate mediation more comprehensively. Finally, future research may wish to explore how CPs may change their levels of concern independent of changes in partner drinking. Perhaps receiving educational information about alcohol's effects on the body or simply reappraising the situation differently could result in changes in partner concern, which may have downstream effects on the relationship e or even actual partner drinking. Conclusion In a sample of partners who were highly concerned with their partner's drinking, we found that this concern is related to poorer communication and relationship quality, and that this is at least partly mediated by CP regulation strategies. This study provides preliminary support that when CPs' concern is reduced over time, their use of maladaptive regulation strategies also decreases, their use of adaptive regulation strategies increases, and their relationship outcomes are improved. Future interventions that specifically target CP regulation strategies and provide coping skills to manage CPD should be evaluated and may have important implications for the CP and their relationship. Acknowledgments The current study was funded by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA; 1R34AA023123, Principal Investigator: Karen Chan Osilla). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIAAA or the National Institutes of Health. The authors would like to thank Dr. Robert J. Meyers for his consultation and guidance adapting CRAFT for this study. The authors also express appreciation to Helen Chin, Marylou Gilbert, Eric Helmuth, Stefanie Howard, Lisa Jonsson, PhuongGiang Nguyen, and Rosalyn Velasquez, without whom this research would not be possible.

Limitations and future directions

Appendix A. Supplementary data

This work should be considered in light of its limitations. First, while this study represents a first look at the longitudinal effects of CPD, the two-timepoint design limits our ability to specifically examine causal mediation analyses. A design with more timepoints e or with timepoints more closely together in time e would provide a more nuanced examination of how CPD, behavioral regulation responses, and relationship functioning co-evolve. Second, the absence of partner data precludes evaluation of whether and how CPD relates to partner relationship evaluations. A truly dyadic perspective on these constructs would provide richer information that would more closely resemble real life interaction processes (e.g., perhaps partners respond to punishment with increased conflict and drinking). Third, all participants expressed concerns about their partner's drinking, as this was part of the inclusion criteria to participate in the trial. Thus, there is a restricted range on the concern over partner drinking variable measured here, and changes discussed here reflect changes in variables for a generally concerned group. As such, results should be interpreted accordingly. Future research may wish to explore these concepts in a sample with variability seen more frequently in the general population. Fourth, although our model here examines how change in regulation mediates the association between changes in concern

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