Login | Forgot password? | Register | MyCME | Point of Care | All CME Activities | E-Lerts | Blog | About Us | Contact Us | Help | visit us on FacebookFacebook
Psychlopedia Main Page | Series Page | CME Background

Working Together To Restore Mental Well-Being and Address Domestic Violence Among Veterans: A Call To Action

Psychiatrist.com Home    Keyword Search

Close [X]

Search Our Sites

Enter search terms below (keywords, titles, authors, or subjects). Then select a category to search and press the Search button. All words are assumed to be required. To search for an exact phrase, put it in quotes. To exclude a term, precede it with a minus sign (-).

Keyword search:

Choose a category:

Choosing the appropriate category will greatly improve your chances of finding the best match.

All files at our sites: J Clin Psychiatry, Primary Care Companion, CME Institute, and MedFair

Search CME offerings:

CME Institute, including CME from journals , supplements, and Web activities for instant CME credit (registered users); also includes information about our CME program

CME activities from regular issues of The Journal of Clinical Psychiatry(registered users)

CME Supplements from The Journal of Clinical Psychiatry (registered users)

Search materials from our journals:

Abstracts from The Journal of Clinical Psychiatry, 1996–present, both regular issues and supplements

PDFs of the full text of The Journal of Clinical Psychiatry, 1996–present, both regular issues and supplements (paid subscribers)

PDFs of the full text of The Primary Care Companion, 1999–present

aspen logo
Supported by an educational grant from Blue Shield of California Foundation.
Instructions

Working Together to Address Domestic Violence Among Veterans

Casey T. Taft, PhD

Department of Psychiatry, Boston University School of Medicine and Staff Psychologist, National Center for PTSD, Boston VA Healthcare System, Boston, Massachusetts

As part of the ongoing Veterans Initiative, a partnership of the Aspen Institute and The Journal of Clinical Psychiatry, a Summit was held in Aspen, Colorado, on June 21, 2013, with representatives from the Department of Defense, the Department of Veterans Affairs, veterans’ advocacy groups, and domestic violence programs. The purpose of the Summit was to identify best practices in preventing domestic violence in families of veterans. This Psychlopedia activity grew out of the ideas presented at the Summit, the highlights of which have been published as a Commentary in The Journal of Clinical Psychiatry.

Domestic violence refers to any physical aggression directed toward a partner, including grabbing, pushing, shoving, and using a weapon. Rates of physical violence among veteran and other military populations have ranged fairly widely in representative samples (14% to 58%), with higher rates typically reported in samples with less psychopathology.1 Research2 comparing military and civilian populations (and adjusting for demographic differences) has shown that, while rates of moderate aggression were similar, severe forms of spousal violence were reported more often in the military population. Anecdotal evidence suggests that the problem of intimate partner violence among veterans’ families may be worsening over time. The Battered Women’s Justice Project reported a 3-fold increase in military-related calls to the National Domestic Violence Hotline from 2006 through 2011 (AV 1).

AV 1. Military-Related Callers to the National Domestic Violence Hotline (00:26)

Data from http://www.bwjp.org/files/bwjp/files/
NDVH_Military_Calls_2006_through_
2011.pdf

Etiology and Risk Factors for Aggression Among Veterans

The survival mode model could explain problems with anger and aggression in military populations.3 This model posits that service members, when deployed to a war zone, need to be constantly vigilant and alert to any potential threats in their environment. This state is adaptive during deployment because these service members need to recognize potential threats and then respond to those threats, sometimes with aggression. They will notice very small changes in their environment, such as objects by the road that are in a different place than they were the day before, and they will focus on people’s facial expressions to determine if others may be a threat. When they return home, this heightened perception of threat can remain, often leading to problems with anger and aggression. Veterans still in survival mode may automatically view others’ intentions as hostile or negative, which can cause a number of different problems. Veterans may misread their partners’ facial expressions as hostile or misinterpret their partners’ reactions and then accuse their partners of attempting to “push their buttons” or engage in hostile acts toward them when that may not be the case.

AV 2. Evidence-Based Risk Factors for Intimate Partner Violence Among Veterans (00:45)

Based on Elbogen et al4
Abbreviation is defined before the References

Studies have reported several risk factors associated with violence among veterans (AV 2).4 The presence of PTSD has been shown to be a strong risk factor for intimate partner violence.1 Research5 in a representative sample of male Vietnam veterans found that those with current PTSD exhibited greater problems with marital and family adjustment and violent behavior than those without PTSD. Hyperarousal symptoms seem to represent the cluster of PTSD symptoms that is most strongly associated with risk for aggression and domestic violence,6,7 which is consistent with the survival mode model. When people are constantly on guard or hypervigilant and have difficulty sleeping, they become irritable and angry and more likely to misinterpret situations in overly hostile ways. They are more likely to assume the worst about others, including their relationship partner, which can escalate disagreements to aggressive incidents.

Other risk factors that have been associated with risk for anger, aggression, and domestic violence include depression,8 alcohol use problems,7 and traumatic brain injury.9 Veterans and service members usually do not present to care providers with just one specific problem. PTSD is often accompanied by depression, alcohol use problems, or a traumatic brain injury.10,11 The clinical picture can often be complicated, and these risk factors can operate together to increase risk for violence.7,8,12

Core Themes Underlying Relationship Difficulties

While relationship problems are associated with PTSD,13 most service members and veterans do not have diagnosable psychiatric disorders. However, a deployment or a traumatic event may have changed the way the veteran sees the world in general and may affect schemas regarding various concepts that are important for relationships. Core themes underlying troubled relationships are mistrust, low esteem for self or others, and power/control conflicts.

Mistrust. Trust is a crucial factor in terms of relationship quality and functioning. Often, when service members experience trauma and come home, they have difficulty trusting other people. Perhaps they saw people do horrible things to one another, they were let down by someone while they were deployed, or they have been in survival mode for too long to trust anyone. Controlling behavior may result from mistrust.

Low esteem. Self-esteem can be affected by trauma and military deployments if the service member engaged in behavior that caused him or her to feel ashamed or guilty. Veterans who feel responsible for someone’s death, for example, may experience extreme guilt and have difficulty with self-esteem. Veterans may also feel guilty because they had to leave their buddies behind when they left the military. Additionally, veterans may have low esteem for others, meaning they now view others more negatively because they have seen people treat each other badly.

Power conflicts. Power conflicts are also relevant to domestic violence.14 Veterans may have felt completely powerless during deployment, especially during traumatic situations.15 Upon returning home, they try to compensate for this feeling of powerlessness by having more power and control over their environment. This compensation can carry over into relationships and lead to power struggles, especially if their family members took on additional roles in the household while the service members were deployed.16

Barriers to Care

One of the largest barriers to helping veterans and their partners with domestic violence is stigma. In fact, stigma is a major barrier to help-seeking for various problems, including PTSD, in returning veterans. This help-seeking problem can be compounded by negative consequences of revealing partner violence. For example, a service member can be discharged from the military or receive a decrease in rank, which will affect not only the service member but also the family in many ways, including financially. Veterans also may receive reduced benefits if involved in the criminal justice system. The Lautenberg Amendment mandates that someone who is convicted of a misdemeanor domestic violence offense will be denied access to firearms, which has implications for service members’ careers. Another barrier to help-seeking is that few confidential and voluntary treatment options exist.

Assessing for and Addressing Domestic Violence

When assessing for domestic violence in military and veteran populations, clinicians should ask direct, specific, and nonjudgmental questions. Depending on relationship satisfaction, veterans may actually be more likely to report perpetrating abuse than their partners are likely to disclose it.17 The veteran or partner should not be pressured to disclose abuse; however, asking questions over time in a supportive way will be more likely to elicit an acknowledgement of violent behavior and abuse.

Clinicians should educate both veterans and their partners about violence. For example, sometimes veterans and family members think that violence is just another symptom of PTSD. They need to know that PTSD is a risk factor for violence but not a cause of it. Clinicians should help partners understand that nothing justifies abusive behavior and that they do not need to tolerate abuse to be supportive of their partner. Providers should also suggest local referral options and discuss support systems and safety plans with partners, that is, people they can talk to and places they can go when a potentially violent situation arises. Partners at risk for violence should be advised to keep a bag packed with important documents and a change of clothes in case they need to leave the house in a hurry.

To address a veteran’s domestic violence, coordination of care is extremely important in reducing recidivism.18 Those involved include the court and prosecution system, counselors, probation officers, and other providers, including those caring for the recipient of the abuse. Treatment programs typically involve psychoeducation and CBT.19 The new Strength at Home intervention for veterans is one such program.

More

The Strength at Home Program

The Strength at Home program has been conducting large, randomized clinical trials funded by the VA, the DoD, and the CDC to develop model programs to prevent and treat intimate partner violence among active duty or veteran populations. These courses incorporate the survival mode model as well as the social information processing model of partner violence (AV 3).20–22 Pilot results are positive at 6-month follow-up.20 The program offers 2 types of courses: a 12-session course for male service members and veterans of any conflict era and a 10-session course for military couples of the Operation Enduring Freedom/Operation Iraqi Freedom era. The groups are relatively small, with about 5 members, and they are led by male and female cotherapists. Each group receives weekly 2-hour sessions. The 4 stages of the program consist of psychoeducation, conflict management, coping strategies, and communication; the 12-session course is described below.

AV 3. Social Information Processing Model in Intimate Partner Violence (00:42)

Based on Taft et al21 and Murphy22

Stage I. The Strength at Home program begins with 2 sessions of education about trauma, violence, and PTSD. An initial exercise is to have participants discuss the temporary gains that they believe they derive from acting abusive and then describe the negative consequences. Veterans are usually able to describe only a couple of temporary gains that reinforce their abusive behavior, such as feeling more in control or expressing their anger. The exercise highlights the many negative consequences of abuse, such as legal and financial repercussions, the potential end of their relationship, feelings of extreme guilt, and the negative impact on their children. The point of this exercise is to facilitate motivation to change. Other topics covered in the first 2 sessions are the different forms of abuse; the core themes of trust, self-esteem, and power and control; and the goals for group members.

Stage II. The second stage of the Strength at Home program covers conflict management strategies. Sessions 3 and 4 emphasize understanding one’s anger response. Topics include the physiological signs of anger, the thoughts that contribute to anger, and the feelings that underlie the anger. Veterans are taught to monitor themselves to recognize the different warning signs for anger. Assertiveness is taught because veterans often tend to be overly passive in relationships—they tend to suppress their anger and all of their feelings until they explode in an aggressive outburst. The program helps veterans learn to talk to their partners about their feelings. They also develop specific time-out plans with their partner so that they can de-escalate situations before abuse occurs.

Stage III. Next, veterans learn coping strategies such as stress management and cognitive-behavioral strategies such as replacing negative, survival-mode thoughts with more adaptive thoughts. Sessions 5 and 6 cover problem-focused versus emotion-focused coping, realistic appraisals of threat and others’ intentions, and relaxation training for anger management.

Stage IV. The last phase of the Strength at Home program is the longest; sessions 7 through 12 cover communication skills. In an exercise called “Roots of Your Communication Style,” veterans talk about how they learned to express anger over the course of their lives. Often, they describe being taught as boys that men hold in their feelings, and their military experience reinforced that idea. Then, the sessions address the importance of active listening, because the best way to improve relationships is to enhance one’s listening abilities. One communication trap that veterans sometimes fall into is “mind-reading,” in which they assume that they know what their partners are thinking. Strategies for giving an assertive message and expressing their feelings more effectively are also included.

Conclusion

Although most veterans do not have psychiatric illness and do not have problems with domestic violence, factors such as PTSD, depression, and substance abuse increase the risk of intimate partner violence. The risk for violence is compounded by the presence of several factors. Veterans may need help with mistrust, low esteem for self or others, and power/control conflicts. Veterans and partners who have relationship difficulties should receive education about any psychiatric diagnosis that is given, the problem of survival-mode thinking at home, and available resources such as cognitive-behavioral interventions to prevent or stop domestic violence. When addressing a veteran’s domestic violence, coordination of care is needed to reduce recidivism.

Clinical Points

  • Recognize risk factors that increase the risk for domestic violence among military veterans (eg, PTSD, depression, substance abuse)
  • If risk factors are present, screen for domestic violence among veterans and their partners using direct, nonjudgmental questions
  • Educate veterans and their partners about violence, discuss support systems and safety plans, suggest local referral options, and coordinate care with other providers

Abbreviations

CBT = cognitive-behavioral therapy
CDC = Centers for Disease Control and Prevention
DoD = US Department of Defense
PTSD = posttraumatic stress disorder
VA = US Department of Veterans Affairs

Take the online posttest.

References

  1. Marshall AD, Panuzio J, Taft CT. Intimate partner violence among military veterans and active duty servicemen. Clin Psychol Rev. 2005;25(7):862–876. PubMed
  2. Heyman RE, Neidig PH. A comparison of spousal aggression prevalence rates in US Army and civilian representative samples. J Consult Clin Psychol. 1999;67(2):239–242. PubMed
  3. Chemtob CM, Novaco RW, Hamada RS, et al. Anger regulation deficits in combat-related posttraumatic stress disorder. J Trauma Stress. 1997;10(1):17–36. PubMed
  4. Elbogen EB, Fuller S, Johnson SC, et al. Improving risk assessment of violence among military veterans: An evidence-based approach for clinical decision-making. Clin Psychol Rev. 2010;30(6):595–607. PubMed
  5. Jordan BK, Marmar CR, Fairbank JA, et al. Problems in families of male Vietnam veterans with posttraumatic stress disorder. J Consult Clin Psychol. 1992;60(6):916–926. PubMed
  6. Taft CT, Kaloupek DG, Schumm JA, et al. Posttraumatic stress disorder symptoms, physiological reactivity, alcohol problems, and aggression among military veterans. J Abnorm Psychol. 2007;116(3):498–507. PubMed
  7. Savarese VW, Suvak MK, King LA, et al. Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans. J Trauma Stress. 2001;14(4):717–732. PubMed
  8. Taft CT, Weatherill RP, Woodward HE, et al. Intimate partner and general aggression perpetration among combat veterans presenting to a posttraumatic stress disorder clinic. Am J Orthopsychiatry. 2009;79(4):461–468. PubMed
  9. Wortzel HS, Arciniegas DB. A forensic neuropsychiatric approach to traumatic brain injury, aggression, and suicide. J Am Acad Psychiatry Law. 2013;41(2):274–286. PubMed
  10. Brady KT, Killeen TK, Brewerton T, et al. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry. 2000;61(suppl 7):22–32. Full Text
  11. Wall PL. Posttraumatic stress disorder and traumatic brain injury in current military populations: a critical analysis. J Am Psychiatr Nurses Assoc. 2012;18(5):278–298. PubMed
  12. Baguley IJ, Cooper J, Felmingham K. Aggressive behavior following traumatic brain injury: how common is common? J Head Trauma Rehabil. 2006;21(1):45–56. PubMed
  13. Monson CM, Taft CT, Fredman SJ. Military-related PTSD and intimate relationships: from description to theory-driven research and intervention development. Clin Psychol Rev. 2009;29(8):707–714. PubMed
  14. Pence E, Paymar M. Education Groups for Men Who Batter: The Duluth Model. New York, NY: Springer Publishing Company; 1993.
  15. Rosenbaum A, Leisring PA. Beyond power and control: towards an understanding of partner abusive men. J Comp Fam Studies. 2003;34(1):7–22.
  16. Schwartz JP, Waldo M, Daniel D. Gender-role conflict and self-esteem: factors associated with partner abuse in court-referred men. Psychol Men Masculinity. 2005;6(2):109–113.
  17. Marshall AD, Panuzio J, Makin-Byrd KN, et al. A multilevel examination of interpartner intimate partner violence and psychological aggression reporting concordance. Behav Ther. 2011;42(3):364–377. PubMed
  18. Murphy CM, Musser PH, Maton KI. Coordinated community intervention for domestic abusers: intervention system involvement and criminal recidivism. J Fam Violence. 1998;13(3):263–284.
  19. Eckhardt CI, Murphy C, Black D, et al. Intervention programs for perpetrators of intimate partner violence: conclusions from a clinical research perspective. Public Health Rep. 2006;121(4):369–381. PubMed
  20. Taft CT, Macdonald A, Monson CM, et al. "Strength at Home" group intervention for military populations engaging in intimate partner violence: pilot findings. J Fam Violence. 2013;28(3):225–231.
  21. Taft CT, Schumm JA, Marshall AD, et al. Family-of-origin maltreatment, posttraumatic stress disorder symptoms, social information processing deficits, and relationship abuse perpetration. J Abnorm Psychol. 2008;117(3):637–646. PubMed
  22. Murphy CM. Social information processing and the perpetration of intimate partner violence: it is (and isn't) what you think. Psychol Violence. 2013;3(3):212–217.

CME Background Information

Supported by an educational grant from Blue Shield of California Foundation.

Objective

After completing this educational activity, you should be able to:

Financial Disclosure

The faculty for this CME activity and the CME Institute staff were asked to complete a statement regarding all relevant personal and financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure is as follows:

Dr Taft has no personal affiliations or financial relationships with any commercial interest to disclose relative to the activity.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hours of Category I credit for completing this program.

To obtain credit for this activity, study the material and complete the CME Posttest and Evaluation.

Release, Review, and Expiration Dates

This Psychlopedia activity was published in October 2013 and is eligible for AMA PRA Category 1 Credit™ through October 31, 2016. The latest review of this material was October 2013.

Statement of Need and Purpose

In April 2012, an Aspen Institute convening on the mental well-being of returning veterans determined a campaign is needed to educate frontline providers in the civilian population about the emotional needs of returning combat veterans and train them in best practices how to help returning veterans reintegrate into society. The convening included representatives from the Department of Defense, Veterans Administration, National Center for PTSD, and Substance Abuse and Mental Health Services Administration, as well as other public and private agencies interested in restoring the mental well-being of veterans who often suffer from PTSD, traumatic brain injuries, or an increased risk of suicide. The group agreed on two main challenges: (1) many veterans are reluctant to participate in mental health treatment because of a perceived stigma, and (2) frontline providers, including health care professionals, do not have adequate training to help these veterans overcome this stigma and seek treatment. Similarly, a Blue Shield Foundation of California Issue Brief, Preventing Violence in the Homes of Military Families, published in April 2012, summarized the results of the Foundation’s $1.6 million investment in organizations attempting to prevent domestic violence in military families. The Brief found that returning veterans have both high rates of mental health issues, eg, PTSD, depression, substance abuse, and elevated incidences of physical aggression, including domestic violence. Since returning veterans often live in civilian rather than military cultures, the Brief noted a need for community organizations to establish models of care that help veterans and their families reintegrate into society. This includes a focus on mental health services, which are generally underfunded in relation to the need. This activity was designed to meet the needs of participants in CME activities provided by the CME Institute of Physicians Postgraduate Press, Inc., who have requested information on veterans’ mental health needs.

Disclosure of Off-Label Usage

Dr Taft has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration–approved labeling has been presented in this activity.

Review Process

The entire faculty of the series discussed the content at a peer-reviewed planning session, the Chair reviewed the activity for accuracy and fair balance, and a member of the External Advisory CME Board who is without conflict of interest reviewed the activity to determine whether the material is evidence-based and objective.

Acknowledgment

This Psychlopedia is derived from the planning teleconference “Working Together to Address Domestic Violence Among Veterans,” held July 19, 2013, and supported by an educational grant from Blue Shield of California Foundation. The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the supporter.