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A 2005 study showed the rate of intimate partner violence (IPV) use among veterans with posttraumatic stress disorder (PTSD) is approximately three times the rate of IPV for veterans without PTSD (Marshall, Panuzio, & Taft). In that study, prevalence rates of IPV among military veterans and active duty servicemen ranged from 13.3 – 58 percent (Marshall et al., 2005). The Veteran’s Health Administration (VHA) is currently addressing the issue of domestic violence and IPV (DV/IPV) by developing interventions for those experiencing relationship violence and disseminating these interventions through collaborative relationships with community mental health providers.

It is important to recognize that PTSD is a major risk factor for DV/IPV among veteran and military populations (Monson, Taft, & Fredman, 2009). DV/IPV can also be a barrier to treatment and recovery (Iverson, Resick, Suvak, Walling, & Taft, 2011). Related literature has considered and examined various associated factors from different theoretical perspectives. Williston, Taft, and VanHaasteren (2015) described the occupational stress and training of military service members as an etiological factor in DV/IPV. 

In addition, systematic responses to ensure survival in the face of threat that include using force are part of military training and drills are vastly different from skills learned by civilians for encountering and responding to conflict and likewise increase the risk for violence in intimate relationships (Williston et al., 2015). 

In a review of military-related PTSD and intimate relationships, Monson et al. (2009) summarized the recent literature on this topic. Specific PTSD symptoms of hyperarousal and avoidance have been investigated in studies which examine the connection between PTSD symptomatology and relationship satisfaction, intimacy, and aggression (Monson et al., 2009). Various studies have found that avoidance has a stronger association with relationship dissatisfaction and reduced intimacy in comparison to other PTSD symptom clusters– whether intimate partner relationships or parenting (Monson et al., 2009). 

Similarly, a study by Savarese, Suvak, King, & King (2001) (as cited in Monson et al., 2009) demonstrated that hyperarousal symptoms were predictive of intimate partner aggression - both psychological and physical – in comparison to other PTSD symptom clusters. Further, a study by Hundt & Holohan (2012) found shame to serve as a stronger contributor to IPV more than PTSD, depression, or guilt and to act as a mediator between PTSD and IPV. 

The repeal of Don’t Ask Don’t Tell and the removal of the military ban on women serving in combat demonstrate evolving U.S. military policy and VHA care in response to social change. Such change necessarily begets new perspectives in systems and institutions that support the U.S. military. In that vein, the increasing inclusion of women in the military has altered the way VHA responds to the needs of returning veterans. 

Women Veterans Health Centers on VHA campuses have increased and issues pertinent to women veterans are impacting the evolution of specialty care for women veterans as well as other populations. Attention to military sexual trauma (MST) and DV/IPV issues has coincided with the increased inclusion of women in the military. Women veterans are more likely to experience lifetime IPV than non-veteran women (Dichter, Cerulli, &Bossarte, 2011). Comparatively, in one study 33% of women veterans endorsed experiencing IPV in their lives, whereas 23.8% of non-veteran women experienced IPV (Dichter et al., 2011). 

The prevalence of DV/IPV is not an issue affecting only women veterans. The importance of considering diversity, gender differences, and the need for services for both parties involved in a violent relationship points to the need for further research and development of culturally informed clinical services in this area of Veteran Mental Health. 

For example, LGBTQ populations may experience additional risk factors which may heighten the risk for and frequency and intensity of DV/IPV but also may have unique resiliency factors to be taken into account (Marsiglio, 2013). 

Improving clinical practice in the assessment and intervention of DV/IPV in the VHA highlights the importance of providing interventions for those who use and experience violence in relationships and making those interventions available for both men and women. 

A myriad of issues – the role of military culture and training, stigma, and criminality – can complicate the evaluation and treatment of DV/IPV for service members and their partners and spouses. Such complications call for the use of multisystemic, interdisciplinary and collaborative approaches to address this mental health issue. Innovative programs attempting to address DV/IPV in this manner within the VA are currently under development after a major push from researchers based at the National Center for PTSD at the Boston VA Health Care System. Their advocacy for routine, efficient and accurate screening to detect DV/IPV that is comprehensive and sensitively delivered prompted a series of studies that drew attention to the problem (Iverson, 2013). 

In 2013, a VHA task force finalized guidelines for DV/IPV intervention which created an IPV Assistance Program Pilot and included 14 recommendations such as the creation of a domestic violence coordinator role at each VA (Ketchum, 2015). Other recommendations included in the IPV Assistance Program Pilot protocol include providing IPV training to specified departments and clinics, and collaboration within and outside of the VHA (Ketchum, 2015). In addition to the IPV Assistance Program Pilot, some VA sites offer additional resources and programs for DV/IPV. 

Strength at Home (SAH), a men’s program developed at the National Center for PTSD, VA Boston Health Care System is a four-stage, 12-week program to educate veterans and teach skills for anger and conflict management, coping, and communication (Ketchum, 2015; Taft, 2013). SAH is currently being implemented in two VA hospitals in New England (Williston et al., 2015). Large, randomized control trials using SAH and funded by the VA, DOD, and CDC are being conducted to prevent and treat the issue of DV/IPV (Taft, 2013). 

Pilot findings of that program showed reductions for both psychological and physical IPV after a 6-month follow-up (Taft, Macdonald, Monson, Walling, Resick, & Murphy, 2013). Groups are small, approximately 3-5 members (veterans only) and each weekly two hour session includes education and skills and capitalizes on the cohesion and camaraderie that is characteristic of military populations (Williston et al., 2015).
Williston et al. (2015) highlight the need for diversion programs and the integration of criminal justice involvement and treatment in order to systematically identify veteran status among those involved with DV/IPV in order to provide appropriate resources for such cases. Presentations through VHA on this issue emphasize the need for community mental health provider collaboration to understand the complications of addressing DV/IPV in veteran and military populations (Iverson, & Latta, 2013; Ketchum, 2015). 

Community providers can be helpful in cases where it is not clinically indicated to treat the couple together, in cases where there is a concern for repercussions that might follow the documentation of DV/IPV (which may be a criminal offense) in a service member’s record, and in other situations in which the involved parties prefer non-VA treatment. A relationship between VA and community providers is beneficial for providing high quality culturally informed care. Such collaboration might include having community providers give presentations to the VA on services that are available, or having VA providers present to community agencies on military culture and its implication on the issue of DV/IPV. 

Overall, the issue of DV/IPV is one that necessitates the involvement of multiple systems and interdisciplinary care. Current actions taken by VHA respond to the need to address this issue although more research and culturally informed approaches are still needed. Working together, community providers and VHA will have the best opportunity of addressing this nuanced mental health issue in a way that reduces recidivism and grants the best likelihood of diminishing the barrier to PTSD recovery that occurs. 
 

About the Author

Belle Zaccari, PsyD, is a clinical research fellow at the Mental Illness Research, Education, and Clinical Center (MIRECC) of the VA Portland Health Care System (VAPHORHCS). Her clinical work specializes in treatment of trauma in veteran populations and previous trauma work included issues of substance use and treatment of co-occurring mental health and addictive disorders. She is currently engaged in a two-year, research-based fellowship studying CAM approaches to PTSD recovery.
 

References

Dichter, M.E., Cerulli, C., & Bossarte, R.M. (2011). Intimate partner violence victimization among women veterans and associated heart health risks. Womens Health Issues, July-August, S190-S194.
Hundt, N.E. & Holohan, D.R. (2012). The role of shame in distinguishing perpetrators of intimate partner violence in U.S. veterans. Journal of Traumatic Stress, 25(2), 191-197.

Iverson, K.M. (2013) Routine screening for intimate partner violence in VHA: A timely opportunity. Journal of General Internal Medicine 29(2).

Iverson, K.M. & Latta, R. (December 9, 2013). Addressing intimate partner violence (IPV) among women in the veterans health administration (VHA): Toward a comprehensive response [PowerPoint slides]. Retrieved from whr.nlm.nih.gov/ipv_iverson_latta.pdf.

Iverson, K.M., Resick, P.A., Suvak, M.K., Walling, S., & Taft, C. (2011). Intimate partner violence exposure predicts PTSD treatment engagement and outcome in cognitive processing therapy. Behavior Therapy, 42(2), 236-248.

Ketchum, K. (May, 2015). Veterans and intimate partner violence (IPV): An introduction to the VHA domestic violence/intimate partner violence (DV/IPV) pilot program. Presented at the Portland VA Health Care System, Portland, OR.

Marshall, A.D., Panuzio, J., & Taft, C.T. (2005). Intimate partner violence among military veterans and active duty servicemen. Clinical Psychology Review, 25(7), 862-876.

Marsiglio, M. (May, 2013). Culturally sensitive treatment of intimate partner violence (IPV) with LGBT veteran relationships. Presented at the Portland VA Health Care System, Portland, OR.

Monson, C.M., Taft, C.T., & Fredman, S.J. (2009). Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clinical Psychology Review, 29(8), 707-714.

Savarese, V.W., Suvak, M.K., King, L.A., & King, D.W. (2001). Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans. Journal of Traumatic Stress, 14(4), 717-732.
Taft, C.T. (2013). Working together to address domestic violence among veterans. Journal of Clinical Psychiatry, 74(12):e25.

Taft, C.T., Macdonald, A., Monson, C.M., Walling, S.M., Resick, P.A., & Murphy, C.M. (2013). “Strength at Home” group intervention for military populations engaging in intimate partner violence: Pilot findings. Journal of Family violence, 28(3), 225-231.

Williston, S.K., Taft, C.T., & VanHaasteren, K.O. (2015). Military veteran perpetrators of intimate partner violence: Challenges and barriers to coordinated intervention. Aggression and Violent Behavior, 21(March- April), 55-60.