Combat-related Co-occurring Conditionsand Intimate Partner Violence

B R I A N C LU B B

M I L I TA RY & V E T E R A N S A D VO C AC Y P R O G R A M

B AT T E R E D WO M E N ’ S J U S T I C E P R O J EC T

OverviewSubstance Use Disorders

Posttraumatic Stress

Insights video and discussion

Depression

Traumatic Brain Injury (TBI)

Screening & Assessment

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Substance UseDisorders (SUDs) and IPV

Both IPV perpetration and victimization are often co-occurring for people seeking alcohol and drug treatment

IPV perpetrators 2-3 times more likely to use illicit drugs and abuse or be dependent on alcohol or other drugs, or have serious mental illness [Lipsky et al., 2011]

While NOT causal, alcohol consumption (particularly binge drinking) linked to severity of IPV perpetration (Fals-Steward, 2003; Gerlock, 2012: NRI-04-040)

More alcohol consumption before violent IPV incidents among veterans and servicemembers [Marshall et al., 2005]

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Post-traumaticStress Disorder (PTSD)

Traumatic event + impairment + time +:◦ Avoidance

◦ Negative Cognitions & Mood

◦ Hyperarousal

◦ Re-experiencing

PTSD prevalence estimates◦ OIF/OEF - 11% - 20%

◦ Desert Storm - 12%

◦ Vietnam - 15%; 30% (lifetime)

◦ General population - 7% - 8%

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DSM V/National Center on PTSD

Post-traumaticStress Continuum

Combat and Operational Stress• Expected and predictable emotional, intellectual, physical

and/or behavioral reactions of those exposed to stressful events in war or military operations.

Acute Stress Response• Includes most components of PTSD, but lasts 2 days-4

weeks

• Presence of dissociative symptoms (numbing, detachment, decreased awareness of surroundings)

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PTSD and IPVMost military servicemembers and veterans with PTSD do not become abusive or violent

Veterans w/PTSD report significantly higher rates of generally violent behaviors and aggression than veterans w/o PTSD

Studies have consistently found veterans w/PTSD to have higher incidence of IPV perpetration than veterans w/o PTSD

Correlation vs. Causation

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PTSD Symptoms vs.Coercion/Control Tactics

Problems with threat appraisal (impulsive/reactive violence)

General aggression significantly related to the hyper-arousal symptom cluster & feeling a lack of control [Taft, et al., 2009]

Heightened arousal may prevent cognitive reappraisal of threat and consideration of alternative ways of behaviorally responding;

Physiological arousal creates a + feedback loop, strengthening hyper-arousal and perceived threat, creating an “Active Threat Schema” [Bell & Orcutt, 2009; Teten, et al., 2009]

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Triple threat: SUDs, MH, & IPVIPV perpetrators 2-3 times more likely to use illicit drugs and abuse or be dependent on alcohol or other drugs, or have serious mental illness [Lipskyet al., 2011]

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Insights intoMilitary Personnel & Veterans

VIDEO AND FACILITATOR’S GUIDE

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PART 3 – Terror and ConsequencesGiven Hector’s explanation of events the night he assaulted his ex-wife, what risk factors made him particularly dangerous?

What context or contexts do you think are present and why?

What observations do you have about the interventions by law enforcement, the jail staff, the courts, and the VA?

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PART 1 – From Childhood to WarriorBrief review of Hector’s childhood and the violence he was exposed to

Why do some men who are exposed to IPV as children become perpetrators themselves and others don’t?

Messages that Hector might have gotten about masculinity and women from his father and the military

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PART 2 – RelationshipsWhat might be the significance of Hector taking the car keys and leaving after an argument? What did he get out of this behavior? What was the impact on his ex-wife?

When the police were called, it seemed to validate Hector’s belief that both parties were responsible. How common is this dynamic?

Why might Hector’s ex-wife be reluctant to tell the authorities about the IPV or the preceding incident?

What do you think about Hector’s statement that he “went totally military?” What are other examples of intimidating behaviors used by men in the military? In general?

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Depression, Suicide, and IPVSuicidal thinking and behaviors is one of the main risk factors for lethal IPV

Veterans are twice as likely to die from suicide as non-veterans

Combat-related guilt and combat stress reactions can lead a depressed veteran to consider hurting or killing themselves

Combat exposure, PTSD, depression, substance abuse, and/or TBI increase the risk of suicide

Veterans are more likely than the general population to use firearms as a means for suicide

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Depression and PTSDDepression PTSD

A person may have a lack of

interest and stop participating in

activities once enjoyed.

A person will avoid participating

in activities in order not to trigger

the PTSD symptoms.

A person may have trouble getting

to sleep and staying asleep or may

awaken early and be unable to get

back to sleep.

A person will have the same type

of disturbed sleep compounded by

nightmares or night terrors. This

results in considerable fatigue and

loss of energy during the day.

A person may have thoughts of

death or actually make plans to kill

him/herself (sometimes following

through with the plan).

A person may wish to be dead

because of survival guilt.. He/she

may feel as if something bad is

about to happen and believe that

there is not long to live.

TraumaticBrain Injury (TBI)

Traumatically induced disruption of brain function and disturbance of consciousness caused by an external injury to the head, possibly resulting in function/disturbance in impairment of cognitive, emotional, and physical functioning

◦ Sleep problems

◦ Poor impulse control

◦ Increased verbal/physical aggression

◦ Irritability, anger, and impatience

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TBI Symptoms vs.Coercion/Control Tactics

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TBI Symptoms and IPV Tactics

Wife of a combat veteran:

“I know he got blown up over there. I can understand him forgetting things. I even understand him getting angry. I just don’t understand…anytime when I take a weekend to work at the arts and crafts fairs he calls me all day long. He calls me awful names. He accuses me of having affairs and sleeping with other men. Now just when am I supposed to do that…In between selling a bracelet and an earring?”

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TBI Symptoms and IPV Tactics

Wife of a combat veteran:

“I know he got blown up over there. I can understand him forgetting things. I even understand him getting angry. I just don’t understand…anytime when I take a weekend to work at the arts and crafts fairs he calls me all day long. He calls me awful names. He accuses me of having affairs and sleeping with other men. Now just when am I supposed to do that…In between selling a bracelet and an earring?”

Case Example

In this example, she identifies the general problems with memory and anger that can be associated with a TBI.

But, she correctly points out how a TBI doesn’t seem to explain his ongoing name-calling, accusations, and constant monitoring of her through the phone calls. This is an example of IPV.

SCREENING

• Quick check to determine if something exists (e.g., high blood pressure)

• Questions routinely asked to determine a problem

• Goal is to identify problem • Conducted by anyone with

some knowledge • Need protocols for action

for positive screen

ASSESSMENT

• A more in-depth, focused look at a problem

• Needed to establish a diagnosis

• Needs to be done by qualified people

• Guides intervention once the problem is confirmed

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Screening vs. Assessment

Screening for Alcohol MisuseAlcohol Use Disorders Identification Test (AUDIT-C)• How often did you have a drink containing alcohol in the

past year? (0 – 4)

• How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? (0 –4)

• How often did you have six or more drinks on one occasion in the past year? (0 – 4)

A positive score of 4 for men, 3 for women indicates probably unhealthy drinking levels

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Screening for Drug MisuseDrug Abuse Screening Test (DAST) (yes/no)• Have you used drugs other than those required for

medical reasons?• Do you abuse more than one drug at a time?• Are you unable to stop using drugs when you want to?• Have you ever had blackouts or flashbacks as a result of

drug abuse?• Does your spouse/partner (or parents) ever complain

about your involvement with drugs?

Score of 2 or more indicates a need for further assessment and possible intervention

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Screening for DepressionPatient Health Care Questionnaire -2 (0 – 3)• Over the past 2 weeks, how often have you been

bothered by any of the following problems?

• Little interest or pleasure in doing things• Feeling down, depressed or hopeless

A score of 3 or more is a positive screen for depression

A negative screen does not mean a person is not depressed, a positive screen does not mean he/she is

If a person appears depressed, refer for a full assessment regardless of score on screening

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Screening for TBIScreening helps determine if brain trauma occurred and if a referral needs to be made

Four sections◦ Section 1 establishes a trauma to the head

◦ Section 2 establishes symptoms and injury immediately at the time of the event

◦ Section 3 establishes the symptoms after the event

◦ Section 4 establishes ongoing symptoms and problems that are connected to the injury

Department of Veterans Affairs Website

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Brief screening for TBIH.E.A.D.S.

Have you experienced:

a. Headaches

b. Ears ringing

c. Altered consciousness

d. Dizziness

e. Something isn’t right

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In your life, have you ever had any experience that was so frightening, horrible, or upsetting that you…

◦ Have had nightmares about it or thought about it when you did not want to?

No=0 Yes=1◦ Have had nightmares about it or thought about it when you did not want to?

No=0 Yes=1◦ Tried hard not to think about it or went our of your way to avoid the situation

that reminded you of it? No=0 Yes=1 ◦ Were constantly on guard, watchful, or easily startled? No=0 Yes=1 ◦ Felt numb or detached from others, activities, or your surroundings? No=0

Yes=13 or more a positive screen for PTSD

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Screening for PTSD

Screening for IPVPerpetration• Have you ever hurt or threatened your partner

(wife/husband/girlfriend/boyfriend)?

• Have you ever pushed, grabbed, slapped, choked, or hit your partner?

• Have you ever forced sex or made your partner perform sexual acts they did not want to?

• Have you ever restricted your partner’s freedom or kept her/him from doing things important to her/him?

• Have you ever belittled, insulted, or blamed your partner?

Institute for Safe Families, Journal of General Internal Medicine, 2008

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