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Commentaries

Advancements in Treating Intimate Partner Violence in Veterans

See article by Hayes et al

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Hayes and colleagues1 chose a challenging topic in our field to investigate—the role of trauma among perpetrators of intimate partner violence (IPV). This topic is difficult for numerous reasons including the legal, ethical, and moral issues involved, as well as logistic and feasibility issues. This may explain why so little had been accomplished in this research area prior to the efforts of Dr Taft, coauthor1 and developer of the Strength at Home Friends and Family intervention, and his team.

Dr Taft spent much of his early career seeking to understand the mechanisms of the association among combat, posttraumatic stress, and perpetration of violence. The work presented in this issue of the Journal represents the beginning of his team’s effort to extend his work by developing and testing an innovative treatment to intervene with military personnel and veterans at risk before such violence becomes manifest.1 This is a particularly salient area of investigation now, given that large segments of our population have taken on the role of “warrior” (be it as a soldier, sailor, marine, or airman) during a protracted war period and are now being asked to reassume a civilian identity as the country attempts to transition back into peacetime. History and current events have demonstrated that such a transition, both for the country as a whole and for those who have been directly involved in the fighting, is likely to be volatile.2,3

We believe that the work presented here1 is groundbreaking for several reasons. First, it represents the concrete integration into treatment of a phenomenon that military and Veterans Administration providers have only recently come to fully acknowledge: family relationships and social support are critical to successful community reintegration for returning military personnel. Second, it takes a bold step in introducing the idea that expending resources on preventative efforts may be more effective than post hoc treatment in terms of both individual postdeployment readjustment and ongoing military readiness. Third, it demonstrates an understanding of the profundity of the shift between warrior and citizen that is required for effective community reintegration after months to years in combat. To understand this shift, it is important to consider that in the military (and particularly in a combat setting), certain characteristics are highly valued and are therefore likely to become central to identity: respect for and internalization of rigid power hierarchies; a capacity for (and positive reinforcement of) aggression; and the sublimation of vulnerable, withdrawal-associated feelings, such as fear, shame, horror, or loss, into the energizing and empowering feeling of anger. Thus, while many of us find it somewhat challenging to slip out of our professional identities to step into our family roles at the end of a work day, what is being asked of a combat veteran upon returning to his or her family from the alien territory of a war zone is no less than a reorganization of fundamental aspects of identity. If the veteran experiences posttraumatic stress disorder (PTSD) from military- or combat-related experiences, the potential for volatility in an attempt to reconcile these 2 aspects of self is high.2,3

This third point is perhaps the most subtle but paradigmatic element of Dr Taft’s work: While commentators from Homer to Hemingway4 to Jonathan Shay5 have written about the cognitive, emotional, and behavioral reorganization that flows from combat trauma and that can lead to the expression of violence, there is little empirical work on how clinicians can most effectively intervene to help those who struggle find alternatives to perpetuating aggressive patterns learned in military training and reified in battle. In this unassuming presentation of a preventative intervention, Dr Taft and his colleagues have built upon the idea that individuals who have been traumatized within a military context may have experienced fundamental changes to the way they process social information and that these changes are likely to have direct effects on the way they behave in their most intimate of relationships.1 In doing so, these researchers have translated literary and clinical observations into the language of science and used this foundation to develop an intervention that challenges how we, as mental health professionals, conceptualize and treat perpetrators of intimate partner violence.

To understand the gravity of this shift in terms of treatment paradigms, Taft’s work can be considered in the context of how perpetration of IPV has been addressed or treated to date. Common treatment models involve a basic assumption that all spouse abusers share the same fundamental psychology, thereby justifying a one-size-fits-all approach to treatment. From this standpoint, treating IPV perpetrators involves identifying them as criminals and referring them to the courts, providing them with cultural and psychological reeducation regarding the patriarchal ideology that underlies their misuse of power and control within the context of the family (ie, feminist-psychoeducational interventions), or identifying and correcting maladaptive cognitions that are thought to contribute to their inappropriate use of violence in achieving relational goals (ie, cognitive behavioral interventions).6 While the latter approach appears to incorporate an effort to understand the way perpetrators think about interpersonal situations in helping them to better adapt their behaviors, the cognitions that are targeted are typically limited to externalizing themes involving beliefs that aggression is an appropriate way to resolve conflict, that “people get what they deserve,” or that “I am the victim here.” Given that the role of trauma-related alterations to social information processing is rarely considered, it is unsurprising that these therapies are largely ineffective.6,7 For a combat veteran who has developed modes of information processing that allow for successful survival in a war zone and who has also been affected by trauma, the challenge of adapting processing patterns to accommodate the radically disparate identities of “traumatized combat veteran” and “civilian family member” is likely to be particularly complex.7 Drawing from cognitive processing therapy for PTSD,8 Hayes and colleagues1 have identified additional themes that may be present in traumatized perpetrators of IPV including trust, self- and other-esteem, and power and control. In doing so, they have adapted traditional treatment for perpetrators of IPV to address changes in information processing in combat veterans with PTSD in a way that neither shames them nor excuses psychologically or physically aggressive behavior.

The fact that the intervention is conducted in a dyadic group format is also noteworthy. Combat veterans are aware that most of their family and friends do not have a context for understanding their experience. In October 2007 in an opinion piece for the Boston Globe, Representative James McGovern described a photograph of a handwritten sign he had seen on a military base in Ramadi, Iraq, reading: “America is not at war. The Marine Corps is at war; America is at the mall.”9 Conducting the intervention in a dyadic group setting takes advantage of the assumption by many veterans with PTSD that a mutual understanding exists among combat veterans that cannot be shared by civilians. The group format addresses the sense of detachment or disengagement from civilians that veterans with PTSD often express and also presents hope for diffusing some of the shame and confusion veterans face when they find they cannot reconcile the expectations of their civilian roles with those of their military identity.7 In a previous report,10 Taft et al emphasized that the intervention is structured but provides sufficient flexibility to allow for processing of individual concerns within the group. This approach concretely acknowledges the relative infancy of our current understanding of the mechanisms of the association between PTSD and IPV and allows for the development of further insight among the veterans and families who viscerally experience IPV. Such a synthesis of structure and flexibility in a group format provides a setting where therapists can work collaboratively as partners with veterans and their families to identify alternatives and solutions that will work for each of them, and it sets a tone of collaboration that may diffuse the shame and anger that appear to perpetuate the dynamic of IPV in relationships.11,12

In summary, the work presented here is an elegant example of a step in intervention development that adheres to the ideals of science-based medicine. However, perhaps more importantly, it also reflects a subtle but important shift in the way that treatment of interpersonal violence among those with PTSD is typically conceptualized. Such a challenge to the dominant approach to addressing such an important public health problem among military personnel and veterans, particularly at such a critical time in our nation’s history, is fundamentally important as we transition into the next phase of conflict:

“When the peace treaty is signed, the war isn’ t over for the veterans, or the family. It’s just starting.

Author affiliations: VISN-6 Mental Illness Research, Education, and Clinical Center (MIRECC); Durham Veterans Affairs Medical Center; and Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Potential conflicts of interest: None reported.

Funding/support: This work was supported in part by Career Development Award #1K2RX001298 (Dr Van Voorhees) and a Merit Review (“Rehabilitation Strategies to Reduce Violence and Anger in TBI and PTSD”) (Dr Beckham) from the Rehabilitation Research and Development Service of the US Department of Veterans Affairs Office of Research and Development (VAORD); a Research Career Scientist Award (Dr Beckham) from the Clinical Science Research and Development (CSR&D) Service of the VAORD; the National Institute of Mental Health grant #5R01MH062482 (Dr Beckham); and with resources and the use of facilities at the Durham Veterans Affairs Medical Center, Durham, North Carolina.

Role of the sponsors: The sponsors had no role in the publication of this commentary.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

REFERENCES

1. Hayes MA, Gallagher MW, Gilbert KS, et al. Targeting relational aggression in veterans: the Strength at Home Friends and Family intervention. J Clin Psychiatry. 2015:76(6):e774-e778.

2. Beckham JC, Feldman ME, Kirby AC, et al. Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder. J Clin Psychol. 1997;53(8):859-869. PubMed doi:10.1002/(SICI)1097-4679(199712)53:8<859::AID-JCLP11>3.0.CO;2-J

3. Macmanus D, Dean K, Jones M, et al. Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study. Lancet. 2013;381(9870):907-917. PubMed doi:10.1016/S0140-6736(13)60354-2

4. Castro CA, Kintzle S. Suicides in the military: the post-modern combat veteran and the Hemingway effect. Curr Psychiatry Rep. 2014;16(8):460. PubMed doi:10.1007/s11920-014-0460-1

5. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York, NY: Simon and Schuster; 1994.

6. Babcock JC, Green CE, Robie C. Does batterers’ treatment work? a meta-analytic review of domestic violence treatment. Clin Psychol Rev. 2004;23(8):1023-1053. PubMed doi:10.1016/j.cpr.2002.07.001

7. Taft C, Walling S, Howard J, et al. Trauma, PTSD, and partner violence in military families. In: MacDermid-Wadsworth S, Riggs D, eds. Risk and Resilience in US Military Families. New York, NY: Springer Science + Business Media; 2011: 195-212.

8. Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy: Veteran/Military Version. Washington, DC: Department of Veterans Affairs; 2014.

9. McGovern JP. The Iraq money pit. The Boston Globe. http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/10/04/the_iraq_money_pit/. Updated October 4, 2007. Accessed February 4, 2015.

10. Taft CT, Howard J, Monson CM, et al. “Strength at Home” intervention to prevent conflict and violence in military couples: pilot findings. Part Abuse. 2014;5(1):41-57. doi:10.1891/1946-6560.5.1.41

11. Jansson PM, Saxonberg S. Are asymmetrical power relations a hidden obstacle to successful rehabilitation of violent men? an explorative study on the methodology to investigate shame. Aggress Violent Behav. 2013;18(6):745-752. doi:10.1016/j

12. Lawrence AE, Taft CT. Shame, posttraumatic stress disorder, and intimate partner violence perpetration. Aggress Violent Behav. 2013;18(2):191-194. doi:10.1016/j.avb.2012.10.002

Submitted: September 29, 2014; accepted October 1, 2014.

Corresponding author: Jean C. Beckham, PhD, Durham VAMC, Mental Health Service Line, 508 Fulton St, 116B, Durham, NC 27705 (jean.beckham@va.gov).

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