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NRI 04-040 – HSR&D Study

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NRI 04-040
Relationships and PTSD Study: Detection of Intimate Partner Violence
April A Gerlock PhD RN
VA Puget Sound Health Care System American Lake Division, Tacoma, WA
Tacoma, WA
Funding Period: July 2007 - September 2011

BACKGROUND/RATIONALE:
There is a significant amount of research evidence that Veterans with posttraumatic stress disorder (PTSD) are more likely to perpetrate intimate partner violence (IPV) than Veterans without PTSD. However, we know that not all veterans with PTSD are intimately violent, but we do not know what distinguishes these two groups. Additionally, there is little evidence nationally about IPV perpetrator access to healthcare, and (beyond the pilot work of the study PI), no evidence on IPV perpetrator healthcare access in the VHA.

OBJECTIVE(S):
The main objective is to understand the differences between Veterans with PTSD who perpetrate intimate partner violence (IPV) and those who do not (non-IPV). Our primary research questions seek to describe those differences and examine what variables may facilitate accurate detection of IPV perpetration by VA providers. Our secondary research questions seek to describe the existing IPV/Non-IPV documentation practices at the VA Puget Sound Health Care System (VAPSHCS).

METHODS:
Phase one of the project involved a retrospective medical record review to gather baseline data about IPV perpetration documentation practices. Phase two of the project involved interviewing Veterans and their intimate partners to identify differences between IPV and non-IPV couples and ways in which PTSD impacts their broader relationships. Random selection and descriptive statistics were used for both project components.

To describe providers' documentation of IPV assessment, we reviewed a random sample of 10% (n=507) of the medical records of male Veterans enrolled in PTSD treatment at VAPSHCS and the Tacoma Vet Center. By conducting a five-year retrospective record review (November 2002 to November 2007) we used descriptive statistics to show whether an IPV perpetration assessment was documented and, if so, when the assessment occurred, in which clinic, by what provider discipline, and how IPV was detected.

To describe the differences between Veterans with and without IPV, a prospective cohort design was used. We recruited a random sample of 441 Veteran/partner dyads (n=882 subjects) from a clinical sample of PTSD treatment-seeking Veterans from the same sites. Subjects completed paper and pencil questionnaires and participated in a structured interview. Descriptive statistics were used to describe the sample, and a discriminant analysis was used to determine if IPV/non-IPV could be reliably categorized based on PTSD severity, relationship mutuality, early IPV exposure, substance abuse, age of the male Veterans, number of months in PTSD treatment, and/or number of months deployed to a war zone. To determine if these variables are associated with clinic providers' detection of IPV perpetration, a logistic regression was performed using the same variables. Further, to identify ways in which PTSD impacts broader relationship behaviors, a purposive sample of 35 Veterans and partners (total sample 70) representing both IPV and non-IPV couples, was selected from the larger random sample. A qualitative analysis using Grounded Theory was used to describe the dynamics of the couples' relationship behaviors across the spectrum from highly distressed (IPV) to thriving.

FINDINGS/RESULTS:
Of the 507 records examined for the record review, 120 (24%) showed documentation of screening for IPV perpetration. Of those, 73 (61%) showed positive results for IPV perpetration, and 61 (51%) showed more than one screening or assessment. Documentation of screening was most likely to have occurred at the Veteran's initial appointment (71%) and in an outpatient mental health setting (72%); IPV perpetration was determined most often as the result of a provider's inquiry (45%). There was a total of 415 screenings, including 356 in records in which there was more than one screening. The documentation of a single screening for IPV perpetration was significantly correlated with the documentation of subsequent screenings and with IPV perpetration determination (Spearman rank correlation = 0.611, p < 0.001). Veterans with documented IPV perpetration and high rates of relationship conflict accessed the healthcare system twice as often as those without such documentation (ANOVA, F = 8.529, df = 405, p < 0.001).

441 male Veterans and their wife/partners agreed to participate (n=882) in phase 2 of the study. 190 (44%) were coded as IPV yes and 251 (56%) were IPV no. The men's ages ranged from 22 to 88 years, reflecting the range of war zone deployments from OIF/OEF to WWII. The only variable to significantly discriminate between the IPV/non-IPV groups was Relationship Mutuality (n=426; IPV Yes = 185 & IPV No = 241): Function Coefficients IPV YES = 7.870; IPV NO = 8.280, Wilks' Lambda = .962; Chi-square = 16.425, df = 8, p = .037. According to the logistic regression, provider awareness of the presence of physical violence on the part of their Veteran patient was significantly related to time in PTSD treatment only (Wald = 14.424, df = 1, p = .000, ExpB).

Saturation (no new emerging variables) for the qualitative analysis was reached at 23 couples. Function/dysfunction of PTSD Veteran couples is experienced in a variety of intertwined tensions: Disability, Caregiving, Responsibility, Trauma, Communication and Community. Three intersecting dynamics determine the couple functioning within each tension: Mutuality, Locus of Control, and Approach to Weakness. A preliminary dyadic functioning model was developed to reflect this complex dynamic.

IMPACT:
Despite the low rate of IPV perpetration screening/documentation, those identified as IPV perpetrators were accessing the healthcare system at a higher rate than those not so identified, and repeated screenings were associated with a higher rate of IPV perpetrator determinations. Phase 2 revealed that healthcare providers become aware of IPV perpetration the longer the Veteran is in treatment. VA healthcare providers should conduct early routine screening for IPV perpetration in this population. Additionally, the impact of relationship mutuality in differentiating the IPV from the non-IPV couples was significant. Relationship mutuality also helped define the thriving couples in the qualitative analysis. Further research on ways to promote relationship mutuality in PTSD treatment-seeking Veterans is warranted.

PUBLICATIONS:

Journal Articles

  1. Gerlock AA, Grimesey JL, Pisciotta AK, Harel O. Documentation of screening for perpetration of intimate partner violence in male veterans with PTSD. The American Journal of Nursing. 2011 Nov 1; 111(11):26-32; quiz 33-4.
  2. Gerlock AA, Grimesey JL, Pisciotta AK, Harel O. Ask a few more questions. The American Journal of Nursing. 2011 Nov 1; 111(11):35-9.
VA Cyberseminars

  1. Gerlock AA. The Complex Dynamics of Intimate Partner Violence in the Lives of Veterans. [Cyberseminar]. 2011 Nov 17.
  2. Gerlock AA, Grimesey JL. The complex dynamics of intimate relationships for treatment seeking Veterans with posttraumatic stress disorder. [Cyberseminar]. 2011 Aug 31.
  3. Gerlock AA. PTSD and relationships: Intimate partner violence across the lifespan. [Cyberseminar]. 2011 Aug 10.
Conference Presentations

  1. Gerlock AA, Sayre G, Grimesey JL. A VA Qualitative Study of Veteran PTSD and Relationships. Presented at: Futures Without Violence Health and Domestic Violence National Biennial Conference; 2012 Mar 30; San Francisco, CA.
  2. Grimesey JL, Gerlock AA. The Impact of Veterans' Posttraumatic Stress Disorder on Intimate Partner Relationships. Presented at: Futures Without Violence Health and Domestic Violence National Biennial Conference; 2012 Mar 30; San Francisco, CA.
  3. Nevins EE, Gerlock AA. Improved Relationships Happen! An unintended benefit for women following participation in research. Presented at: Futures Without Violence Health and Domestic Violence National Biennial Conference; 2012 Mar 30; San Francisco, CA.
  4. Gerlock AA, Grimesey JL, Sayre GG. The Complex Dynamics of Intimate Relationships for Treatment Seeking Veterans with Posttraumatic Stress Disorder. Presented at: American Association for Marriage and Family Therapists Annual Conference; 2011 Sep 24; Fort Worth, TX.
  5. Gerlock AA. Posttraumatic stress disorder and relationships: Intimate partner violence across the lifespan. Presented at: West Sound Advanced Practice Association Annual Nursing Symposium; 2011 Mar 5; Bremerton, WA.
  6. Gerlock AA. PTSD and DV: What negotiators need to know about service members, Vets, their families & their struggles. Presented at: Western States Hostage Negotiators' Association Annual General Membership Meeting; 2010 May 24; Tacoma, WA.
  7. Gerlock AA. The War at Home: Detecting Intimate Partner Violence Perpetration in PTSD Treatment-Seeking Veterans. Presented at: Washington Chapter International Association of Forensic Nurses Annual Conference; 2010 May 18; Seattle, WA.
  8. Gerlock AA. PTSD and Violence: Perpetrator or Victim? Presented at: Association of Advanced Practice Psychiatric Nurses Annual Meeting; 2010 Apr 9; Seattle, WA.
  9. Gerlock AA. Posttraumatic Stress Disorder and Intimate Partner Violence Perpetration among Treatment-Seeking Veterans. Presented at: VA H. John Heinz III Progressive Care Center Grand Rounds; 2010 Jan 27; Pittsburgh, PA.
  10. Gerlock AA. Posttraumatic Stress Disorder and Intimate Partner Violence Perpetration. Presented at: Trauma Spectrum Disorders Annual Conference; 2009 Dec 10; Bethesda, MD.
  11. Gerlock AA. The War at Home: Preventing Family Violence in Military Families - Plenary Session. Presented at: Futures Without Violence Health and Domestic Violence National Biennial Conference; 2009 Oct 26; New Orleans, LA.
  12. Gerlock AA. Skills Building Workshop: Assessing dangerousness and responding to it when your patient is a perpetrator of intimate partner violence. Presented at: Futures Without Violence Health and Domestic Violence National Biennial Conference; 2009 Oct 9; New Orleans, LA.
  13. Gerlock AA. Intimate Partner Violence and Military-Related PTSD: Assessment Practices and Implications for Intervention. Presented at: University of Washington School of Nursing Annual Pacific Northwest Ambulatory Care Nursing Conference; 2009 Apr 29; Seattle, WA.
  14. Gerlock AA. Introduction to the Evidence Based Practice Toolkit: Driving Excellence and Achieving Results: VA Nursing Vision to Realty. Paper presented at: VA Nursing Leadership Annual Conference; 2008 Apr 23; Seattle, WA.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: Epidemiology, Prognosis
Keywords: Dual diagnosis – substance abuse and mental health, Intimate Partner Violence, PTSD
MeSH Terms: none

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