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 Portfolio Assignment: Women's Health |
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. External Links for this ProjectDimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Substance Use Disorders
DRE: Epidemiology, Prognosis Keywords: Dual diagnosis – substance abuse and mental health, PTSD MeSH Terms: none |