Background/Rationale: Violence involving intimate partners or others (non-partners) is a common problem among Veterans with substance use disorders (SUDs), and has significant medical and psychosocial costs to Veterans, their families, and communities. Violence in active duty and recently returning Veterans has been linked to SUDs, psychiatric problems (e.g., PTSD), medical, marital and occupational problems. Addressing violence in Veterans is critical given evidence that returning Veterans could be at heightened risk for engaging in violence. Presently, Behavioral Couples Therapy (BCT) is the only SUD treatment intervention that has empirical support for reducing violence. However, BCT only focuses on partner relationships and as such is only appropriate for the small subset of SUD patients who have a partner willing/able to engage in BCT. Thus, alternative interventions are needed that address violence and substance use irrespective of participants' current relationship status.
Objectives: The primary objective was to evaluate the effects on clinical outcomes (violence, substance use)) of: a) an integrated Motivational Interviewing-Cognitive Behavioral Treatment intervention (MI-CBT) targeting violence and substance use; and b) MI-CBT plus a violence and substance use prevention Continuing Care intervention (MI-CBT+CC), compared to c) control (enhanced treatment as usual - E-TAU). Additional objectives and secondary aims were to examine the impact of the interventions on service utilization, and potential mediators or moderators of intervention outcomes (e.g., service utilization, OEF/OIF status, etc.).
Methods: Participants were recruited from outpatient SUD and MH services at the VA Ann Arbor Healthcare System. Potentially eligible participants completed informed consent and a screening survey to determine eligibility for the randomized clinical trial (RCT). Veterans reporting substance use and recent violence (e.g., past year physical aggression) were eligible for the RCT. Exclusion criteria were: 1) acute suicidality; 2) presence of schizophrenia symptoms and/or mental incompetence to consent; and 3) living outside the study catchment area (i.e., a 45 mile radius of the VA Ann Arbor Healthcare System).
We screened a total of 840 unique individuals for a sample size of 180 participants that consented to and met criteria for the RCT. Eligible participants were randomized to one of three conditions: MI-CBT (6 individual sessions delivered during an 8-week acute treatment phase - Phase 1), MI-CBT+CC (Phase 1 MI-CBT plus a Continuing Care weekly telephone intervention for the subsequent 3 month phase - Phase 2), or E-TAU, with brief assessments following phase 1 and phase 2, and follow-up interviews at 3, 6 and 12-months post Phase 2. Treatment sessions were led by master's level and above therapists (i.e., social workers, psychology trainees/postdocs). Participants continued to receive their standard of care at the VA. Both intervention conditions included enhancing motivation to prevent violence and substance use, CBT skills (e.g., time out, "calm down skills," coping alternatives, communication), with the MI-CBT+CC condition receiving an additional 12-weeks of weekly telephone monitoring/counseling. The E-TAU condition included brief advice to avoid interpersonal violence, and a printed referral booklet (information on community support groups, anger-management treatment resources, SUD and mental health services, etc.).
Participants completed brief assessments following Phases 1 and 2, and follow-up interviews at 3, 6 and 12-months post-Phase 2. Each assessment (including the baseline) lasted 1 to 1.5 hours and consisted of surveys/questionnaires, and semi-structured interviews to assess violence and substance use (Conflict Tactics Scale-Structured Interview-CTS-SI; Time Line Follow Back Interview-TLFB). Participants were also asked to provide a urine sample and breathalyzer to assess for recent substance use and to enhance validity of self-report measures. Follow-up rates indicate that over 86% (ranging from 83% to 93%) of assessments were completed at each time point for those eligible for follow-up.
Findings/Results: The sample was, on average 43 years of age, 92% male, 46% OEF/OIF/OND era, and 37% nonwhite. Randomization was successful; the groups did not differ significantly on baseline variables (demographics, violence, substance use, etc.). For overall physical aggression, rates and frequencies [mean (sd) aggressive acts per month] at baseline (6-months pre-treatment) and follow-up over 12-months were 69% and 28%, and .84 (2.05) and .22 (.48), respectively. Rates and frequencies for nonpartner violence at baseline and the follow-up were somewhat higher than rates and frequencies of partner aggression; both showed reductions from baseline to follow-up. Preliminary repeated measures analyses of outcomes over the 12-months indicated that all groups showed some significant reductions in violence and substance use from baseline. Given issues with data skewness on the violence outcomes, non-parametric tests (Wilcoxin Sign Ranks Tests) were completed for each treatment condition to examine baseline to follow-up changes in our 9 violence outcomes: partner physical aggression, injury and total aggression (summing physical aggression and injury scales); non-partner physical aggression, injury and total aggression; and total (summing partner and non-partner data) physical aggression, injury and total aggression. For the E-TAU and MI-CBT groups, significant reductions (p < .01) were observed for 2 of the 9 violence outcomes, whereas for the MI-CBT+CC condition, significant reductions (p < .01) were observed for 6 of the 9 violence outcomes.
Impact: To our knowledge, this is the first study to examine the impact of interventions targeting partner and non-partner violence, as well as substance use. The preliminary results show some reductions in violence and substance use for all groups, with some evidence that those receiving MI-CBT+CC showed significant reductions on more violence outcomes than the other two groups. The results are promising and further research can assist in evaluating predictors of intervention response, the potential impact of such interventions in other settings (e.g., primary care), and by other means of delivery (e.g., telehealth). The development of empirically validated interventions for reducing violence and substance misuse can greatly enhance the current set of treatment options for Veterans.
- Chermack ST, Bonar EE, Goldstick JE, Winters J, Blow FC, Friday S, Ilgen MA, Rauch SAM, Perron BE, Ngo QM, Walton MA. A randomized controlled trial for aggression and substance use involvement among Veterans: Impact of combining Motivational Interviewing, Cognitive Behavioral Treatment and telephone-based Continuing Care. Journal of substance abuse treatment. 2019 Mar 1; 98:78-88.
- Bennett DC, Morris DH, Sexton MB, Bonar EE, Chermack ST. Associations between posttraumatic stress and legal charges among substance using veterans. Law and human behavior. 2018 Apr 1; 42(2):135-144.
- Anderson RE, Bonar EE, Walton MA, Goldstick JE, Rauch SAM, Epstein-Ngo QM, Chermack ST. A Latent Profile Analysis of Aggression and Victimization Across Relationship Types Among Veterans Who Use Substances. Journal of studies on alcohol and drugs. 2017 Jul 1; 78(4):597-607.
- Davis AK, Bonar EE, Goldstick JE, Walton MA, Winters J, Chermack ST. Binge-drinking and non-partner aggression are associated with gambling among Veterans with recent substance use in VA outpatient treatment. Addictive Behaviors. 2017 Nov 1; 74:27-32.
- Buchholz KR, Bohnert KM, Sripada RK, Rauch SA, Epstein-Ngo QM, Chermack ST. Associations between PTSD and intimate partner and non-partner aggression among substance using veterans in specialty mental health. Addictive Behaviors. 2017 Jan 1; 64:194-199.
- Davis AK, Bonar EE, Ilgen MA, Walton MA, Perron BE, Chermack ST. Factors associated with having a medical marijuana card among Veterans with recent substance use in VA outpatient treatment. Addictive Behaviors. 2016 Dec 1; 63:132-6.
- Chermack ST, Bonar EE, Kraus S, Walton M, Ilgen M, Epstein-Ngo Q, Rauch S, Perron B, Booth B, Blow F. Predictors of Aggression Across Relationship Types Among Veterans in Substance Use Disorder Treatment. Paper presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2014 Apr 16; Ann Arbor, MI.
Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial