Posttraumatic Stress Disorder And The Perpetration Of Domestic Violence

By David S. Riggs, Ph.D.

NCP Clinical Quarterly 7(2): Spring 1997

There is evidence that the impact of trauma and posttraumatic stress disorder (PTSD) extends beyond trauma victims to significantly disrupt their intimate relationships and families (1-4). One area of marital or relationship functioning that should be of particular concern to clinicians working with PTSD veterans is the perpetration of violence toward their intimate partners (2, 5). This paper outlines some of the issues related to domestic violence that are likely to be confronted by clinicians working with traumatized populations, particularly combat veterans. Because it is clear that violence occurs within relationships not legally classified as marriage (e.g., dating, cohabitating), the term domestic violence will be used in this paper to refer to violence between romantic partners.

Veterans with PTSD have less cohesive, less expressive, more conflictual and more violent relationships than veterans without PTSD (2, 3, 6). PTSD in Vietnam veterans is also associated with increased risk for perpetrating domestic violence (2, 5). Further, this finding fits into a broader pattern of evidence that many men in treatment for spouse abuse have previously experienced traumatic events (7, 8). For example, in a sample of incarcerated men, the presence of physical abuse in childhood increased the probability of perpetrating family violence by 500% (7).

Studies of combat veterans suggest that it is not the experience of trauma per se that places men at risk for perpetrating domestic violence but rather the presence of enduring trauma-related symptoms such as PTSD (2, 9). For example, data from a national survey of Vietnam era veterans (the National Vietnam Veterans Readjustment Survey; NVVRS) indicate that 33% of Vietnam veterans with PTSD had assaulted their partners in the previous year as compared to about 15% of veterans without PTSD (2). The average number of aggressive acts perpetrated in the prior year by the veterans with PTSD was 4.86 as compared to 1.32 for veterans without PTSD. Rates of domestic violence may be even higher among treatment seeking veterans. In a study focused on veterans seeking treatment for PTSD, 63% of PTSD veterans had aggressed against their partners in the last year compared to 23% of a non-PTSD sample (9) and the presence of severe PTSD symptoms appears to be related to increased perpetration of domestic violence by combat veterans (5, 10).

The domestic violence reported by PTSD veterans and their partners covers a spectrum of behaviors including verbal aggression (e. g., cursing, criticism), emotional abuse (e. g., controlling behavior) and physical violence (e. g., shoving, hitting, kicking). Typically, the most frequent acts of physical aggression are those considered least likely to produce lasting injury (e. g., pushing, grabbing). However, a significant portion of veterans with PTSD (approximately 12% of the NVVRS sample) report more severe forms of aggression (e. g., hitting with a fist, beating up) in their relationships (2). This rate is likely to be even higher among veterans seeking treatment for PTSD (5).

Understanding The Connection Between PTSD And Domestic Violence

As with other variables associated with domestic violence, it is too simplistic to state that PTSD is the cause of men’s violence toward their intimate partners. Years of research into the problem of domestic violence has made it clear that this phenomenon is multiply determined and is related to many variables. However, the association between PTSD and domestic violence suggests that this disorder should be seen as a marker or risk factor for intimate violence. Therefore, it is important for clinicians to attend to and assess the potential for domestic violence when working with PTSD patients.

We do not as yet know what mechanisms underlie the association between trauma-related symptoms and domestic violence, however, similarities between patients with PTSD and men who perpetrate violence against their partners (see Table 1), offer some clues. For example,

Table 1. Similarities Between Characteristics Of PTSD Veterans And Domestically Violent Men

persons with PTSD often experience clinically significant levels of depression (11), and depression symptoms have also been related to the perpetration of domestic violence by men (12). Similarly, alcohol and substance abuse, a problem commonly identified among veterans with PTSD (11), is also associated with men’s violence toward their partners (13). Thus, it may be that veterans with PTSD are more likely to perpetrate domestic violence because they tend to be depressed and abuse alchohol and drugs. Importantly, none of the studies linking depression or substance abuse to domestic violence assessed for trauma or PTSD. Therefore, the observed associations between these other disorders and domestic violence may arise because of undiagnosed PTSD or other trauma-related symptoms.

Some of the characteristics that potentially link PTSD and domestic violence are identified as symptoms of the PTSD itself. For example, intense emotional reactions to perceived threats and aggressive behavior are both closely linked to specific PTSD symptoms (emotional reactions to trauma reminders and irritability/angry outbursts). Domestically violent men have also been found to react strongly to perceived threats from their wives (14). Similarly, a subgroup of domestically violent men engage in significant aggressive behavior outside of the relationship as well (15). Another factor that may link symptoms of PTSD and domestic violence is the presence of marital distress and conflict, one of the most robust correlates of violence within relationships (16). PTSD veterans and their wives report more distress and conflict in their relationships than do non-PTSD veterans and their wives (3). Additional factors that could link PTSD and domestic violence include day-to-day stress and general problem solving deficits observed in both PTSD patients and domestically violent men.

Given the number and variety of factors that might link PTSD symptoms and domestic violence, it is probably the case that among persons with PTSD (as with other populations) the "causes" of violence are many and varied. One person may strike his wife only after consuming alcohol, another only when reminded of past traumatic events, and yet another may become violent only when stressed by financial difficulties. Further, many of these factors may interact with one another to increase the likelihood of violent altercations. When approaching the problem of domestic violence in the context of PTSD treatment, clinicians must recognize the importance of careful assessment of the PTSD, domestic violence and possible links between the two. Without a careful assessment, interventions aimed at alleviating or preventing domestic violence are likely to fail and may exacerbate the problem.

Assessment Of Domestic Violence In The Context Of PTSD

Given the high rates of domestic violence associated with PTSD it is important to assess for the perpetration of such violence in all patients seen for PTSD treatment who are in relationships (whether or not they are cohabitating with their partner). When one or more additional risk factors (e.g., depression, relationship distress) are also present, the evaluation of domestic violence becomes imperative. Clinicians should be aware that many, though not all, perpetrators tend to minimize the severity and frequency of their violence, some to the point of complete denial. Researchers in the area have suggested obtaining information about marital conflict and violence through multiple mechanisms and from multiple sources if possible (17). Thus, clinicians should assess perpetration by interviewing the patient, administering open-ended questions and using psychometrically sound paper-and-pencil measures such as the Conflict Tactics Scales (CTS; 18). If possible within the confines of the case, clinicians may also wish to contact the patient’s partner to assess for the presence of domestic violence. However, one should note that victims of domestic violence also have reasons for denying or minimizing the violence.

Clinicians should evaluate the frequency and severity of the violence as well as the actual and potential impact on the victim. This evaluation is important not only for establishing the safety of the victim, but also because different treatment approaches are typically used to intervene with mild versus severe violence. Ongoing studies by O’Leary and his colleagues (19) indicate that couples based treatment aimed at reducing conflict and improving communication and problem solving skills may be effective in cases of low-level violence (e.g., an infrequent push during an argument that does not result in injury or intense fear). Importantly, such interventions are not recommended in cases of severe violence or abuse. In cases of abuse, most experts in the area of domestic violence treatment recommend that the members of the couple be treated separately. Perpetrator treatment typically focuses on recognizing the impact of both physical and emotional abuse, taking responsibility for the aggressive behavior, and stopping the violence. Treatment for victims of abuse often focuses on providing support and empowerment to the victim, and aiding the victim in obtaining necessary resources for extricating herself from the relationship. It is likely that many PTSD therapists will wish to refer the domestically violent patient to another clinician or program that is experienced in treating domestic violence. Therefore, clinicians treating patients with PTSD should be aware of the resources in their community for intervention in violent marriages.

Once a clinician has established that a patient with PTSD does perpetrate domestic violence, one must also develop a safety/treatment plan for stopping the violence and reducing the likelihood that it will recur. Establishing this plan is not always easy since perpetrators of domestic violence are often resistant to acknowledging a need for treatment. Once a plan has been developed to prevent or reduce the violence, it becomes necessary for the clinician to determine whether and how treatment for PTSD will proceed and/or be integrated into the treatment for the violence. Guiding this process are the assessment results that describe how PTSD symptoms and other factors might impact on the occurrence of domestic violence. Thus, if the assessment indicates that the patient is aggressive primarily when his depression deepens or when drinking, the intervention should incorporate treatment for these disorders. If the aggression occurs primarily in the aftermath of a trauma-related flashback or intrusion, the intervention may focus on providing the veteran and his partner with skills for coping with these intense emotional experiences. Similarly, if the violence occurs only in the context of conflict and arguments, then training in problem solving and conflict resolution skills may be helpful in reducing the violence. However, it should be stressed that these treatments can not be seen as "cures" for domestic violence. Although they may help to reduce the problem, domestic violence therapists generally agree that the problem must be addressed directly.

In all cases where domestic violence has been identified and linked to PTSD, clinicians must endeavor to coordinate treatment of the two issues. In some cases, this will require coordinating one’s own work aimed at alleviating the PTSD symptoms with those of other providers who are working to reduce the violence. In other cases, the responsibility for addressing both issues may fall on the PTSD clinician either because specialized treatment for domestic violence may not be available or because such treatment is refused by the client. In either case, the clinician must remain acutely aware that interventions may impact not only on PTSD symptoms but also on domestic violence and, more importantly, that the impact may not be the same in both domains. Thus, substantial effort must be applied to evaluating changes in both areas resulting from the intervention. This is not a foreign idea to clinicians working with traumatized veterans. It is common to evaluate the effects of an intervention on PTSD symptoms and urges to drink, for example. Domestic violence merely represents another outcome variable of interest. One that, unfortunately, carries the threat of substantial and severe consequences to the client’s partner.

References

1. Carroll, E. M., Rueger, D. B., Foy, D. W., & Donahoe, C. P. (1985). Vietnam combat veterans with posttraumatic stress disorder: Analysis of marital and cohabiting adjustment. Journal of Abnormal Psychology, 94(3), 329-337.

2. Jordan, B. K., Marmar, C. R., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., Weiss, D. S. (1992). Problems in families of male Vietnam veterans with posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 60, 916-926.

3. Riggs, D. S., Byrne, C. A., Weathers, F. W. & Litz, B. T. (in press). The quality of intimate relationships in male Vietnam veterans: The impact of posttraumatic stress disorder. Journal of Traumatic Stress.

4. Waysman, M., Mikulincer, M., Solomon, Z., & Weisenberg, M. (1993). Secondary traumatization among wives of posttraumatic combat veterans: A family typology. Journal of Family Psychology, 7, 104-118.

5. Byrne, C. A. & Riggs, D. S. (1996). The cycle of trauma: Relationship aggression in male Vietnam veterans with posttraumatic stress disorder. Manuscript submitted for publication.

6. Solomon, Z., Mikulincer, M., Fried, B., & Wosner, Y. (1987). Family characteristics and posttraumatic stress disorder: A follow-up of Israeli combat stress reaction casualties. Family Process, 26, 383-394.

7. Dutton, D. G. & Hart, S. G. (1992). Evidence for long-term, specific effects of childhood abuse and neglect on criminal behavior in men. International Journal of Offender Therapy and Comparative Criminology, 36, 129-137.

8. Murphy, C. M., Meyer, S. L., & O’Leary, K. D. (1993). Family of origin violence and MCMI-II psychopathology among partner assaultive men. Violence and Victims, 8, 165-176.

9. Riggs, D. S., Byrne, C. A., Weathers, F. W. & Litz, B. T. (1995, July). The cycle of trauma: Marital violence in Vietnam veterans with PTSD. Paper presented at the Fourth International Family Violence Research Conference, Durham, NH.

10. Prince, J. (1992). The effect of post-traumatic stress disorder on emotional intimacy, conflict resolution, and family functioning. Unpublished doctoral dissertation, University of Georgia, Athens, Georgia.

11. Keane, T. M., & Kaloupek, D. G. (in press). Comorbid psychiatric disorders in PTSD: Implications for research. To appear in R. Yehuda and A. McFarlane (Eds.) Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Science.

12. Pan, H. S., Neidig, P. H., & O'Leary, K. D. (1994). Predicting mild and severe husband-to-wife physical aggression. Journal of Consulting and Clinical Psychology, 62, 975-981.

13. Murphy, C. M., & O’Farrell, T. J. (1994). Factors associated with marital aggression in male alcoholics. Journal of Family Psychology, 8 (3), 321-335.

14. Margolin, G., John, R. S., & Gleberman, L. (1988). Affective responses to conflictual discussions in violent and nonviolent couples. Journal of Consulting and Clinical Psychology, 56, 24-33.

15. Holtzworth-Munroe, A., & Stuart, G. L. (1994). Typologies of male batterers: Three subtypes and the differences among them. Psychological Bulletin, 116, 476-497.

16. O'Leary, K. D., Malone, J., & Tyree, A. (1994). Physical aggression in early marriage: Pre-relationship and relationship effects. Journal of Consulting and Clinical Psychology, 62, 594-602.

17. O'Leary, K. D., Vivian, D., & Malone, J. (1992). Assessment of physical aggression against women in marriage: The need for multimodal assessment. Behavioral Assessment, 14, 5-14.

18. Straus, M. A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family, 41, 75-88.

19. O’Leary, K. D., Heyman, R. E., & Neidig, P. H. (1995). An empirical comparison of physical aggression couples treatment vs. gender-specific treatment. Paper presented at the Fourth International Family Violence Research Conference, Durham, NH.

David S. Riggs is a staff psychologist at the Boston VA Medical Center and an Assistant Clinical Professor of Psychiatry at Tufts University School of Medicine. He has been conducting research on the causes and consequences of interpersonal violence for over ten years. His work has focused on potential causes of domestic violence and PTSD in rape victims and combat veterans. He recently completed a study examining perpetration of domestic violence by Vietnam veterans with PTSD.

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