JSM Addiction Medicine and Therapy

Considerable research exists for the prevalence of intimate partner violence in civilian couples, though the opposite is true for married or cohabitating couples consisting of active duty soldiers or veterans. Since its start, more than 2.5 million United States Military Veterans have served in the Global War on Terror (Operations Enduring and Iraqi Freedom). The high rates of combat exposure among military personnel serving in Iraq and Afghanistan (as high as 90%), and high-profile homicides among military personnel and their intimate partners have led to concern by military and civilians regarding the impact of combat exposure and military member psychological wellbeing on marital stability and IPV. Military personnel are exposed to unique stressors that can contribute to risk factors associated with increased IPV. Thus far, prevention and treatment programs for military personnel and their families are based off of programs used within the civilian community. Results of the effectiveness of these treatments within the military are discouraging at best. This review examines risk factors of IPV within the military and overviews treatment. Additionally, lack of confidentiality within the military will be examined.

Keywords:Partner violence; Military veterans; Homicides; Domestic violence

Considerable research exists for the prevalence of intimate partner violence in civilian couples, though the opposite is true for married or cohabitating couples consisting of active duty soldiers or veterans. Since its start, more than 2.5 million United States Military Veterans have served in the Global War on Terror [1].The high rates of combat exposure among military personnel serving in Iraq and Afghanistan [2], (as high as 90%; and highprofile homicides among military personnel and their intimate partners [3], have led to concern by military leaders and civilian researchers regarding the impact of combat exposure and military member psychological well-being on marital stability and IPV. Because the military is the second largest employer in the United States with over 1.4 million active duty members and over 1.1 Reservists and National Guard personnel [4], the significance of intimate partner violence cannot be minimized.

Military employment provides institutional benefits including family housing allotments, medical coverage, and stable employment. Yet, economic struggles, time pressures, and job strain are inevitable, as with civilian families. In addition to these factors, military families experience a unique set of stressors on family systems including: frequent transfers to sometimes undesired relocations, separation from immediate and extended family members, uncertainty about future assignments, varying schedules, long hours, strenuous training and physically demanding jobs, repeated deployments throughout the course of separation, and fears for the military member’s safety [5,6]. Taken as a whole, these factors may be associated with increased likelihood of partner violence due to their strain on military members and their family units. Because service members and their families may be exposed to numerous psychological risks which potentially tax the family system and increase risk for marital instability and related problems [7], increased understanding of these families may be important for prevention and intervention efforts.

Intimate partner violence (IPV) is a widespread public health concern impacting social, ethnic, and socioeconomic domains and affecting over 40 million individuals at least once during their lifetime. The term “intimate partner violence” encompasses physical and sexual violence, stalking, and psychological aggression by a present or prior intimate partner (Centers for Disease Control and Prevention [CDC], 2016). Among the various negative implications for partners and families are economic, emotional, physical, and social consequences; this is especially worrisome considering the stressors experienced by military families discussed above [8].

There has surprisingly been little research on risk factors for IPV within military personnel. Most of the available research has focused on civilian couples. While some of these risk factors may overlap, military personnel are exposed to unique stressors that may contribute to incidents of IPV [9]. In fact, many military personnel have been exposed to high levels of stress over the past 15 years as a result of the global War on Terror [10]. There is some initial evidence that other military specific variables might also be important factors to consider in moderating and/ or mediating IPV, for example, longer periods of deployment increase the risk of more severe forms of IPV within 1-year of post-deployment [9].

Researchers Rodrigues et al., sought to review and synthesize the available research on risk factors of IPV within the military. Results of their study indicated that PTSD is an important link between trauma-related factors, for example, combat exposure as well as IPV. More severe symptoms of IPV may also be associated with depression, hyperarousal, quantity of alcohol use, and experiencing abuse or maltreatment as a child [9,10]. Alcohol use is another risk factor often present in more severe forms of violence [10]. Smither-Marek et al., conducted a meta-analysis to see if risk factors differ between civilian and military couples and found important gaps in the research agenda, with more focus on active duty males than females. Variable results have been found regarding the effect of deployment as a risk factor for IPV. However, it can be concluded that there is a small, but significant increase in self-reported severe spousal aggression in U.S Army soldiers 1-year post deployment [10]. Relational problems are also a risk factor for IPV in military samples, with newer marriages or relationships increasingly the likelihood that IPV will occur [10].

Examination of risk markers for IPV among the military male population compared to the civilian male population show there are more similarities than differences in strength of risk factors for IPV between male civilian and male military personnel [10]. There may be factors at the contextual level that will attribute to group differences. It is clear that more research is needed in the area of IPV risk factors for military personnel particularly among female soldiers and veterans.

Treatment should focus on the individual variables that may have led to IPV. For example, PTSD is a risk factor for IPV, and should be explicitly addressed during treatment. There are several routes of treatment that are effective for IPV. Entering therapy (individual or couples) prior to active duty, during active duty (nonmilitary) partner, and post active duty is highly recommended to decrease the chance of IPV or if IPV is present, to work towards eliminating maladaptive behaviors and learning healthier ways to resolve conflict [11]. Evidence shows that service members who experience deployment are at risk for lower relationship satisfaction, and high levels of separation or divorce. Implementing relationship-focused prevention and treatments for this group can decrease the likelihood of IPV starting in the first place [12].

Developing effective prevention and treatment programs for military members and their families is extremely important considering the high stress military members have been exposed to over the past 15 years [10]. The United States Department of Defense (DOD) has allocated funds and resources towards prevention and treatment programs for military members and their families [10]. Most of these programs are based on programs offered in the general community. However, in order for these programs to be successful, they must take into account the unique risk factors for IPV in the military. Programs should then be adapted to the unique risk factors that military personnel experience. Unfortunately, research on the availability and effect of IPV treatment programs for military personnel is limited [9].

Individual or couples therapy (depending on the severity of violence) focused on relationship stability, healthy conflict resolution, and clear communication prior to active duty, during active duty (non-military partner), and post-duty is currently recommended to lessen the chance of the development of IPV [11]. The challenge for researchers and clinicians is in adapting current effective treatments for IPV in civilian populations for use with members of the military, with particular attention paid to the uniqueness of working with active duty and veteran populations. Treatment may involve providing psychoeducation, offering support/resources, and recommending peer support groups [11].

Although individual-based treatment is the most common modality used, couples therapy has been found to be equally to more effective for treating couples in which the violence is bidirectional, mild, and not being used as a form of power and control [13]. This format of treatment teaches partners important skills to solve problems, manage anger, and resolve conflict [11].

Reports of suspected domestic violence are expected of all military personnel (except chaplains), regardless of how the suspicions arise or whether the victim wants this information to be communicated to the command and others. However, many victims are reluctant to report incidents due to fear of negative career consequences for their partner, particularly since the person notified of the violence is considered the person’s boss [8]. In addition, there may also be career implications for the perpetrator if he or she is convicted of a domestic-violence related offense with consequences ranging from reassignment to discharge. Relatedly, criminal conviction of even a misdemeanor involving IPV can end a military career and impact individuals’ ability to possess firearms. Finally, higher ranking active duty females may be reluctant to report partner abuse out of fear over the stigma attached to being perceived as a victim and the professional and career implications of this decision. This may also hold true for male victims of female batterers; men may be reluctant to report partner violent episodes due to fear of negative perception. Along these lines, the results of two recent studies revealed that among persons diagnosed with PTSD, many will not engage in treatment because of the perceived stigma attached to the mental health process [14]. These results seem to provide evidence that there is a strong stigma attached to helpseeking behavior.

Partner violence is a tremendous public health concern. Given the unique stressors associated with military service (deployment, financial and emotional strain, trauma, etc.), active duty and veteran populations are at increased risk for partnerviolent behavior. Moreover, institutional barriers may also serve to limit the likelihood of help-seeking behaviors because of threat of reprisal, negative stereotype around seeking help, or potential negative career consequences to the perpetrator. Further study is needed to determine how to best engage those in need of services as well as to identify specific treatments which may be helpful.