Posttraumatic Stress Disorder, Intimate Partner Violence, and the Military War Veteran

1. Posttraumatic Stress Disorder, Intimate Partner Violence, and the Military War Veteran Presenters: Shauna Moore Reynolds, Ed.D, LCPC-S, LPC, NCC, ACS Lena Jackson, B.A.

2. The Current Situation

3. Military service members, veterans, and their families are a growing community exposed to traumatic events. Military involvement in combat that causes losses and fears; injuries associated with combat; repeated deployments and/or relocations; and military sexual violence—all may exert an emotional toll on military personnel, their families, and their communities (SAMHSA, 2014).

4. Combat exposed military deployment correlates to increased violence creating a social problem for military personnel, their families, and their communities (SAMHSA, 2014). While intimate partner violence (IPV) is historically kept as a family secret, IPV is now viewed as a widespread societal and public health problem with negative outcomes for perpetrators, victims, children and society at large (Klostermann, Mignone, Kelly, Musson, & Bohall, 2012).  Mental health professionals may be able to help ease post-deployment reintegration and reduce risk factors for violence in military families.

5. Intimate Partner Violence

6. Intimate Partner Violence Intimate Partner Violence is physical abuse, psychological (emotional) abuse, sexual abuse, financial abuse or the stalking of current or former spouses, boyfriends, or girlfriends including same sex relationships in order to establish and maintain power and control over the other person.

7. Intimate Partners Include… • Current spouses (legal or common law) • Current non-marital partners: • Dating (including first date) • Boyfriends or girlfriends • Same sex-partners • Divorced, former, or separated spouses • Former non-marital partners: • ex-boyfriends • ex-girlfriends • ex-same-sex partners

8. Types of IntimatePartner Violence

9. Physical Abuse The use of physical force with the potential for causing death, disability, injury or physical harm. • Shoving • Strangulation/ Choking • Shaking • Slapping • Punching • Burning • Use of a weapon • Use of restraints • Use of one’s size and strength against another person

10. Psychological (Emotional) Abuse • The communication of the intent to cause • Death • Disability • Injury • Physical harm Through the use of words, gestures or weapons.

11. Sexual Abuse • The use of physical force to compel a person to engage in a sexual act unwillingly • An attempt or completed sexual act involving a person who is: • Unable to understand the nature of the condition of the act • Declines participation in the act • Communicate unwillingness to engage in the act • Abusive sexual contact

12. Financial Abuse • It is another way for an abuser to isolate and control a victim. Financial domestic abuse can include: • stealing money • using someone’s credit without consent • forbidding someone to work • forcing someone to work in a threatening or dangerous job (for instance, forcing someone to sell drugs or do sex work) • or forbidding someone access to their own money. • If someone is the victim of financial domestic abuse, it can be hard for him/her to leave the abusive situation since s/he can be without any financial resources.

13. Stalking • Harassing or threatening behavior that an • individual engages in repeatedly • Sending the victim unwanted presents • Following or laying in wait for the victim • Damaging or threatening to damage the victims property • Appearing at the victims home or place of business • Defaming the victims character or spreading rumors • Harassing the victim via the internet by posting personal information

14. Post Traumatic Stress

15. Post Traumatic Stress Post-Traumatic StressDisorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. (Mayo Clinic, 2017)

16. Examples of Traumatic Events Experienced Directly • Military combat • Violent personal assault (sexual assault, physical attack, robbery, mugging) • Being kidnapped • Being taken hostage • Terrorist attack • Torture • Incarceration as a prisoner of war or in a concentration camp • Natural or manmade disasters • Severe automobile accidents • Being diagnosed with a life-threatening illness

17. Examples of Witnessed Traumatic Events • Observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster • Unexpectedly witnessing a dead body or body parts

18. Examples of Events Experienced by Others that are Learned About • Learning of a violent personal assault, serious accident, or serious injury experienced by a family member or a close friend • Learning of a sudden, unexpected death of a family member or a close friend • Learning that one’s child has a life-threatening disease

19. The Links Between Intimate Partner Violence and Post Traumatic Stress • Current military conflicts involving combat and estimates of troops exposed to combat over the past 2-3 decades • Statistic regarding exposure to combat reveal: • Involvement in both the Iraq and Afghanistan conflicts presented opportunity for exposure to combat by some estimates as high as 90% thus taking a toll on marriages and mental health as a major concern (Hoge, Auchterlonie, & Milliken, 2006). • A review and meta-analysis of 17 studies published between 2001 and 2014 involving United States and United Kingdom soldiers found, across studies that violence and physical aggression were prevalent and became more intense and frequent with exposure to combat traumas (Graph, Charts).

20. The Links Between Intimate Partner Violence and Post Traumatic Stress • Results and effect on society: Combat exposed military deployment correlates to increased Intimate Partner Violence (IPV). IPV generally kept as family secret. • social problem that often predicts negative outcomes for: • military personnel, • their families • and their communities (SAMHSA, 2014).

21. Research on Combat exposure and the Adverse Affects on IPVs Reveals: • Although the military covers some life essentials such as housing, medical needs and employment, there are other ecological implications of military deployment that adversely affect marriage satisfaction and that may exacerbate psychological effects of combat. • Ecological Preventing Intimate Partner Violence among Combat implications include military installation transfers, distance from extended family, unpredictable schedules and long hours are among other considerations with negative effects. In addition, combat exposure, injury and exposure to death leave soldiers with significant psychological problems (Klostermann, Mignone, Kelly, Musson, & Bohall, 2012)

22. Research on Combat Exposure and the Adverse Affects on IPVs Reveals: • PTSD, a signature injury among combat exposed military personnel. • Military personnel exposed to combat are at increased risk for Post Traumatic Service Disorder (PTSD) and other psychological conditions • Post-traumatic stress disorder (PTSD) is often found post-deployment and is considered a “signature injury with symptoms that include: amplified anger, emotional dysregulation, dissociation or flashbacks and sleep disturbances (Finley, Baker, Pugh, & Peterson, 2010). • Military rates vs. rates among US adults (Klostermann, Mignone, Kelly, Musson, & Bohall, 2012). (CHART) • Although PSTD is the focus of many IPV studies, substance abuse remains a key factor in the prevalence of military violence as well (MacManus, 2015).

23. Research on Combat Exposure and the Adverse Affects on IPVs Reveals: • Vets with PTSD show violence more frequently (2-3X national average) compared to civilian families and therefore are more likely to experience : • Marital dissatisfaction • Increased intent to divorce • Increased IPV abuse

24. Risk Factors • Risk factors for IPV include: • deployment and combat exposure, • pre-military violence, • some studies suggest is more strongly associated with self–reported violence and other deployment related risk factors, • psychopathology and PTSD, • childhood exposure to aggression and violence, • alcohol misuse strong association with violence (effects of alcohol on comorbid conditions), • prior arrests (MacManus, 2015). • Risk factors for female IPV: • research indicates exposure to childhood physical violence and childhood sexual abuse increase the risk of IPV and are two strong predictors of violence. • In addition, age (younger adults), • level of education, • social economic status and • the branch of service are also associated with IPV risks for women in military families (MacManus, 2015).

25. Readjustment • Readjustment and reintegration post deployment • Readjustment refers to how returning soldiers integrate back into close relationships and lifestyle back at home from deployment. • Research on adjustment reveals 33% of military families report violence after readjustment versus 13.5% without PTSD (Norman, Eibogen, & Schnurr, 2016

26. Barriers to Reporting IPV Intimate partners’ perception of the impact of their reporting keeps them from reporting and they may develop a war tolerance for violent and aggressive behavior despite risks to their own personal safety despite the bad model it sets for children in the home. • Victims’ reasons for doing this include: • attributing violence to PTSD, • the fact that a spouse may be found to be disabled Preventing Intimate Partner Violence among Combat due to PTSD • they think to themselves their spouse fought four our country, therefore guilt hinders self-advocacy (Finley, Baker, Pugh, & Peterson, 2010). • Effectiveness of existing post deployment violence screenings is unclear but research does support the idea that valid tools of assessment are needed because identifying risk factors will support prevention and may inform intervention strategies (MacManus, 2015).

27. What Counselors Can Do:

28. What Counselors Can Do… • Understand the barriers to counseling for personnel: • military mindset that personnel not reveal, disclose vulnerabilities. • Shame around the PTSD diagnosis (Monson, Taft, & Fredman, 2009). • military personnel typically share little if anything at all about their combat experiences due to shame, fear, tendency toward internalizing traumatic experience • resistance to sharing with others who’ve not shared their experience. • Understand the issues around victim’s reporting: • All military personnel except chaplains and family victim advocates are required to report suspected domestic violence, but since a criminal conviction for domestic violence in the military can result in consequences ranging from reassignment to discharge many victims are hesitant to report incidents fearing the negative consequences for their partner (Klostermann, Mignone, Kelly, Musson, & Bohall, 2012). • Engage victim advocates at military installations

29. Know the Opportunities… • Assessments toward effective IPV identification, prevention and treatment (Granello & Young, 2011). • Since it is widely held that military families at greater risk for violence compared to non-military families, standards of medical care should include screening for violence at medical appointments. • Assessment should Preventing Intimate Partner Violence among Combat be considered both prior to military enlistment and over the course of the military career as well as through VA services post-service. • Skill development for clients • Support should be offered to military families in terms of intimate relationship wellness and parenting skills. • Services of family advocacy program (SAMHSA, 2014).

30. Know the Opportunities…. • Pre-marital counseling • 6 months of counseling helpful prior to marriage to increase marital satisfaction and he proposes that young adult couples are at higher risk for challenges. • Cultivating awareness around risk factors: • ACE’s research • Genograms • History of violence or substance abuse. • Advocacy on behalf of military population.

31. Questions ?

32. References • FOCUS: Family Resiliency Training for Military Families. (2014, March 14). Retrieved from Project FOCUS: http://www.realwarriors.net/family/change/MFLC.php • Administration, S. S. (2014, September 29). Veterans and Military Families. Retrieved from Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/veterans-military-families • Mayo Clinic (2017, February 18). Post-traumatic Stress Disorder Overview. Retrieved from The Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/home/ovc-20308548 • Finley, E., Baker, M., Pugh, M. J., & Peterson, A. (2010). Patterns and Perceptions of Intimate Partner Violence Committed by Returning Veterans with Post-Traumatic Stress Disorder. Journal of Family Violence, 738-741. • Granello, D. H., & Young, M. E. (2011). Counseling today: Foundations of professional identity. United States: Pearson College Div. United States: Pearson College Div. • Hoge, C. W., Auchterlonie, J., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA, 1023.

33. References Continued • Klostermann, K., Mignone, T., Kelly, M., Musson, S., & Bohall, G. (2012). Intimate Partner Violence in the Military: Treatment Considerations. Aggression and Behavior, 53-58. • MacManus, D. R. (2015). Aggressive and violent behavior among military personnel deployed to Iraq and Afghanistan: Prevalence and link with deployment and combat exposure. Epidemiologic Reviews, 37. • Monson, C. M., Taft, C. T., & Fredman, S. J. (2009). Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clinical Psychology Review, 707-714. • Norman, S., Eibogen, E. B., & Schnurr, P. P. (2016, February 23). Research on PTSD, aggression, and violence. Retrieved from Department of Veteran's Affairs: http://www.ptsd.va.gov/professional/co-occurring/research_on_ptsd_and_violence.asp • Social, R. P. (2015). Body count Casualty Figures after 10 Years of the “War on Terror. Washington, D.C.: International Physicians for the Prevention of Nuclear War. Retrieved from www.ippnw.org/pdf/2015-body-count.pdf

34. Contact Information • Dr. Shauna Moore Reynolds, Ed.D., LCPC-S, LPC, NCC, ACS dr.shauna@smrcounselingservices.com 240-389-1487 • Ms. Lena Jackson, B.A. ljackson2@loyola.edu