Heidi Lary Kar, PhD. San Francisco Veterans Affairs Medical Center. K. Daniel O Leary, PhD. Stony Brook University

Transcription

1 Violence and Victims, Volume 28, Number 5, 2013 Emotional Intimacy Mediates the Relationship Between Posttraumatic Stress Disorder and Intimate Partner Violence Perpetration in OEF/OIF/OND Veterans Heidi Lary Kar, PhD San Francisco Veterans Affairs Medical Center K. Daniel O Leary, PhD Stony Brook University Veterans with posttraumatic stress disorder (PTSD) are at elevated risk for perpetrating intimate partner violence (IPV). Little research exists on the link between PTSD and physical IPV in Operational Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans. A sample of 110 male participants was recruited from the Northport Veterans Affairs Medical Center (VAMC). Three separate models were compared to determine which best explained the relationships between PTSD, IPV, emotional intimacy, and relationship satisfaction. Constructs were assessed via a battery of standardized, self-report instruments. Thirty-three percent of veterans had clinically elevated PTSD scores, and 31% of the men reported that they engaged in physical IPV in the past year. Poor emotional intimacy mediated the association between PTSD symptoms and perpetration of physical IPV. Past predeployment IPV perpetration was shown to be a predictor for current postdeployment physical IPV perpetration. Keywords: aggression; path analysis; couples; mental health The psychological impact of posttraumatic stress disorder (PTSD) on returning veterans has been well studied, but the secondary impact of PTSD on the veterans close relationship functioning is less well understood. Veterans with PTSD experience a multitude of relational problems including marital/relationship dissolution (Ruger, Wilson, & Waddoups, 2002), intimate partner violence (IPV; Jordan, et al., 1992), marital dissatisfaction, and emotional distancing or numbing (Galovski & Lyons, 2004; Hoge, Auchterlonie, & Milliken, 2006; Sayers, Farrow, Ross, & Oslin, 2009; Taft, Watkins, Stafford, Street, & Monson, 2011). Various studies have offered a glimpse into ways combat experience and/or PTSD symptoms negatively affect veterans relationship functioning across these domains. Although PTSD, emotional intimacy, relationship satisfaction, and IPV have been studied Springer Publishing Company

2 PTSD/IPV in Veterans 791 individually, to our knowledge this study is the first to compare models of the PTSD physical IPV relationship through investigation of our specific hypothesized associations of these four constructs among young veterans. In addition, we investigate whether previous IPV perpetration adds any new information to understanding the relationship between PTSD and current IPV. A recent meta-analysis by Taft and colleagues (2011) calls for examination of models that can help explain types of relationship difficulties associated with PTSD in military populations; this study evaluates a model in which emotional intimacy mediates the associations between PTSD symptom severity and physical IPV perpetration. Many prevalence studies have suggested that although veterans without a PTSD diagnosis perpetrate IPV at rates similar to the general population, veterans with PTSD perpetrate IPV at much higher rates (e.g., Carroll, Rueger, Foy, & Donahoe, 1985; Jordan et al., 1992). A recent meta-analysis found a medium-sized association ( p 5.36) between IPV and PTSD (Taft et al., 2011). As such, expanding knowledge to better understand what about having PTSD symptoms is, specifically associated with perpetrating partner violence, can help with design of early intervention programs for this population. The temporal relationship between past and current IPV is an often overlooked association. A central tenet of behavioral psychology is that past behavior is one of the best predictors of future behavior (Bonta, Law, & Hanson, 1998; Triandis, 1977). Attachment theory supports this behavioral psychology tenant when one considers that patterns of relating between children and caregivers often correlate to similar patterns of relational functioning later in life (Bowlby, 1973). Specific to the issue herein of IPV, associations between both separation anxiety and unhealthy attachment history have been repeatedly demonstrated in children (e.g., Bowlby, 1976) and adulthood (e.g., Hazan & Shaver, 1987). Early attachment theory is based on the idea that the characteristics of early caretaking relationships provide a prototype for later social relationships. Bowlby, Robertson, and Rosenbluth s (1952) early pioneering work in attachment theory introduced the concept of separation anxiety. Ainsworth, Blehar, Waters, and Wall (1979) and later researchers, Main and Solomon (1986), expanded on Bowlby s attachment work to delineate four key attachment styles in children that have been shown to be associated with a range of different personality and behavioral correlates through a wealth of attachment research. Later work spearheaded by Hazan and Shaver (1987) found that these different attachment styles in children are similarly demonstrated in adults; furthermore, they found that adult attachment styles predicted very different future views on romantic love. For example, whereas securely attached adults viewed romantic love as long lasting and enduring, avoidant attachment adults viewed romantic love as temporary/fleeting. Bowlby s (1973) hypothesis is that for some with separation anxiety, anger and hostility are behavioral manifestations of the underlying fear of abandonment. This rich attachment literature can inform recent empirical findings from our laboratory, which suggest that poor emotional coping skills (which are presumably poor because the adult never learned healthy attachment/emotional coping skills) are associated with perpetration of IPV (Foran & O Leary, 2011). Adopting this view, it logically follows that those veterans who enter traumatic wartime experiences with unhealthy attachment styles and poor emotional coping skills (as evidenced through use of IPV) would be less equipped to deal with trauma experiences well and would hence go on to develop PTSD at higher rates than their better equipped peers. This group with poorer attachment and emotional coping abilities would also, logically, go on to continue to perpetrate IPV at higher rates while simultaneously struggling with their PTSD symptoms. Based on these two theoretical platforms and empirical work in emotional skill deficits, we hypothesized that predeployment IPV would predict postdeployment IPV.

3 792 Kar and O Leary The empirical literature has demonstrated that lower levels of relationship satisfaction are consistently reported in relationships characterized by IPV among veterans with PTSD. Studies with Vietnam veterans have demonstrated that veterans without PTSD report relationship satisfaction similar to reports from the general community (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004; Riggs, Byrne, Weathers, & Litz., 1998), whereas veterans with PTSD have significantly lower relationship satisfaction scores. Riggs et al. (1998) found that among a sample of 50 cohabitating veteran couples, 70% of those couples in which the veteran suffered from PTSD reported relationship distress as opposed to only 30% of couples in which the veteran did not suffer from PTSD. An association between PTSD and marital discord/dissatisfaction has been documented with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans (Goff, Crow, Reisbig, & Hamilton, 2007), but the mechanism through which these constructs are related remains unclear. The recent meta-analysis by Taft and colleagues (2011) found the association between PTSD and marital discord to be p 5.38, a medium-sized association. Emotional numbing has been repeatedly documented to be the most salient component of PTSD regarding relationship problems among veterans (Riggs et al., 1998; Ruscio, Weathers, King, & King, 2002). The definitional component of emotional numbing that refers to relationships is feeling distant from others. This idea can be conceived of as a lack of emotional intimacy with others. Relationship satisfaction has generally been thought of as a global evaluation of one s marriage, which includes domains of communication, intimacy, extent of agreement on finances, values, and ways of spending time (Bradbury, Fincham, & Beach, 2000), whereas emotional intimacy is conceptualized as a much narrower construct. Theoretically, those who are unsatisfied in their relationship and who do not feel emotionally close to their partner may be more inclined to use physical violence during conflicts and may not feel as inhibited as those who are satisfied in their relationships. Although many studies have assessed relationship satisfaction as an indicator of relationship quality, few have specified emotional intimacy as the variable of interest. However, there are few studies that have demonstrated that increased intimacy in a relationship leads to increases in relationship satisfaction (e.g., Dandeneau & Johnson, 1994). Unfortunately, lack of clarity regarding the definitions of emotional intimacy and intimacy contribute to difficulty in interpreting this literature. For the purposes of this study, we adopted Prager s (1995) definition of intimacy which we term emotional intimacy. Although emotional intimacy is a part of overall relationship satisfaction, as noted earlier, it is a more specific, narrow concept that captures the essence of both a feeling of closeness and self-disclosure ability with one s romantic partner. Two of the original intimacy researchers, Schaefer and Olson (1981) described emotional intimacy as... a process and an experience which is the outcome of the disclosure of intimate topics and sharing of intimate experiences (p. 51). The difficulty in studying this construct validly and reliably comes from the fact that operationalizing this concept has been a struggle for researchers. As such, many different quantifiable variables have been used to represent this construct including problems in expression of care, anxiety regarding intimacy, and difficulties in self-disclosing to partners. It is important to acknowledge that literature on adult attachment remains distinct from literature on intimacy, although both constructs denote a strong, emotional bond between two people. Veterans with PTSD have problems expressing caring (Egendorf, Kaduschin, Laufer, Rothbart, & Sloan, 1981) and they often have lower levels of emotional expression and self-disclosure (Carroll et al., 1985). Veterans have also reported higher levels of

4 PTSD/IPV in Veterans 793 anxiety related to being intimate with their partners (Riggs et al., 1998). Furthermore, Vietnam veterans with PTSD reported less expressiveness and less disclosure to their partners (Carroll et al., 1985). Less ability to be emotionally intimate with one s partner presumably would lead to lower levels of relationship satisfaction. In fact, several crosssectional studies have found that among combat veterans with PTSD, those with higher endorsements of the avoidance/numbing symptoms also report higher levels of intimate relationship problems (e.g., Evans, McHugh, Hopwood, & Watt, 2003; Solomon, Dekel, & Mikulincer, 2008). Dekel, Enoch, and Solomon (2008) tested a model in which PTSD symptoms among couples in which one partner was a prisoner of war (POW) led to partner violence; the results suggested that self-disclosure (one aspect of emotional intimacy) partially mediated this relationship. In a recent study of combat veterans, Solomon and colleagues (2008) found that self-disclosure partially mediated the relationship between avoidance symptoms and marital intimacy. Consequently, this study herein aims to assess both overall relationship satisfaction as well as the specific construct of emotional intimacy to evaluate whether emotional intimacy is a more robust mediator of the PTSD IPV relationship than is relationship satisfaction. Most research on the familial impact of the veteran s PTSD has focused on Vietnam veterans. Although there is substantial knowledge gained from research regarding Vietnam veterans, the differing demographics and military experiences of the typical male who has served in Iraq and/or Afghanistan (Litz, 2007) diminishes our ability to generalize from these findings (National Center for PTSD; Record & Terrill, 2004). Incorporating these different theoretical bases, we hypothesized, first, that predeployment IPV will predict postdeployment IPV; second, we predicted that both emotional intimacy and relationship satisfaction will mediate the relationship between PTSD and postdeployment IPV; and third, we hypothesized that emotional intimacy will better explain the association between PTSD symptomatology and IPV than will relationship satisfaction. METHOD Participants A sample of 110 male OEF/OIF veterans was recruited from the Northport Veterans Affairs Medical Center (VAMC) medical records database from January to May The research coordinator sent letters to all OEF/OIF veterans registered at the Northport VAMC and followed up with individual phone calls. Of the 1,500 male OEF/OIF veterans whom we attempted to contact, 298 were reached via phone. Of the 298 veterans contacted, 135 were eligible to participate. The largest reason for ineligibility was not being involved in a cohabitation and romantic relationship for a minimum of 6 months. Out of the 135 eligible participants, 110 agreed to participate (82% participation rate). The two reasons given for not wishing to participate were not enough time (n 5 21) and not interested in talking about their relationship issues (n 5 4). Participants must have had at least one OEF/OIF deployment, must be either married or cohabitating with a female partner for the previous 6 months, and finally, must have been in a committed relationship with a female partner prior to their first deployment. Regarding relationship length, 12% of the sample had been with their current partner less than 1 year, 57% between 1 and 5 years, and the remaining 31% between 5 and 10 years.

5 794 Kar and O Leary Procedure Participants who met all inclusion criteria for this study attended one in-person study session at the Northport VAMC. During the session, the research coordinator explained the study in detail, obtained participants consent, administered the battery of questionnaires which included information on demographic characteristics, and paid the participant $25. The data were collected one-on-one in a private office and the method of data collection was via paper and pencil. Following the appointment, the research coordinator transferred the data to the VAMC s secure electronic database. Data collection took place between January and September Assessments Revised Conflict Tactics Scale (CTS2). The CTS2 (Straus, Hamby, Boney-McCoy, & Sugarman, 1996) is a 78-item inventory that assesses the frequency (on scales ranging from 0 5 never to 6 5 more than 20 times) of perpetration behaviors engaged over the previous 12 months for current IPV and over the 12 months prior to veteran s first deployment for past IPV. The physical assault scale comprises five mild and seven severe items. As per Straus and Gelles s (1990) scoring system for previous 12-month prevalence scoring, all 12 physical assault items (i.e., thrown an object that could hurt, twisted arm or hair, pushed or shoved, grabbed, slapped, beat up, burned or scalded on purpose, kicked, slammed against a wall, choked, punched or hit with an object that could hurt, and used a knife or gun ) were recoded (i.e., 7 to be 0 and values of 3 through 6 to be the midpoints) and the items were summed to compute an overall physical assault score. One overall category of physical aggression was used in this study, which included the sum of Straus (1996) mild and severe endorsements. The previous 12-month physical assault perpetration subscale reliability was alpha 5.75, and the predeployment 12-month physical assault perpetration subscale reliability was alpha Posttraumatic Stress Disorder Checklist Military (PCL-M). The PCL-M (Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report that measures the 17 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of PTSD. Respondents rate how much they were bothered by that problem in the past month. Items are rated on a 5-point scale ranging from 1 5 not at all to 5 5 extremely. A rating of 2 or more was considered an endorsement of that symptom for this study. The three subscales (B, C, and D) correspond to the criteria clusters in the DSM-IV. Previous research on the PCL-M indicated mean scores of 64.2 (SD 5 9.1) for PTSD participants and 29.4 (SD ) for non-ptsd participants (Weathers et al., 1993). A cutoff score of 50 had a sensitivity of.82 and specificity of.83 when compared to the Structured Clinical Interview for DSM-IV (SCID) diagnosis. In this sample, full scale alpha was.96. Personal Assessment of Intimacy in Relationships (PAIR). The PAIR (Schaefer & Olson, 1981) subscales have adequate convergent and discriminant validity, internal consistency, and split-half reliability. The emotional closeness subscale (six items) was the only subscale used for these analyses; its alpha was.87. This subscale includes the following items that incorporate both elements of emotional closeness and self-disclosure ability: My partner listens to me when I need someone to talk to ; I can state my feelings without him/her getting defensive ; I often feel distant from my partner ; My partner can really understand my hurts and joys ; I feel neglected at times by my partner ; and I sometimes feel lonely when we re together. Participants indicate their extent of

6 PTSD/IPV in Veterans 795 agreement with each item: strongly agree, agree, moderately agree, disagree, and strongly disagree. Some items in this scale had to be reverse coded to match directionality of the answer responses across items. Dyadic Adjustment Scale (DAS). The DAS (Spanier, 1976) is a 32-item scale measuring dyadic adjustment (measured by dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression) and has a range of By convention, those with scores of 97 and lower are interpreted to have low levels of relationship satisfaction. Using the present sample, alpha was.86 and the mean score was 64.4 (SD ). Some of the DAS items also were reverse coded, as is indicated in the scoring procedures. Data Analysis The PAIR and DAS scales were recoded so that higher scores indicate less emotional intimacy and poorer relationship satisfaction. Data analyses began with an inspection of the integrity of the data (e.g., screening for outliers and non-normality). Path analyses to calculate the paths of the model that reached significance were conducted using Mplus (version 6.0); all additional quantitative analyses were conducted using SPSS (version 12.0). RESULTS Descriptive Statistics The average age of this sample was years (SD years). At the time of evaluation, 61.8% of participants reported being married and 38.2% were unmarried but currently cohabitating with a female partner. Forty-nine of the participants were in a relationship with the same partner predeployment/postdeployment, whereas the remaining 57 participants were in different relationships predeployment/postdeployment. Violence data was not used for the remaining four participants who failed to indicate whether they were with the same or different partner predeployment and postdeployment. Whereas 38.2% of Veterans identified their highest level of education as high school/ general educational development (GED), 55.5% had completed at least some college, and 5.5% had completed some graduate training. Regarding ethnicity, 68.2% of the sample self-identified as White, whereas the remaining 31.8% identified as some minority group with the largest minority group represented by Hispanic/Latino veterans (17.3%; n 5 19) and the second largest group consisting of African Americans (6.4%, n 5 7). In terms of socioeconomic status, 9.4% of participants reported family income lower than $20,000/ year; 32.3% reported family income between $20,000 and $70,000; 23.9% reported family income between $70,000 and $85,000; and finally, 34.4% of participants reported family income higher than $85,000. Most (80.0%) of the veterans had participated in one (41.8%) or two tours (38.2%) of duty during their military service, and the mean time since the most recent deployment was 3 years, 8 months. The remaining 20.0% of veterans had participated in three or more tours of duty. The previous 12-month prevalence rate of physical perpetration was 30.9%. The past predeployment prevalence rate of physical perpetration was 31.4%. The overall mean and standard deviation of the PCL-M scores was 42.8 (17.4). The scores ranged from 17 to 81. Most veterans experienced several PTSD symptoms. Using a diagnostic cutoff score of equal to or greater than 50 on the PCL-M scale, 33.0% of veterans in the sample met diagnostic cutoff criteria for PTSD.

7 796 Kar and O Leary TABLE 1. Means and Standard Deviations of Study Variables PTSD (PCL-M) Past Perpetration (CTS2) Emotional Intimacy (PAIR) Current Perpetration (CTS2) Marital Satisfaction (DAS) (17.41) (0.22) (5.91) (0.34) (13.82) Note. PTSD 5 posttraumatic scale disorder; PCL-M 5 PTSD Checklist Military; CTS2 5 revised Conflict Tactics Scales; PAIR 5 personal assessment of intimacy in relationships; DAS 5 Dyadic Adjustment Scale. Table 1 includes the mean and standard deviation of each variable described here. This study analyzes models using the PAIR and the DAS in an attempt to compare which measure of relationship quality has the best model fit. Path Analytic Strategy and Model Fit Mplus version 6.0 statistical software (Muthén & Muthén, 2009) with maximum likelihood estimation was used to conduct the path analyses. Bootstrap procedures were implemented in Mplus to estimate indirect effects and associated standard errors for the hypothesized models. Chi-square is the conventional measure of fit (nonsignificant values indicate good model fit), but following Hu and Bentler s (1998) guidelines, model fit was evaluated with multiple indices including the comparative fit index (CFI; Bentler, 1990), standardized root mean square residual (SRMR; Bentler, 1995), and chi-square. Model fit was evaluated with the following criteria: CFI..95, SRMR,.08, root mean square error of approximation (RMSEA),.06, and a nonsignificant chi-square. TABLE 2. Correlations Among All Variables PTSD Past Perpetration Emotional Intimacy Current Perpetration Marital Satisfaction PTSD **.25* 2.30** Past perpetration ** 2.03 Emotional intimacy 2.26**.62** Current perpetration 2.18 Marital satisfaction Note. PTSD 5 posttraumatic stress disorder. *p,.05. **p,.01.

8 PTSD/IPV in Veterans 797 PTSD symptomatology (PCL-M).27(.09)** Emotional intimacy.27(.07)*** Current physical aggression (PAIR) (CTS2) Prior physical aggression (CTS2).33(.11)** Figure 1. Model A. Standardized path coefficients are provided with standard errors in parentheses. Model fit statistics: x , df 5 2, p 5.22; comparative fit index (CFI) 5.96, standardized root mean square residual (SRMR) 5.04, root mean square error of approximation (RMSEA) PTSD 5 posttraumatic scale disorder; PCL-M 5 PTSD Checklist Military; CTS2 5 revised Conflict Tactics Scales; PAIR 5 personal assessment of intimacy in relationships. **p,.01. ***p,.001. Path Analytic Results Original Hypothesized Model (A). The first model (A) tests the hypothesized model identified in Figure 1. For the original hypothesized model, excellent fit was indicated. Specifically, CFI 5.96, SRMR 5.04, RMSEA 5.070, x (df 5 2; p 5.22). All path coefficients reflect standardized values. All hypothesized paths were significant. Model A showed significant paths from PTSD symptomatology to emotional intimacy, from past aggression to current aggression, and from emotional intimacy to current aggression. The Akaike information criterion (AIC) for Model A was The overall model had excellent model fit. Two alternative models were tested. Mediation Analyses. A priori hypotheses included a mediation model with PTSD symptomatology predicting current aggression via emotional intimacy as presented in Figure 1. Bootstrap procedures were implemented in Mplus to estimate the indirect effect and associated standard error. Emotional intimacy significantly mediated the association between PTSD symptoms and physical aggression perpetration (Model A: 0.27; 95% confidence interval [CI] 5.09,.45, p 5.003). Alternative Model (B). Model B differed from Model A only in its substitution of the DAS total score for the emotional intimacy construct (Figure 2). This substitution was carried out to understand if focusing on emotional intimacy as opposed to the more often used representation of relationship quality, marital satisfaction, was supported by actual evidence. The overall model fit of this second model was inadequate. Specifically, CFI 5.88, SRMR 5.05, RMSEA 5.116, whereas x (df 5 2; p 5.09). The CFI result of.88 is not adequate for model fit. As such, DAS was not an adequate mediator in the model. Combined Model (C). Model C differs from all other models in that it simultaneously tests the constructs of emotional intimacy and relationship satisfaction within a model (Figure 3). This combined approach was designed to understand which, if either, one of these constructs is better at explaining the relationship between PTSD symptomatology

9 798 Kar and O Leary PTSD symptomatology.28(.10)**.21(.06)*** Current physical Marital satisfaction aggression Prior physical aggression.33(.11)** Figure 2. Model B. Standardized path coefficients are provided with standard errors in parentheses. Model fit statistics: x , df 5 2, p 5.09; comparative fit index (CFI) 5.88, standardized root mean square residual (SRMR) 5.05, root mean square error of approximation (RMSEA) PTSD 5 posttraumatic stress disorder. **p,.01. ***p,.001. and current aggression. The overall model fit of this third model was good. Specifically, CFI 5.97, SRMR 5.05, RMSEA 5.065, whereas x (df 5 3; p 5.23). Of particular interest is the fact that the relationship between DAS and IPV was nonsignificant once emotional intimacy was added to the model. Although both emotional intimacy and relationship satisfaction were associated with PTSD, only emotional intimacy retained its significant association with current aggression when relationship satisfaction was included..28(.10)** Marital satisfaction.07(.09) PTSD symptomatology Current physical aggression.27(.09)** Emotional intimacy.23(.10)*.33(.11)** Prior physical aggression Figure 3. Model C. Standardized path coefficients are provided with standard errors in parentheses. Model fit statistics: x , df 5 3, p 5.23; comparative fit index (CFI) 5.97, standardized root mean square residual (SRMR) 5.05, root mean square error of approximation (RMSEA) PTSD 5 posttraumatic stress disorder. *p,.05. **p,.01.

10 PTSD/IPV in Veterans 799 DISCUSSION No previous study has examined emotional intimacy as a mediator of the association between PTSD symptomatology and physical IPV perpetration. As hypothesized, PTSD symptomatology predicted emotional intimacy, relationship satisfaction, and physical aggression in all models. Although both Models A and C demonstrated good overall model fit, Model B did not. Because Models A and B only differ from each other on the relationship functioning construct (emotional intimacy vs. relationship satisfaction), these preliminary results suggest that emotional intimacy may be more important in understanding the relationship between PTSD and current IPV in this population. More specifically, although both relationship satisfaction and emotional intimacy were predictive of partner aggression, it was emotional intimacy that had a unique association with partner aggression when both were assessed simultaneously. In addition, predeployment IPV predicted postdeployment IPV. Given the extensive literature base on relationship satisfaction and its association with IPV (e.g., Schumacher & Leonard, 2005; Stith, Green, Smith, & Ward, 2008), it is important to recognize that emotional intimacy, one particular piece of overall satisfaction, may be a more salient subconstruct to continue to assess in future studies. Results demonstrated that relationship satisfaction and emotional intimacy are highly correlated (r 5.60), as expected, but it may be more clinically meaningful to better understand in what ways they are different. Theoretically, the emotional numbing aspect of PTSD points to a loss of emotional intimacy in close relationships although not necessarily affecting other aspects of marital functioning such as agreement on financial issues, values, and/or household decision making. It is also important to note that although marital satisfaction proved predictive of current IPV in Model B, the results from a bivariate correlation indicated no significant relationship with IPV. This odd statistical finding may, indeed, be a result of the uniformly low scores on the relationship satisfaction measure. Initial results from qualitative interviews conducted with this sample suggest that, for many veterans, their sexual functioning suffers when they report decreased emotional intimacy (Kar, Long, & O Leary, 2013). Further work to understand the specific relationship problems (including IPV) that are specifically aligned with emotional intimacy may prove very helpful to clinicians both for individual PTSD treatment to veterans and for couples therapy to veterans and their partners. Attachment theory describes disorganized or fearful attachment as high on avoidance and high on ambivalence this attachment perspective may be very helpful in elucidating the underlying mechanism between PTSD symptoms and IPV perpetration. More recent attachment work with adults has demonstrated higher rates of partner violence in couples in which there exists a mismatch of attachment styles (Doumas, Pearson, Elgin, & McKinley, 2008). In addition, theoretical and empirical work that focuses on delineating the points of intersection and distinction (if any) between attachment and emotional intimacy is needed. Limitations and Future Directions All measures used were self-reported, and only the male partner s report was obtained. Although reliance on self-report instruments is not ideal, a recent meta-analysis has suggested that response biases (single reporter bias for relationship adjustment and social desirability for partner aggression) do not substantially impact the relationships of interest (Taft et al., 2011). Because of the range in ages of participants as well as range of

11 800 Kar and O Leary length of time since first deployments, there may have been some temporal biases involved in remembering levels of predeployment aggression. In addition, although the theoretical base informing this study was that of the intimacy-focused literature, the researchers wish they had included attachment-informed instruments. This sample s overall relationship satisfaction mean score was 64.4, whereas the mean of the DAS in a sample of parents recruited via random digit dialing in the same geographic area was (O Leary, Smith Slep, & O Leary, 2007). This low mean score is indicative of relationships characterized by extremely low relationship satisfaction, and it indicates that 99% of this sample of veterans was maritally discordant. Had there been a larger range of DAS scores present in this sample, our ability to test the association between IPV and relationship satisfaction might have been increased. In addition, this sample was mixed in that 57 of the participants reported on aggression across different relationships and 49 reported on aggression of one relationship over time. A larger sample size would have allowed for comparative analyses between these two types of relationship histories. Because this study s focus is on understanding the effects of PTSD symptomatology on relationships and required participants to be cohabitating, generalizing results to male OEF/OIF veterans who are not in relationships must be done with caution. The most prevalent reason (e.g.,. 95%) for veterans not meeting the inclusion criteria was that they were not currently in a relationship. This means there is a large group of male OEF/OIF veterans whose data are not reflected in these results because their romantic relationships have dissolved. Future research directions include investigating the context of the veteran s PTSD symptomatology and his female partner s aggression. Whether most female partner aggression in this population is in response to increased stress and frustration at caring for their partner with PTSD (i.e., caregiver burden), a direct response to their partner s instigation of physical aggression, some other specific readjustment factor, or related to a combination of factors is very important information to enhance the field s conceptualization of IPV in this population. More advanced models that can take the victimization reports of both partners into account is an important next step. Unfortunately, our limited sample size prevented inclusion of a hypothesized path from past predeployment IPV to current PTSD. One conceptualization of the relationship between IPV and PTSD is that an individual s poor emotional coping skills can lead to both perpetration of IPV and of development of PTSD (as opposed to use of other more adaptive ways of coping with anger and negative emotions). The sample size also prevented us from including demographic covariate variables in the models. Finally, it is salient that no causal directionality can be inferred from this cross-sectional data. In addition, the cross-sectional nature of the data are not ideal for meditational analyses, so future studies that collect mediator and outcome variable data across different periods are needed. Clinical Implications These findings support a multivariate conceptualization of partner aggression, which incorporates mental health symptoms (PTSD symptoms), individual factors (aggression perpetration), and dyadic factors (emotional intimacy/relationship satisfaction). The findings herein suggest that the emotional intimacy between a veteran and his spouse may be an important aspect to focus on regarding preventing partner violence

12 PTSD/IPV in Veterans 801 among veterans with PTSD. A focus on strengthening the emotional intimacy between the partners may serve in preventing or curtailing partner abuse from occurring in this population. Offering treatments designed to increase the emotional intimacy in these couples, such as emotion-focused therapy (Greenberg & Johnson, 1988), may prove the most helpful in this population than those that focus more generally on thoughts/behaviors such as cognitive behavior therapy-focused marital therapy. REFERENCES Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1979). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Bentler, P. (1990). Comparative fit indexes in structural models. Psychological Bulletin, 107(2), Bentler, P. M. (1995). EQS structural equations program manual. Encino, CA: Multivariate Software. Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism among mentally disordered offenders: A meta-analysis. Psychological Bulletin, 123, Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation, anxiety, and anger. New York, NY: Basic Books. Bowlby, J. (1976). Separation: Anxiety and anger (Vol. 2). New York, NY: Basic Books. Bowlby, J., Robertson, J., & Rosenbluth, D. (1952). A two-year-old goes to hospital. Psychoanalytic Study of the Child, 7, Bradbury, T. N., Fincham, F. D., & Beach, S. R. H. (2000). Research on the nature and determinants of marital satisfaction: A decade in review. Journal of Marriage and the Family, 62, 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, Cook, J. M., Riggs, D. S., Thompson, R., Coyne, J. C., & Sheikh, J. L. (2004). Posttraumatic stress disorder and current relationship functioning among World War II ex-prisoners of war. Journal of Family Psychology, 18, 36 45, Dandeneau, M. L., & Johnson, S. M. (1994). Facilitating intimacy: Interventions and effects. Journal of Marital and Family Therapy, 20, tb01008.x Dekel, R., Enoch, G., & Solomon, Z. (2008). The contribution of captivity and post-traumatic stress disorder to marital adjustment of Israeli couples. Journal of Social and Personal Relationships, 25(3), Doumas, D. M., Pearson, C. L., Elgin, J. E., & McKinley, L. L. (2008). Adult attachment as a risk factor for intimate partner violence: The mispairing of partners attachment styles. Journal of Interpersonal Violence, 23(5), Egendorf, A., Kaduschin, C., Laufer, R., Rothbart, G., & Sloan, L. (1981). Legacies of Vietnam: Comparative adjustment of veterans and their peers (Vols. 1 5). New York, NY: Center for Policy Research. Evans, L., McHugh, T., Hopwood, M., & Watt, C. (2003). Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners. Australian and New Zealand Journal of Psychiatry, 37, Foran, H., & O Leary, K. D. (2011). The role of relationships in understanding the alexithymia depression link. Unpublished manuscript, Stony Brook University, New York, NY. Galovski, T., & Lyons, J. A. (2004). Psychological sequelae of combat violence: A review of the impact of PTSD on the veteran s family and possible interventions. Aggression and Violent Behavior, 9,

13 802 Kar and O Leary Goff, B. S., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. Journal of Family Psychology, 21, Greenberg, L., & Johnson, S. M. (1988). Emotionally focused therapy for couples. New York, NY: Guilford Press. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), Hoge, C. W., Auchterlonie, J. L., & 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. Journal of the American Medical Association, 295(9), Hu, L., & Bentler, P. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3(4), 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 disorder. Journal of Consulting and Clinical Psychology, 60(6), Kar, H., Long, S., & O Leary, K. D. (2013). Contextual realities of intimate partner violence among young OEF/OIF veterans: Qualitative perspectives. Manuscript in preparation. Litz, B. (2007). The unique circumstances and mental health impact of the wars in Afghanistan and Iraq: A National Center for PTSD Fact Sheet. Washington, DC: National Center for Posttraumatic Stress Disorder, Department of Veteran Affairs. Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented attachment pattern. In T. B Brazelton & M. W. Yogman (Eds), Affective development in infancy (pp ). Westport, CT: Ablex. Muthén, L. K., & Muthén, B. O. (2009). Mplus user s guide (6th ed.). Los Angeles, CA: Author. O Leary, K. D., Smith Slep, A. M., & O Leary, S. G. (2007). Multivariate models of men s and women s partner aggression. Journal of Consulting and Clinical Psychology, 75, Prager, K. J. (1995). The psychology of intimacy. New York, NY: Guilford Press. Record, J., & Terrill, W. A. (2004). Iraq and Vietnam: Differences, similarities, and insights. Carlisle, PA: Strategic Studies Institute, U.S. Army War College. Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of the intimate relationship of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11, Ruger, W., Wilson, S. E., & Waddoups, S. L. (2002). Warfare and welfare: Military service, combat, and marital dissolution. Armed Forces and Society, 29, Ruscio, A. M., Weathers, F. W., King, L. A., & King, D. W. (2002). Male war-zone veterans perceived relationships with their children: The importance of emotional numbing. Journal of Traumatic Stress, 15(5), Sayers, S. L., Farrow, V., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans. Journal of Clinical Psychiatry, 70, Schaefer, M., & Olson, D. (1981). Assessing intimacy: The PAIR inventory. Journal of Marital and Family Therapy, 7(1), Schumacher, J. A., & Leonard, K. E. (2005). Husbands and wives marital adjustment, verbal aggression, and physical aggression as longitudinal predictors of physical aggression in early marriage. Journal of Consulting and Clinical Psychology, 73(1), Solomon, Z., Dekel, R., & Mikulincer, M. (2008). Complex trauma of war captivity: A prospective study of attachment and post-traumatic stress disorder. Psychological Medicine, 7, 1 8. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, Stith, S. M., Green, N. M., Smith, D. B., & Ward, D. B. (2008). Marital satisfaction and marital discord as risk markers for intimate partner violence: A meta-analytic review. Journal of Family Violence, 23(3),

14 PTSD/IPV in Veterans 803 Straus, M. A., & Gelles, R. J. (Eds.). (1990). Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction Books. Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, B. B. (1996). The revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283. Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79(1), Triandis, H. C. (1977). Interpersonal behavior. Monterey, CA: Brooks/Cole. Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Acknowledgments. This study was conducted at the Northport Veterans Affairs Medical Center in Northport, New York. This research was supported by the Melissa Institute for Violence Prevention and the Stony Brook University Marital Clinic. We are grateful to Dr. Heather Foran and Dr. Tom Olino for their data analysis assistance and to the dissertation committee members: Amy Smith-Slep, PhD, Daniel Klein, PhD, Stephen Long, PhD, Jacquelyn Campbell, PhD, and Bonita London-Thompson, PhD. We sincerely thank Dr. Stephen Long for his enormous support, mentoring, and many contributions to this study. Correspondence regarding this article should be directed to Heidi Kar, PhD, Psychology Service, Northport Veterans Affairs Medical Center, Northport, NY Heidi.Kar@va.gov

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