Intimate Partner Violence and Alcohol Use

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Intimate Partner Violence and Alcohol Use

• Carol R. Schermer MDDirector of Trauma and
  Critical CareUniversity of New Mexico

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Intimate Partner Violence(IPV)

• Lifetime prevalence of IPV 18-30
• Annual incidence physical IPV 1-13
• Leading cause of serious injury for women 15-44
• 1/3 female homicide victims killed by intimate
  partner
• Up to 33 of ED visits by women for injury are
  due to IPV
• Subsequent Health problems well described
• 77 of women never screened for IPV
• Women go unrecognized by health care providers

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Risk Factors for IPV

• IPV risk is multi-factorial
• Physical aggression is accepted or tolerated
• Poverty
• Unemployment
• Racial/ethnic differences
• Power and control
• Excessive alcohol consumption is considered
  controversial

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Magnitude of the problem

• In the general population
• alcohol problems are over-represented in
  partner-violent men
• Men in batterer intervention programs
• high rates of alcohol abuse and dependence
• Men seeking alcohol treatment
• High rates of partner violence
• 50-60 in year prior

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Views of Alcohol and IPV

• Broad agreement that
• Violent men are often heavy drinkers
• Heavy drinking often accompanies violence
• Disagreement whether alcohol plays a causal role
• Some argue no credible evidence
• Alcohol is an excuse
• Aggression does not stop with successful alcohol
  Tx
• Causal
• Resolution of drinking problems yields decreased
  IPV

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Association of Alcohol and IPV

• Extensive theoretical and empirical evidence
  linking substance abuse and male to female IPV
• Alcohol is the drug MOST commonly associated with
  IPV
• Paucity of good studies linking acute
  intoxication
• Female victims report partners had consumed
  alcohol prior 40-90 of time
• Cant separate out from drinking in general
• Hard to tell if drinking and violence are related

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Magnitude of the Problem

• Evaluation of men recruited from DV intervention
  programs and men entering alcoholism treatment
  programs
• M to F IPV 8-10 times more likely to occur on a
  day the male partner drank compared to those he
  did not drink
• 17-20 times more likely to occur on a heavy
  drinking day compared to a non-drinking day
• (Fals-Stewart 2003)

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Alcohol and Aggression

• Studies of aggressive behavior show
• Alcohol makes subjects more aggressive
• Increases negative verbal behavior
• Old research shows no associations
• Newer research consistently shows associations of
  
• Acute intoxication and IPV
• Physical violence more prevalent than verbal
• Episodes where husband was drinking
• More acts of violence and
• More severe violence

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Alcohol and Violence Events

• Alcohol use more common in serious physical
  assault events
• Violence most likely to occur within 4 hours
  after drinking
• Men more likely to have had 6 or more drinks
  prior to the events
• Estimated Blood alcohol concentrations
• 0.19 during violence episodes
• 0.11 during non-violent conflict episodes

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Alcohol and personality

• Alcohol appears to act synergistically with
  hostile motivations
• Except in those with very high hostile
  motivations
• Certain subsets of men are SO violent (ASPD)
• Violence episodes are not related to alcohol
• But alcohol worsens the severity of violence that
  occurs

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Interventions

• If there is evidence of causality between alcohol
  and violence can intervene
• Addressing excessive drinking behavior in
  individuals who behave in a violent way while
  drinking
• Relative ineffectiveness of batterer intervention
  programs may be due to
• Different types of batterers
• One-size fits all treatment programs

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Data on Alcohol and IPV

• Case control and epidemiologic studies
• Consistent associations of heavy drinking and DV
• 2/3 of all IPV alcohol is involved (DOJ 1996)
• Upper half of drinkers 2X risk of violence as
  lower half (Lipsey 1997, meta-analysis)
• Longitudinal studies report
• Drinking patterns are predictive of subsequent DV
• Controlling for prior DV

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Data on Alcohol and IPV

• Multivariate studies show drinking behavior
  associated with DV independent of
• Age
• Socio Economic Status
• Occupational status
• Race/ethnicity
• Hostility and anti-social behavior
• Normative views of aggression
• Drug problems

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Alcohol Treatment and IPV

• Recent reports show successful alcohol treatment
  reduces
• Verbal aggression
• IPV
• Decrease in drinking improves the relationship
  which improves the violence
• Couples alcohol treatment may work better than
  individual treatment
• Does not eliminate violence
• Makes it equal to those in non-alcoholic couples
• Alcoholics who relapse do not reduce their
  violence

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IPV and Female Problem Drinking

• Conflicting findings
• Women screening positive for IPV
• more likely to screen positive for problem
  drinking
• Little work has been done
• evaluate female problem drinking while
  controlling for partner drinking

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Study Objectives

• Identify women experiencing IPV
• Determine acceptability of screening
• Identify a potentially treatable IPV risk factor
• problem drinking

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Hypotheses

• Prevalence of IPV among female trauma center
  patients is greater than national samples
• Alcohol problems among abused women and their
  partners are greater than those among non-abused
  women
• Female problem drinking is an independent risk
  factor for IPV
• Female trauma patients endorse IPV screening

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Methods

• Women ages 18-80 admitted to Trauma Service
• Anonymous interview
• Eligible patients
• English speaking
• Excluded
• severe head injury
• major psychiatric disorder

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Measures

• IPV Conflict Tactics Scales (CTS)
• Severe items physical assault, sexual coercion,
  injury
• Not psychological items
• Lifetime and Past year IPV were evaluated
• Past year asked if partner gt2 months
• Alcohol Use Disorders Identification Test (AUDIT)
• AUDIT gt8 defined as problem drinkers

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Participant Demographics (n95)
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Demographics (continued)

• Partners
• N77
• Unemployed 23
• Problem Drinkers (AUDITgt 8) 38
• Missed subjects (10)
• Non-English speaking (5)
• Missed due to short hospital stay (5)
• No women declined interview

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(No Transcript)
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Association of drinking with past-year IPV
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Risk Factors for past-year IPV
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F Female P Partner PD problem drinker NPD
non-problem drinker ?2 for trend plt.001
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Multivariate Analysis of Risk Factors for IPV

• Logistic regression female and partner alcohol
  use
• Both female problem drinking and partner problem
  drinking independently predict IPV
• Partner problem drinker OR 8.9
• Female problem drinker OR 5.8
• Individually added other factors
• Race/ethnicity, age, partner unemployment
• None were independently predictive of IPV
• None decreased the association of problem
  drinking and IPV

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Views on IPV Screening
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Views on IPV Screening Among IPV Victims
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Logistic regression models of past year IPV
(n77)
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Logistic Model of Correlates of Past-year Severe
IPV
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UNM Study Conclusions

• Female trauma patients
• High lifetime prevalence (46)
• High past-year IPV (26 past year)
• Male and female alcohol use independently
  associated with IPV
• Female trauma patients should be screened for IPV

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Study methodology and associations of alcohol and
IPV

• Cross-sectional data do not establish causality
• Event based designs
• Stress may cause both drinking and violence
• Longitudinal Designs
• Assess temporal nature
• Experimental Studies may not translate out of the
  lab
• Treatment studies remove a putative causal factor
• Cause of the cure not necessarily the cause of
  the disorder

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Arguments for and against causality

• Alcohol is neither necessary or sufficient cause
  of violence
• Alcohol is not the primary determinant
• Alcohols influence on IPV is not uniform

• Alcohol contributes to violence in some people
  under certain circumstances
• Alcohol appears to act synergistically with
  hostile motivations

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Interventions

• Violence Intervention programs
• Relatively ineffective (USPSTF)
• Where should attention be focused?
• Can outcomes be improved?
• Meta-analysis of batterer intervention studies
• Effect size for batterer intervention programs
  very small
• Women 5 less likely to be re-assaulted if male
  had arrest and batterer treatment referral vs
  arrest alone
• Babcock, Green, and Robie 2004

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Interventions

• Majority of men arrested for partner violence
  drink alcohol hazardously
• Increased risk for violence recidivism after
  intervention more so than non-problem drinkers
• Frequency of husband drunkeness related to
  violence recidivism
• Probability of violence recidivism reduced by 30
  to 40 if batterer obtains substance abuse
  treatment
• Integrate or use SA treatment as an adjunct
• Jones and Gondolf 2001

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Summary IPV and Alcohol Use

• Relationship between husband-to-wife IPV and male
  problem drinking
• well described
• Does excuse versus causality matter?
• Male alcohol treatment
• IPV decreases with cessation of male problem
  drinking
• Couples alcohol treatment
• Decreases IPV rates
• New Studies to evaluate efficacy of treating
  female problem drinking to decrease IPV