Tens of Thousands of Combat

Tens of thousands of combat veterans returning from the war on terrorism in Iraq and Afghanistan are experiencing the effects of their traumatic experiences in ways that have contributed to an increased incidence of domestic violence. Although many of these combat veterans seek out marital counseling therapy, others continue down a path of self-destructive behaviors and many relationships end up in divorce or through suicide. Given the current push to send even more troops to the Middle East to help prosecute the war in Afghanistan, it is reasonable to suggest that these trends will not reverse themselves in the near future. It is therefore vitally important to identify the extent of the problem and a set of best practices that clinicians can use to help these combat veterans make the readjustments needed to live a meaningful and fulfilling life after their return. To this end, this study seeks to determine whether veterans who suffer from post traumatic stress disorder who seek couples therapy have a higher level of domestic violence than veterans without PTSD who seek couples therapy.

The Incidence of Domestic Violence in Combat Veterans with PTSD

Introduction

To date, more than 5,100 soldiers have died fighting the war on terrorism in Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in Afghanistan (Faces of the fallen, 2009). These grim statistics, though, do not reflect the other toll exacted by armed conflicts in the form of the trauma it can cause those who wear the uniform of the armed forces of the United States is these far-flung regions of the world. Faced with a population that contains insurgents as well as friends, and the potential for death as a result of undetectable improvised explosive devices, it is difficult for most American sitting in the comfort of their own homes to imagine the terror that these combat troops face on daily basis. In fact, the suicide rate among returning veterans has reached inordinately high levels and clinicians and military officials alike are seeking answers to what is causing this reaction by those who have participated in these wars in the Middle East and what can be done to reverse this ugly trend. It is little wonder, as well, that combat veterans of this area of the world have experienced more than their fair share of posttraumatic stress disorder (PTSD), a potentially debilitating condition that may be responsible in large part for the current high suicide rate among these returning combat veterans. It is also not surprising that many of the combat veterans who suffer from PTSD also experienced problems in their marital and family relationships in ways that contribute to a higher incidence of domestic violence.

Statement of the Problem

Domestic violence rates among active-duty servicemen, couples seeking relationship therapy, and Vietnam veterans with and without posttraumatic stress disorder (PTSD) have been shown to be higher than those from the general population; however, there remains a paucity of timely and relevant studies concerning couples who seek relationship therapy in which the veteran has PTSD to explore how these relationships compare with other couples (Sherman, Sautter, Jackson, Lyons & Han, 2006). According to Howard and Rheem (2009), "Combat-related trauma can be particularly detrimental to marital and other intimate relationships. Marital instability is present at higher rates in combat veterans. Veterans with post traumatic stress disorder (PTSD) and their spouses report significantly higher rates of impaired relationship functioning than those without PTSD" (p. 21). Because of the established relationship between the existence of PTSD and an elevated risk for violence among these couples, the treatment-seeking behavior, and the relationship distress, those couples who consult marital counselors for relationship therapy represent a particularly vulnerable population (Sherman et al., 2006). Therefore, identifying the respective levels of domestic violence among those combat veterans who suffer from PTSD compared to those combat veterans who do not represents a timely and important enterprise which is discussed further below.

Review of Related Literature

The military has learned a number of valuable lessons from its experiences in the world wars and the wars in Korea and Vietnam in the 20th century. Unlike veterans returning from deployment to combat areas in these conflicts, the armed forces attempt to provide active duty military personnel with the information and training they will need to help make the transition from combat duty to life in the United States and perhaps civilian life more seamless and less traumatic. In this regard, Fennell and Fennell (2002) note that, "Active duty military personnel and spouses have all completed a series of activities preparing them for reunion prior to the actual event. Thus, the active duty families have a cognitive sense of what to expect. The cognitive awareness of many of the issues is helpful, but does not by itself make the reconstitution of the family painless" (p. 1).

Indeed, combat veterans who return to their homes and families may encounter some unexpected problems besides just readjusting to a lifestyle where an unseen enemy is not trying to kill them and their comrades. For instance, Mabray, Bell and Bray (2009) recently reported that, "When soldiers return home, marital therapy is often needed to reintegrate. Common issues include lack of trust due to possible extramarital affairs, financial issues and disagreements about how money was spent, the returning soldier having difficulty thinking in terms of 'we' instead of 'I,' and the spouse who was left at home becoming more independent during deployment and having difficulty relinquishing duties" (p. 33). These issues may contribute to yet other problems, including veterans believing they no longer enjoy a space in their own homes or with their families, exaggerated expectations on the part of the veteran's spouse to contribute more than the veteran's fair share of the marital responsibilities because he or she was forced to "go it alone" for so long and wants a break from these tasks, elevated demands on the spouse's time and attention to the detriment of the relationships that were forged during the soldier's absence, and unrealistic expectations on the part of the returning soldier that things will be the same as when he or she was deployed (Mabray et al., 2009).

Not only do many returning veterans experience problems with their spouses, they can also have problems reestablishing meaningful relationships with their children. According to Mabray et al., "Soldiers coming back from deployment also face challenges in dealing with their children. Some have expectations that things will be the same, and are often confused when their children feel resentment towards them, seem distant or afraid, or do not show the same respect as before" (p. 32). Moreover, the child or children involved may have grown emotionally attached to the mother or father who stayed at home during the soldier's absence, and the return event may spawn new fears concerning the potential for future separations as well (Mabray et al., 2009). Clearly, these marital conflicts and familial problems can even be further exacerbated when the returning combat veteran experiences the potentially debilitating effects pf PTSD (Mabray et al., 2009).

Studies have shown time and again that combat veterans with PTSD display increased rates of anger compared to combat veterans who do not suffer from PTSD, findings that lend support to the notion that anger is a concomitant of PTSD instead of the combat experience itself; these higher rates of displayed anger can be manifested in hostile behavior (Sherman et al., 2006). For example, the results of a study of Vietnam combat veterans suffering from PTSD found that there was a higher incidence of hostility and increased hostile behaviors in interpersonal interactions compared to veterans who did not suffer from PTSD veterans or those subjects who served as community controls (Beckham, Roodman, Barefoot, Haney, Helms, Fairbank, et al., 1996). Likewise, a study by Rosenbaum and Leisring (2003) found that traumatic experiences can have a significant impact on the subsequent development of aggression in relationships, a finding the authors suggest "is not surprising given the evidence for a relationship between post-traumatic stress disorder (PTSD), anger, and aggression in other populations" (p. 7). According to Rosenbaum and Leisring, "Studies with PTSD samples suggest that PTSD is related to anger dysregulation as well as to relationship violence. Combat veterans with PTSD had more difficulty controlling anger than both combat veterans without PTSD and noncombat veterans with other psychiatric diagnoses" (p. 8). In addition, veterans who suffer from PTSD have been shown to exhibit increased levels of hostility and physically aggression toward their wives compared to veterans who did not suffer from PTSD (Rosenbaum & Leisring, 2003).

Not surprisingly, such elevated hostility and aggression levels can result in increased violence in their domestic relationships. For instance, Riggs, Byrne, Weathers, and Litz (1995) determined that almost two-thirds (63%) of those veterans who sought assistance for PTSD had reported being aggressive with their partners during the previous year. Likewise, Byrne and Riggs (1996) analyzed 50 volunteer Vietnam combat veterans and their partners and determined that nearly half (42%) of the male participants had been physically aggressive toward their domestic partners during the past year, an overwhelming majority (92%) were shown to have been aggressive verbally, and all of the subjects had used psychological aggression (based on combined veteran/partner reports of violence). These findings are truly alarming given the fact that fully 65% of the military personnel who have served in Iraq report a history of combat experience and these experiences can clearly result in physical and emotional injuries, with PTSD being expected to develop in between 5 and 15%, with other estimates ranging even higher (Gutierrez & Brenner, 2009). For instance, Gutierrez and Brenner cite the results of a recent analysis conducted by the RAND Corporation that found the range of prevalence estimates for PTSD was 5% to 15% of the military personnel deployed the Middle East; when these rates were applied to the 1.64 million military personnel who have already completed their deployment, Rand estimated the number of individuals with PTSD will be between 75,000 to 225,000.

Given the large numbers of returning combat veterans today and these disturbing rates of PTSD, these findings suggest that more needs to be done to help these brave men and women make the readjustment from a combat zone to a civilian life, and those clinicians who treat these veterans in family counseling settings must be able to differentiate between PTSD-related hostilities and the disagreements and conflicts that are characteristic of all marital relationships. For example, Gutierrez and Brenner (2000) emphasize that, "In part, clinicians' ability to facilitate treatment for those with PTSD will be enhanced by understanding that symptoms such as hypervigilance are adaptive while in theater. For some, the long-term adoption of such strategies may have been reinforced across multiple deployments. Upon returning home, these same symptoms can impede reintegration with the civilian community" (p. 96).

It is possible for combat veterans to experience many of the effects of PTSD without gong on to develop the condition in its full-blown state according to the diagnostic criteria provided by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed). In this regard, Gutierrez and Brenner (2009) emphasize that the more clinicians understand and appreciate these factors and the earlier clinical interventions are provided, the better. According to these researchers, "As individuals return from deployments to Iraq and Afghanistan, clinicians will be seeing clients at differing points in their recovery. Many individuals are exhibiting symptoms but do not yet meet the full diagnostic criteria for PTSD" (Gutierrez & Brenner, 2009, p. 95). By providing interventions that can help these combat veterans better manage their transition and cope with the expected and unexpected problems they will inevitably encounter on their return, it may be possible to minimize the impact of full-blown PTSD on some while preventing its development in others. As Gutierrez and Brenner conclude, "Providing treatments which help these individuals more effectively manage their symptoms may indeed lead to fewer clients developing PTSD. Early interventions may change the trajectory of recovery in positive directions" (p. 96).

Research Question

The study proposed herein will be guided by the research question, "Do veterans with PTSD (post traumatic stress disorder) who seek couples therapy have a higher level of domestic violence than veterans without PTSD who seek couples therapy?" The independent variable related to this research question will be veterans with PTSD who seek couples therapy vs. those veterans who do not have a PTSD diagnosis; the dependent variable will be the respective rates of domestic violence among these subjects.

Statement of the Hypothesis

The working hypothesis of the study proposed herein is that veterans with PTSD who seek couples therapy will have a higher level of domestic violence than veterans without a PTSD diagnosis who seek couples therapy. Based on the growing body of evidence concerning PTSD, this hypothesis is based on the notion that the nature of PTSD combined with combat experience will naturally lead to increased levels of domestic violence.

Significance of Study

While many Americans may have forgotten about the impact that the two world wars, and the Korean and Vietnam wars had on entire generations of veterans, many of these men and women still suffer from the effects of their involvement in a war that they fought because they felt that it was their duty to do so. Although the majority of these veterans have managed to go on to lead meaningful and fulfilled lives with normal family relationships, numerous others have been adversely affected by posttraumatic stress disorder in ways that remain better describes in the literature than they are understood. What is known, though, is that PTSD can affect combat veterans in ways that detract from their ability to maintain normal relationships with others, including those they were close to prior to their combat experiences. According to Johnson and Williams-Keeler (1998), "Distressed and unstable relationships are a significant part of the aftereffects of trauma and posttraumatic stress disorder. It is not surprising that traumatized partners seek out marital therapy to help them deal with the relationship distress that has been generated, maintained, or exacerbated by the effects of trauma" (p. 25).