Introduction to the Special Issue on the Systematic Response to Intimate Partner Violence and Programs for Veterans

ABSTRACT

This manuscript provides an introduction to the special double issue: A Systematic Response to Intimate Partner Violence (IPV) in Healthcare: Examining IPV Programs for Veterans. The special double issue within the Journal of Aggression, Maltreatment & Trauma consists of thirteen articles. Many articles describe screening rates and processes associated with IPV experience among veterans, including extension into special populations that have received relatively less study historically. Other articles discuss innovative treatment approaches and promising practices. The scope of articles ranges from single VA medical center pilot studies to descriptions of large-scale implementation at multiple VA sites across the country. The special double issue contributes to knowledge about IPV-related needs and services for veterans and highlights the Veterans Health Administration as a robust example of large-scale response across the healthcare system. Taken together the collective findings can spark the next phase of exploration and implementation of best practices.

KEYWORDS:

• Healthcare
• innovation
• intimate partner violence
• system implementation
• veteran

Intimate Partner Violence (IPV) is a serious life-threatening, yet preventable, concern that can impact psychological and physical health, as well as many aspects of the security and stability (e.g., financial) of individuals and communities. While definitions utilized across research and other contexts may vary, a “uniform definition” put forth by the Centers for Disease Control states that IPV includes physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner; Breiding et al., 2015). The uniform definition further specifies that intimate partners may or may not be cohabiting and can be opposite or same sex partners (Breiding et al., 2015).

The financial costs associated with IPV are long-standing. For instance, the cost of intimate partner rape, physical assault, and stalking in the United States alone was nearly $6 billion twenty years ago (i.e., $5.8 billion in 2003) with the majority of those costs (i.e., $4.1 billion) being related to healthcare services for the psychological and physical impacts of IPV (National Center for Injury Prevention and Control, 2003). Fast forward approximately one decade (i.e., 2014) and the estimated lifetime costs added up to $3.6 trillion in population economic burden with 59% of that estimate being associated with medical costs (i.e., $2.1 trillion; Peterson et al., 2018).

The healthcare setting has been identified as an appropriate and advantageous context in which to identify those at risk for or impacted by IPV, to educate providers and patients, and to offer resources and services that aim to prevent and/or intervene in this critical public health concern. The healthcare setting can allow providers to have private (e.g., medical examination occurring without a partner present) discussions about violence in the context of health which in turn can help patients understand the direct (e.g., physical health) and indirect (e.g., difficulty getting to medical appointments) impacts (de Boinville, 2013). Moreover, patients believe healthcare providers should screen for IPV and feel it is an appropriate conversation to have in a medical setting (Iverson et al., 2014). While many healthcare agencies address IPV and serve veterans, the Veterans Health Administration (VHA) is the largest integrated healthcare system in the nation providing care to over nine million veterans (www.va.gov). Notably, active duty servicemembers and veterans have been found to report higher rates of IPV experience and use compared to that of the general population, calling for the need for responses within military and veteran-specific settings (Cowlishaw et al., 2022).

The impetus for the special double issue was heightened awareness of veterans as a population of special interest and the desire to highlight efforts toward addressing veteran’s needs within the healthcare setting. The journal solicited contributions that addressed a wide range of topics across the spectrum of IPV programs and services offered to veterans, particularly in the VA healthcare system. These included education, prevention, intervention, and screening; gaps and challenges to addressing IPV within a healthcare system; and other topics such as safety planning and risk assessment. The range of methodologies considered included empirical studies, evidence-based treatment, primary and secondary research, qualitative and mixed methods, program evaluation, and secondary analyses of administrative data with significance and applicability to IPV programming at a systems level. Both theoretical and conceptual articles were considered. Ultimately, thirteen articles were selected for inclusion in the special double issue.

As was asserted nearly a decade ago by Iverson (2014), the “VHA is well-positioned to serve as a national model for best practices for IPV screening and response.” Accordingly, the majority of papers in this special double issue utilized data from within the VHA to evaluate the response to IPV and programs for veterans, most commonly in association with the VHA Intimate Partner Violence Assistance Program (IPVAP). Established in 2014, the IPVAP provides a systematic response to IPV within the VA healthcare system along five action areas: raising awareness, building community partnerships, services for veterans who experience violence, services for veterans who use violence, and support for VA employees. While these action areas are not rigidly linear in nature, there is a notable progression such that awareness of IPV prevalence and impact informs and motivates the establishment and strengthening of partnerships. These foundational elements (e.g., awareness and partnership) then drive and support the development and implementation of services (which includes screening and response). The distribution of focus areas found in the special double issue fell naturally in line with this progression. First, because services for veterans who experience IPV has a longer history of implementation, most articles in the special double issue focus on screening for, and response to, IPV experience. Secondly, the special double issue includes articles related to services for veterans who use violence, an emerging area of research and practice. Finally, there was a relative scarcity of content related to employees, indicative of the need for future attention and effort in this area.

In addition to serving as an example of large-scale systematic response in the healthcare setting, the IPVAP is a prevailing context in which many of the papers in this special issue implemented services and evaluated processes. As such, principles that underlie programmatic efforts toward training/education, screening, and intervention are of relevance when considering this collection of work. Moreover, this is an opportunity to put forth principles that are considered to offer a collective framework for best practices in the development and implementation of services for veterans in the healthcare setting – and in the context of this special double issue to foster reflection on the totality of contributions that are putting these principles into practice.

The foundational principles on which the IPVAP was developed offer a framework across the special double issue through which to examine the cutting edge of best practices. These four principles include ensuring that services and programming is veteran-centric, recovery-oriented, trauma-informed, and person-first. Being veteran-centric means recognizing the experiences, sacrifices, and service of veterans and treating them with dignity and respect. Veterans may experience unique stressors that can impact their relationships (e.g., challenges associated with separations due to deployment and then re-integration into the family). Relatedly, being veteran-centric also means recognizing that maintaining healthy relationships may be difficult and that there could be other factors that may be more frequent concerns for some veterans that also are risk or associated factors for IPV (e.g., housing instability, suicidality). The principle of being recovery-oriented points to the fundamental belief in the ability for one’s circumstances and functioning to improve and that one pathway to this is by building on the existing strengths and resilience of veterans and their families. Likewise, being trauma-informed is a core principle underlying service delivery and programming. This principle fosters awareness, recognition, and response that is mindful of the impact of trauma and aims to provide a safe environment across all domains (e.g., physical, psychological) that promotes healing and empowerment. Some of the ways in which this is realized is through trauma-informed screening and documentation processes and tools which provide collaboration, choice, and control to veterans (e.g., whether to respond to standardized screening questions, what is safe to document in the medical record, what services if any to engage in and when). Finally, is the principle of being person-first. Through this approach, each veteran is viewed as a unique individual with their own collection of needs and strengths. Moreover, this approach intersects with other principles of being trauma-informed and recovery-oriented by creating a respectful space to support the veteran in pursuing information and services. These principles are reflected (e.g., in clinical services, operations and programming, training) through a deliberate focus on the behavior associated with IPV over the labeling of the individual, illustrated through the use of intentional language (e.g., veterans who “experience” or “use” IPV). As such, throughout this introduction, in the conclusion article, and within many of the articles authored by VHA affiliates, you will see this language utilized over terms such as “victim” or “batterer.” That said, we recognize that this is a growing movement and no expectations were set within the special double issue to modify the language chosen for use within individual articles.

This special double issue is particularly timely to reflect on the significant expansion of programs and services in the healthcare setting for veterans that has occurred in the last ten years since the VHA task force was chartered in 2012 to determine the needs and recommendations in this domain, and the IPVAP was subsequently developed in 2014 to help address them. It is our hope that the special double issue will increase awareness about the work being done to address the needs of veterans and their families who may be at risk for or impacted by IPV and to motivate the next decade of development, implementation, and research – both within VHA and across other healthcare settings.

Articles in the special issue

In line with the focus of the special issue on systematic response to IPV in the healthcare system, Miller et al. (2022, this issue) examine the first six years of IPV screening implementation among women veteran primary care patients across VA medical centers. This article contributes a combination of history on the need for screening within the healthcare system, data on screening rates, and a description of the programmatic implementation and growth that has occurred nationally through the spread of an electronic health record screening tool and promotion of associated provider practices for screening and response. Dichter et al. (2021, this issue) build further on our knowledge of screening response within the VA healthcare system by examining what happens after a positive screening is obtained. The authors utilized a combination of chart review and stakeholder (e.g., patient and staff) interviews to identify actions that took place in the six months following a positive screening at two VA medical centers.

Prior research has yielded a wealth of knowledge on the rates and concern about the impacts of IPV. Not surprisingly, investigations have historically focused on populations of increased risk for IPV, such as women, and on IPV experience. While the importance of, and motivation for, continued work in this area cannot be understated, one area of necessary growth is expanding this knowledge to better understanding relatively lessor known rates and impacts across special contexts and populations. A number of articles within this special issue do just this, and moreover explore the intersectionality with veteran status and the ways in which services are impacted by the systems and environments in which they are embedded.

Recognizing the higher rates of IPV experience reported by lesbian and bisexual women compared to heterosexual women and higher rates among women veterans compared to women who have not served in the military, Webermann et al. (2022, this issue) further contribute to the literature by examining associations between self-reports of IPV experience, mental health symptoms, and physical health problems at three time points for individuals at the intersection of these special populations. Ketchum and Dichter (2022, this issue) also aim to extend our knowledge into special populations by examining the feasibility of screening veterans with positive HIV status for past-year IPV experience. The authors also provide insights into the rates of response obtained from the veterans screened within the VA medical center examined in this article. Building further on the examination of special populations, Liu et al. (2022, this issue) explore the intersection of IPV experience and homelessness. Their article describes rates of response among users of VA homeless program services who were screened for IPV experience at five VA medical centers. Moreland and Yalch (2023, this issue) describe the association between opioid misuse and IPV experience, and more specifically, variations in association based on the subtype of IPV experience (e.g., psychological, physical, sexual) among women of unknown veteran status.

Tuepker et al. (2022, this issue) describe a specific context in which screening and potential disclosure may occur within the VA healthcare system, specifically within the Patient Centered Medical Home (PCMH) model. Within this context, they further describe four themes that emerged from interviews conducted at two VA medical centers with women veterans who experienced IPV and were screened – some of whom disclosed IPV history subsequent to screening and some who did not. In addition to providing additional history on the development of the IPVAP, Buckholdt et al. (2022, this issue), describe how the national office responded in the context of the COVID-19 pandemic by mobilizing the workforce of IPVAP Coordinators, harnessing partnerships within VHA and the community, adapting to the observed needs, and ultimately forging a path forward of progress in the face of uncertainty and challenge.

Consistent with recovery-orientated and person-centered principles, a tenet held by leading policy and practice influencers such as the VHA IPVAP and Office of Women’s Health, is that IPV is an experience (or when referring to IPV use, a behavior) rather than a diagnosis. As such, needs raised in conjunction with requests for “treatment for IPV” can often be satisfied by utilizing existing interventions, when needed, to address person specific targets (e.g., one veteran might have depressive symptoms and benefit from Cognitive Behavioral Therapy, another might have PTSD and benefit from Cognitive Processing Therapy, one might not need any treatment at all, and another might need support for financial independence). At the same time, there is growing interest and demand for interventions that do specifically focus on IPV and some of the articles within this special issue explore the development and expansion of such treatment options.

Taking a global perspective, Scott and Jenney (2022, this issue) discuss utilization of a trauma- and violence-informed care (TVIC) framework when identifying and intervening with individuals who may use violence in relationships. More specifically, they discuss the intersection of trauma and violence and how the TVIC lens can be used to improve outcomes across services. Evans et al. (2022, this issue) identify a need for further development of treatment response options for women veterans who are experiencing or have experienced IPV and note a need for options beyond individual or in person modalities. Accordingly, the authors describe initial observations and feedback from three participants in an eight-week virtual group intervention delivered at a VA medical center. Recognizing the range of health consequences for individuals who experience IPV, Kim et al. (2022, this issue) take a closer look at the specific psychiatric, neurobehavioral, and functional impacts associated with IPV experience among a sample of male and female post-9/11 veterans. In addition to describing patterns of associations between the areas of examination, the authors put forth a skills-based intervention that could have utility in addressing some of the comorbid impacts of investigation. In Mitchell and Wupperman’s (2022, this issue) review, mindfulness is explored as a potentially beneficial component in interventions that target the use of domestic violence and associated symptomology (e.g., emotion dysregulation). In reviewing six studies which were not specific to veteran populations, and that included mindfulness components, the authors also provide an informative history and comparison of some treatments that have been used and adapted in the context of domestic violence intervention. Also in line with the focus of the special issue on systematic response to IPV in the healthcare system, Creech et al. (2023, this issue) describe the Strength at Home intervention for veterans who use violence and the impact of a program implementation strategy deployed at twenty-seven VA medical centers to help enhance treatment adoption.

The topics presented in the special double issue articles contribute to our understanding of essential elements for addressing IPV in the healthcare setting, and more generally the needs and services for veterans at risk for, or impacted by, IPV. Finally, in the conclusion article Portnoy et al., (2023, this issue) synthesize the findings from the thirteen articles in the special double issue. Reflections on the totality of the contributions to the special issue, common themes, challenges, and cumulative lessons learned are discussed. This in turn provides next steps and directions for future research stemming from remaining gaps in the literature and building on the growing edges of our knowledge about special populations, innovative approaches, and best practices for prevention and intervention.

Acknowledgments

A project of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV).

Disclosure statement

The views or opinions expressed in this introductory article are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs or The United States Government. No potential conflict of interest was reported by the authors.