Journal of Substance Abuse Treatment 46 (2014) 532–539

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Journal of Substance Abuse Treatment

Prediction of intimate partner violence by type of substance use disorder Fleur L. Kraanen, M.Sc. a,⁎, Ellen Vedel, Ph.D. b, Agnes Scholing, Ph.D. a, Paul M.G. Emmelkamp, Ph.D. a, c a b c

Forensic outpatient clinic De Waag, Zeeburgerpad 12b, 1018AJ Amsterdam, The Netherlands Jellinek substance abuse treatment centre, Arkin, Postbus 3907, 1001 AS Amsterdam, The Netherlands Center for Social and Humanities Research, King AbdulAziz University, Jeddah, Saudi Arabia

a r t i c l e

i n f o

Article history: Received 16 January 2013 Received in revised form 5 October 2013 Accepted 8 October 2013 Keywords: Intimate partner violence Perpetration Victimization Substance use disorders Alcohol Cannabis Cocaine

a b s t r a c t The present study investigated whether (combinations of) specific substance use disorders predicted any and severe perpetration and victimization in males and females entering substance abuse treatment. All patients (N = 1799) were screened for IPV perpetration and victimization; almost one third of the sample committed or experienced any IPV in the past year. For males, an alcohol use disorder in combination with a cannabis and/or cocaine use disorder significantly predicted any IPV (perpetration and/or victimization) as well as severe IPV perpetration. For females, alcohol and cocaine abuse/dependence predicted both any IPV (perpetration and/or victimization) and severe IPV perpetration. Results from the present study emphasize the importance of routinely assessing IPV in patients in substance abuse treatment and demonstrate that clinicians should be particularly alert for IPV in patients with specific substance use disorder combinations. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Intimate partner violence (IPV) is a prevalent societal problem; Schafer, Caetano, and Clark (1998) demonstrated that about 20% of the couples in the US general population experienced past year physical IPV. Dutch figures (although not completely comparable because of the longer reference period) appeared somewhat lower: in the past 5 years 49% reported any IPV, of whom 9% reported severe IPV (Van der Veen & Bogaerts, 2010). Consequences of IPV can be very serious and may lead to injuries and mental health problems in victims and children witnessing IPV (e.g., Campbell, 2002; Holt, Buckley, & Whelan, 2008; Kitzmann, Gaylord, Holt, & Kenny, 2008; Plichta, 2004; Wood & Sommers, 2011). A large body of research has identified risk factors for IPV perpetration as well as victimization. Risk factors related to physical IPV perpetration are verbal abuse, life stress, marital dissatisfaction, anger, and depression, to name a few (for reviews, see: Schumacher, Feldbau-Kohn, Smith Slep, & Heyman, 2001; Stith, Smith, Penn, Ward, & Tritt, 2004; Leonard & Senchak, 1996). Robust risk factors associated with physical IPV victimization include childhood abuse, depression, fewer years of education, and violent behavior toward the partner (Schumacher et al., 2001; Seedat, Stein, & Forde, 2005; Stith et al., 2004; Whitfield, Anda, Dube, & Felitti, 2003). A prominent risk factor for both IPV perpetration and

⁎ Corresponding author. Zeeburgerpad 12b, 1018AJ, Amsterdam, The Netherlands. Tel.: +31 20 4626 333; fax: +31 20 4626 334. E-mail address: [email protected] (F.L. Kraanen). 0740-5472/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsat.2013.10.010

victimization is substance use (Schumacher et al., 2001; Stith et al., 2004). The current study elaborated on previous research and aimed to assess IPV perpetration and as well as victimization among patients in substance abuse treatment. At the same time it was intended to examine whether specific (combinations of) substance use disorders predicted IPV perpetration and/or victimization. 1.1. The relationship between substance use and IPV perpetration The co-occurrence of substance use and IPV perpetration has been studied extensively; up to about 60% of patients in domestic violence treatment were diagnosed with a substance use disorder (e.g., Brown, Werk, Caplan, & Seraganian, 1999; Kraanen, Scholing, & Emmelkamp, 2010, 2012; Stuart, Moore, Kahler, & Ramsey, 2003; Stuart, Moore, Ramsey, & Kahler, 2003). Furthermore, a number of studies found that IPV perpetration was overrepresented among patients in substance abuse treatment: past year prevalence rates of physical IPV perpetration in this group ranged from 40% to 60% (e.g., Chermack et al., 2008; Murphy & O’Farrell, 1994; O’Farrell & Murphy, 1995; Stuart et al., 2002; Vedel, 2007). In addition, Smith, Homish, Leonoard, and Cornelius (2012) demonstrated that the relationship between substance use and IPV perpetration was different for specific combinations of substance use. Data from a large general population survey showed that a combination of alcohol and cannabis use disorders decreased the likelihood of IPV perpetration compared to either an alcohol or a cannabis use disorder. In contrast, alcohol and cocaine use disorders increased the odds of IPV perpetration compared to only an alcohol use disorder, but decreased the odds for IPV perpetration compared to only cocaine abuse/dependence.

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Various explanations have been proposed for the relationship between substance use and IPV perpetration. Alcohol use and IPV perpetration may be causally related (e.g., Leonard, 2005) since direct pharmacological effects of alcohol lead to a distorted appraisal of cues and to disinhibition, which in turn may lead to committing IPV (Foran & O’Leary, 2008). As for the relationship between cannabis use and IPV, some have suggested that IPV is mediated by irritability resulting from withdrawal from cannabis (e.g., Hoaken & Stewart, 2003; Moore et al., 2008), or that a shared variable (e.g., impulsivity) may be responsible for both IPV and cannabis use (Moore & Stuart, 2005). Further, cocaine use might be related to IPV through direct pharmacological effects (Moore et al., 2008) since cocaine intoxication affects the serotonergic signaling system that may facilitate aggression (e.g., Patkar et al., 2006). However, underlying personality traits might be responsible for this relationship as well (Hoaken & Stewart, 2003). Finally, even though a significant proportion of substance abusers use more than one substance (Moore, 2010), little is known about the effect of interactions between different substances and their relationship with IPV.

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Murphy & O’Farrell, 1994; Taft et al., 2010). Since the relationship between various substances (and their interactions) and IPV is different and different mechanisms appear to underlie the relationship between different substances and IPV, an important purpose of this study was to examine whether particular substance use disorders predicted any IPV (perpetration and/or victimization), severe IPV perpetration, and severe IPV victimization, all in the past year. In addition, participants were categorized according to the substance use disorder(s) they were suffering from since a significant proportion of patients suffer from more than one substance use disorder, and there is evidence that interactions of different substances may lead to different outcomes regarding IPV (Smith et al., 2012). Because research on the effects of using multiple substances in relation to aggressive behavior is scarce, Smith et al.'s (2012) study was used to formulate hypotheses. It was expected that 1) patients with both an alcohol and a cannabis use disorder and 2) patients with both an alcohol and a cocaine use disorder were at higher odds for IPV perpetration than patients with an alcohol use disorder alone. Other substance use disorder combinations as predictors for IPV were studied exploratory.

1.2. The relationship between substance use and IPV victimization 2. Materials and methods IPV victimization is also associated with substance use. IPV victimization is prevalent in patients who follow substance abuse treatment; studies in this group revealed past year IPV victimization figures up to over 50% (Chermack et al., 2008; El-Bassel, Gilbert, Schilling, & Wada, 2000; El-Bassel et al., 2004; Gilbert et al., 2006; Chermack, Walton, Fuller, & Blow, 2001). Several mechanisms have been proposed for the relationship between substance use disorders and IPV victimization. Some have argued that problematic substance use might lead to stress in the relationship that may eventually lead to IPV (e.g., Goldstein, 1985); others hypothesized that IPV victims use alcohol (e.g., Kaysen et al., 2007) and cannabis (e.g., Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997) to cope with stress, anxiety and pain resulting from IPV. Some recent studies provided evidence for a causal relationship between substance abuse and victimization in women (e.g., Gilbert, El-Bassel, Chang, Wu, & Roy, 2012; Parks, Romosz, Bradizza, & Hsieh, 2008). Riggs, Caulfield, and Street (2000) concluded that even though a relationship between substance abuse and IPV victimization exists, perpetrator substance abuse appears to influence IPV more strongly. 1.3. The current study Studies that assessed IPV perpetration and victimization in patients in substance abuse treatment share some limitations. 1) Nearly all studies (with the exception of Chermack et al.'s (2008) study) either assessed IPV perpetration or IPV victimization but not both, even though IPV is reciprocal in many cases (Archer, 2000, 2002). 2) Most studies did not distinguish between any and severe IPV, a distinction that may be important from a clinical viewpoint. 3) Most studies investigating the prevalence of IPV victimization did so in very specific samples, such as females in methadone treatment (e.g., El-Bassel et al., 2000, 2004; Gilbert et al., 2006), but not in general samples of patients in substance abuse treatment. Therefore, the present study examined any IPV (perpetration and/or victimization) as well as severe IPV perpetration and victimization in a large, representative sample of male and female patients entering substance abuse treatment. Further, only a small number of studies focused on identifying risk factors for IPV perpetration among substance abusers (Chermack et al., 2008; Kachadourian, Taft, O’Farrell, Doron-LaMarca, & Morphy, 2012; Murphy & O’Farrell, 1994; Taft et al., 2010). Results demonstrated that, for example, younger age, alcohol use problem severity, antisocial personality characteristics, and anger were associated with IPV perpetration (Chermack et al., 2008; Kachadourian et al., 2012;

2.1. Participants Participants were patients who sought treatment at the cure department of Jellinek (in contrast to the care department that focuses on harm reduction in chronic patients), a large community substance abuse treatment center in Amsterdam, the Netherlands. Patients were allocated to either inpatient or outpatient treatment according to the stepped care principle (Sobell & Sobell, 2000); the majority of patients received outpatient treatment (about 95%). Patients were included if they met the following inclusion criteria: 1) having a partner in the past year (i.e., being married, co-habiting or having a living-apart-together relationship), 2) being 18 years old or older, and 3) current abuse or dependence of one or more psychoactive substances, with the exception of nicotine. Patients were excluded in case of: 1) severe mental problems that required acute care (e.g., psychosis or suicidal ideation), 2) severe cognitive disorders (e.g., Korsakov's syndrome), 3) insufficient knowledge of the Dutch language, or 4) severe intoxication or withdrawal at intake. All patients who had an intake at the Jellinek substance abuse treatment center between July 1st 2009 and January 15th 2012 were screened for eligibility. In total, 4529 unique patients had an intake of which 2300 met inclusion criteria. The final sample consisted of 1799 patients (78.2% of those eligible to participate) (for an overview, see Fig. 1). In total, 501 patients (21.8%) were not included because they met one or more exclusion criteria or for logistic reasons (N = 239; 10.4%). Examples of logistic reasons were insufficient time to complete the IPV questionnaire during intake or that the intaker had forgotten to administer the questionnaire. In addition, 55 patients completed more than one questionnaire because they had multiple intakes during the study period. Thirty-five of these patients (63.6%) obtained the same scores on the questionnaire; 20 patients (36.4%) obtained different scores. If patients obtained the same score on both screeners, only one of the screeners was included; if patients obtained different scores, the J-IPV with the highest score was used. 2.2. Instruments 2.2.1. Jellinek Inventory for assessing Partner Violence (J-IPV) The J-IPV (Kraanen, Vedel, Scholing, & Emmelkamp, 2013) was administered to all patients during intake (care-as-usual) to assess IPV. The J-IPV is a short structured interview aiming to identify past year IPV perpetration and victimization. The instrument consists of 4 yes/no items asking if someone was threatened by their partner, was

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F.L. Kraanen et al. / Journal of Substance Abuse Treatment 46 (2014) 532–539

Fig. 1. Overview of participants and dropouts.

physically abused by their partner, had threatened their partner, or had physically abused their partner in the past year. The J-IPV was validated in two separate studies with the Revised Conflict Tactics Scales (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) as ‘gold standard’ to detect any IPV (perpetration and/or victimization), severe IPV perpetration, and severe IPV victimization in the past year. Severe IPV perpetration/victimization involved at least one of the following incidents in the past year: using a knife/gun, punching or hitting with something that could hurt, choking, slamming against a wall, beating up, burning, and/or kicking (Straus et al., 1996). Any IPV perpetration/victimization involved one of the following acts in addition to the severe IPV acts: throwing something that could hurt, twisting arm/pulling hair, pushing/shoving, grabbing and/or slapping (Straus et al., 1996). Both studies conducted by Kraanen et al. (2013) found the same optimal cutoff score for detecting both any IPV perpetration and any IPV victimization, i.e., a cutoff score of 1 (answering positive to at least 1 J-IPV item) (any IPV perpetration: sensitivity = .80/.84 and specificity = .80/.82; any IPV victimization: sensitivity = .83/.80 and specificity = .84/.81). That the same cutoff score was found for both any IPV perpetration and victimization is due to the fact that IPV is often reciprocal (Archer, 2000, 2002). In Kraanen et al.'s two studies, perpetrators and victims of any IPV were overlapping in 69.4% and 73.7% of the cases, respectively. Since it was not possible to distinguish perpetrators and victims of any IPV using the J-IPV, patients who obtained a score of 1 or more were labeled as perpetrator/victim of any IPV. As for severe IPV, to detect perpetration, using a cutoff score of 2 resulted in optimal psychometric properties (sensitivity = 1.00/1.00; specificity = .83/.79). To detect severe IPV victimization, a positive answer to J-IPV item 1 resulted in optimal psychometric properties (sensitivity = 1.00/1.00; specificity = .68/.69). 2.2.2. Measurements in the Addictions for Triage and Evaluation (MATE) The MATE (Schippers, Broekman, & Buchholz, 2007) was administered during the intake to assess patient substance use and cooccurring problems and to determine treatment allocation. In order to diagnose substance use disorders, the Composite International Diagnostic Interview (CIDI; World Health Organization, 1997) was

included in the MATE. Substance use disorder (combinations) categories that were distinguished for male participants were: only alcohol, only cannabis, only cocaine, alcohol and cannabis, alcohol and cocaine, cannabis and cocaine, alcohol and cannabis and cocaine, and other (combinations of) substance use disorders. Since we intended to have at least 5 participants in every cell, some substance use disorder categories were collapsed for females, leaving the following: only alcohol, only cannabis, alcohol and cannabis, alcohol and cocaine, alcohol and cocaine and cannabis, and ‘other’. No distinction was made between substance abuse and dependence, since this would result in too many different categories for statistical analyses. 2.3. Procedure The current study obtained data by reviewing intake reports that were extracted from patients' charts. Intakes were carried out by members of the treatment staff (psychologists). During these structured intakes, first the MATE was administered and subsequently the J-IPV (duration between 45 and 60 minutes). Usually, patients were alone during the intake, but in very few instances a relative, friend, or another professional accompanied them. 2.4. Data analyses First, men and women were compared for age, substance use disorder diagnosis and IPV. Independent samples t-tests were used for continuous variables; chi-square tests for dichotomous outcomes. Direct binomial logistic regression analyses were performed on any IPV, severe IPV perpetration and severe IPV victimization as outcome variables and (combination of) substance use disorders as predictor. Since several studies indicated that younger age is positively related to IPV (e.g., Chermack et al., 2008; Stith et al., 2004), age was entered as covariate in the equation as well. Since men and women differ in the physiological and behavioral responses to substances (Brady & Randall, 1999; Lynch, Roth, & Carroll, 2002), we initially intended to enter gender as a predictor for IPV and to conduct interactions between gender and substance use disorder diagnosis. However, after inspection of the data, we found that women were underrepresented

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in certain categories. Since this would result in low statistical power, male and female patients were analyzed separately. Because ‘substance use disorder’ is a categorical variable, the variables were entered in the analyses using dummy coding. The category ‘only alcohol’ was used as reference category since it was the largest group for both males and females and IPV was the least prevalent in patients that entered treatment for alcohol use disorder only. In addition, assumptions for conducting logistic regression were assessed. No serious violation of the assumption of linearity between continuous predictors and outcome was detected using the Box-Tidwell approach as suggested by Tabachnick and Fidell (2007). Also, no evidence for multicollinearity among predictors was found after assessing tolerance and VIF statistics, eigenvalues of the scaled, uncentered crossproducts matrix, the condition index and the variance proportions for each index as recommended by Field (2009). 3. Results 3.1. Participants Age, substance use disorder diagnosis, and J-IPV outcomes of male and female participants as well as the total sample are displayed in Table 1. Male and female participants differed significantly regarding (combination of) substance use disorders (X 2 (7) = 19.71; p = .01). Standardized residuals demonstrated that fewer females than males were diagnosed with alcohol, cannabis and cocaine use disorders. Also, on average, more men were diagnosed with substance use disorder than women (t (1793) = 2.52; p = .00). In addition, more female than male patients reported any IPV (perpetration and/or victimization) (X 2 (1) = 7.34; p = .01), severe IPV perpetration (X 2 (1) = 12.15; p = .00), and severe IPV victimization (X 2 (1) = 18.97; p = .00) in the past year. Although the omnibus chi-square test for number of substance use disorders by category (i.e., 1, 2, or 3 or more substance use disorders) was statistically significant (X 2 (2) = 7.05; p = .03), standardized residuals do not reveal specific differences

Table 1 Age, (number of) substance use disorders and prevalence of past year IPV in patients who completed the Jellinek Inventory for assessing Partner Violence (J-IPV). Males

Females

Total

n = 1339

n = 458

N = 1799

n (%)

n (%)

N (%)

Age M (s.d.) 40.4 (10.89) 40.5 (11.07) 40.5 (11.00) SUD1⁎ 752 (41.9) Alcohol 534 (39.9) 218 (47.6)2 Cannabis 117 (13.2) 62 (13.5) 239 (13.3) Cocaine 69 (5.2) 12 (2.6) 81 (4.5) Alcohol & cannabis 148 (11.1) 41 (9.0) 189 (10.5) Alcohol & cocaine 133 (9.9) 40 (8.7) 173 (9.6) Cannabis & cocaine 46 (3.4) 11 (2.4) 57 (3.2) Alcohol, cannabis, & cocaine⁎ 88 (6.6) 16 (3.5) 104 (5.8) Other 142 (10.6) 58 (12.7) 200 (11.1) Number of substance use disorders M 1.52 (0.72) 1.42 (0.67) 1.50 (0.71) (s.d.) Number of substance use disorder by category⁎2) 1 substance use disorder 805 (60.2) 304 (66.4) 1110 (61.8) 2 substance use disorders 383 (28.6) 119 (26.0) 502 (28.0) 3 or more substance use disorders 149 (11.2) 35 (7.6) 184 (10.2) IPV No IPV 959 (71.8) 298 (65.1) 1257 (70.1) Any IPV perpetration/victimization⁎ 337 (28.2) 160 (34.9) 537 (29.9) Severe IPV perpetration⁎ 261 (19.5) 125 (27.3) 386 (21.5) Severe IPV victimization⁎ 202 (15.1) 110 (24.0) 312 (17.4) SUD = substance use disorder(s); IPV = intimate partner violence; M = mean; s.d. = standard deviation; 1 = abuse and/or dependence; 2 = in further analyses, for female patients, some categories of substance use disorders were collapsed). ⁎ p b .05.

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between men and women. Finally, male and female patients did not differ regarding age. 3.2. Logistic regression analyses for any IPV (perpetration and/or victimization), severe IPV perpetration and severe IPV victimization in male patients entering substance abuse treatment In Table 2, the proportion of male participants that were involved in any IPV (perpetration or victimization, severe IPV perpetration and severe IPV victimization in the past year by (combination of) substance use disorders are displayed. Table 3 displays results from the logistic regression analyses for any IPV (perpetration and/or victimization), severe IPV perpetration and severe IPV victimization in male participants. For all three models, the overall statistic was significant (any IPV (perpetration and/or victimization): X 2 (8) = 29.96; p = .00; severe IPV perpetration: X 2 (8) = 35.20; p = .00; severe IPV victimization: X 2 (8) = 23.67; p = .00). For all models, (combination of) substance use disorders and age were significant predictors. Specifically, for any IPV perpetration/victimization, male patients with alcohol and cannabis use disorders, alcohol and cocaine use disorders, and alcohol, cocaine and cannabis use disorders were at higher odds for any IPV perpetration/victimization compared to patients with only alcohol abuse/dependence. Also, increased age was negatively associated with any IPV (perpetration and/or victimization). For severe IPV perpetration, substance use disorder and age were also significant predictors. Specifically, males with alcohol and cannabis use disorders, alcohol and cocaine use disorders, alcohol, cannabis, and cocaine use disorders, or ‘other’ substance use disorders were at higher risk for severe IPV than those with only an alcohol use disorder. Again, increased age was negatively associated with severe IPV perpetration. For severe IPV victimization, only age was a significant predictor; increased age was negatively associated with severe IPV victimization. 3.3. Logistic regression analyses for any IPV, severe IPV perpetration and severe IPV victimization in female patients entering substance abuse treatment In Table 2, past year prevalence of any IPV (perpetration and/or victimization), severe IPV perpetration and severe IPV victimization by (combination of) substance use disorder(s) is displayed for female participants. Regression analyses for female participants are displayed in Table 3. The overall models for any IPV perpetration/victimization and severe IPV perpetration as outcome variables were significant (any IPV (perpetration and/or victimization): X 2 (6) = 22.92; p = .00; severe IPV perpetration: X 2 (6) = 20.30; p = .00). For any IPV (perpetration and/or victimization), both substance use disorders and age were significant predictors. Specifically, the presence of both alcohol and cocaine use disorders (compared to the presence of alcohol abuse or dependence alone) was positively related to any IPV (perpetration and/or victimization); increased age was negatively associated with any IPV. For severe IPV perpetration, only age was a significant predictor; increased age was negatively related to severe IPV perpetration. Substance use disorder diagnosis did not predict severe IPV perpetration in women (p = .08). The overall model for severe IPV victimization was not significant, which indicated no significant relationship between predictors (substance use disorder diagnosis and age) and IPV victimization. 3.4. Additional analyses – number of substance use disorders as predictor for IPV perpetration and victimization in male and female patients in substance abuse treatment From the above, it is noteworthy that individuals with more than one substance use disorder placed individuals at risk for IPV.

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Table 2 Prevalence of any IPV perpetration/victimization, severe IPV perpetration and severe IPV victimization among male and female patients entering substance abuse treatment. Predictor

Any IPV

Male participants

No (N = 958)

Yes (N = 376)

No (N = 1074)

Yes (N = 260)

No (N = 1136)

Yes (N = 201)

N (%)

N (%)

N (%)

N (%)

N (%)

N (%)

41.3 (11.29)

38.6 (9.56)

41.0 (11.18)

37.9 (9.19)

40.8 (11.12)

38.2 (9.17)

412 134 48 95 83 32 55 99

121 43 21 52 49 14 33 43

459 146 52 107 98 39 63 110

Age (M, s.d.) Substance use disorder Only alcohol Only cannabis Only cocaine Alcohol & cannabis Alcohol & cocaine Cannabis & cocaine Alcohol, cannabis & cocaine Other Female participants

Age (M, s.d.) Substance use disorder Only alcohol Only cannabis Alcohol & cannabis Alcohol & cocaine Alcohol, cannabis & cocaine Other

(77.3) (75.7) (69.6) (64.6) (62.9) (69.6) (62.5) (69.7)

Severe IPV perpetration

(22.7) (24.3) (30.4) (35.4) (37.1) (30.4) (37.5) (30.4)

(86.1) (82.5) (75.4) (72.8) (74.2) (84.8) (71.6) (77.5)

Severe IPV victimization

74 (13.9) 31 (17.5) 17 (24.6) 40 (27.2) 34 (25.8) 7 (15.2) 25 (28.4) 32 (22.5)

477 153 56 118 110 40 68 114

(89.3) (86.4) (81.2) (79.7) (82.7) (87.0) (77.3) (80.3)

57 (10.7) 24 (13.6) 13 (18.8) 30 (20.3) 23 (17.3) 6 (13.0) 20 (22.7) 28 (19.7)

No (N = 298)

Yes (N = 160)

No (N = 333)

Yes (N = 125)

No (N = 348)

Yes (N = 110)

N (%)

N (%)

N (%)

N (%)

N (%)

N (%)

41.7 (11.66)

38.3 (9.54)

41.3 (11.29)

37.9 (9.97)

41.1 (11.47)

38.6 (9.51)

157 37 23 16 10 55

(72.0) (59.7) (56.1) (40.0) (62.5) (67.9)

61 25 18 24 6 26

(38.1) (40.3) (43.9) (60.0) (37.5) (32.1)

170 45 29 20 10 59

(78.0) (72.6) (70.7) (50.0) (62.5) (72.8)

48 (22.0) 17 (27.4) 12 (29.3) 20 (50.0) 6 (37.5) 22 (27.2)

176 44 31 24 11 62

(80.7) (71.0) (75.6) (60.0) (68.8) (76.5)

42 (19.3) 18 (29.0) 10 (24.4) 16 (40.0) 5 (31.3) 19 (23.5)

IPV = intimate partner violence; M = mean; s.d. = standard deviation.

Exploratory binomial logistic regression analyses were run to examine whether the number of substance use disorders in an individual was related to IPV perpetration/victimization. Patients were classified among 3 categories: 1) 1 substance use disorder, 2) 2 substance use disorders, and 3) 3 or more substance use disorders. ‘Number of substance use disorders’ was entered as a categorical variable using repeated contrasts comparing 2 to 1 substance use disorder(s) and 3 or more to 2 substance use disorders. Again, age was entered in the analyses as well. Results from the logistic regression analyses are displayed in Table 4. For male patients, all three models were statistically significant (any IPV (perpetration and/or victimization): X 2 (3) = 27.16; p = .00; severe IPV perpetration: X 2 (3) = 29.49; p = .00; severe IPV victimization: X 2 (3) = 21.37; p = .00). Number of substance use disorders and age were significant predictors in all 3

models: 2 substance use disorders increased the likelihood that a patient was involved in any/severe IPV compared with one substance use disorder; there were no differences between 2 versus 3 or more substance use disorders. Again, increased age was negatively related to IPV in all three models. For females, all three overall models were statistically significant as well (any IPV (perpetration and/or victimization): X 2 (3) = 15.79; p = .00; severe IPV perpetration: X 2 (3) = 18.68; p = .00; severe IPV victimization: X 2 (3) = 7.88; p = .05). ‘Number of substance use disorders’ was a significant predictor for any IPV (perpetration and/or victimization) and severe IPV perpetration. Again, 2 substance use disorders increased the likelihood of any IPV (perpetration and/or victimization) and severe IPV perpetration, but 3 or more substance use disorders did not increase odds compared to 2 diagnoses. Also, increased age was negatively related to any IPV

Table 3 Logistic regression analyses for predictors of any IPV, severe IPV perpetration and severe IPV victimization in male patients entering substance abuse treatment. Predictor

Male participants Age Substance use disorder Only cannabis vs. alcohol Only cocaine vs. alcohol Alcohol & cannabis vs. alcohol Alcohol & cocaine vs. alcohol Cannabis & cocaine vs. alcohol Alcohol, cannabis & cocaine vs. alcohol Other vs. alcohol (Constant) Female participants Age Substance use disorder Only cannabis vs. alcohol Alcohol & cannabis vs. alcohol Alcohol & cocaine vs. alcohol Alcohol, cannabis & cocaine vs. alcohol Other vs. alcohol (Constant)

Any IPV

Severe IPV perpetration

Severe IPV victimization

B (S.E.)

Wald X2

Odds ratio (CI)

B (S.E.)

Wald X2

Odds ratio (CI)

−.02 (.01)

7.62⁎⁎ 14.66⁎ 0.21 0.70 5.57⁎ 6.38⁎

0.98 (0.97–1.00)

−.22 (.01)

0.98 (0.96–0.99)

0.91 1.27 1.63 1.72 1.27 1.67 1.35 0.66

(0.60–1.38) (0.72–2.23) (1.09–2.45) (1.13–2.62) (0.65–2.47) (1.01–2.75) (0.89–2.05)

.49 (.25) .52 (.31) .68 (.23) .58 (.24) −.09 (.44) .65 (.28) .48 (.24) −.84 (.35)

8.60⁎⁎ 17.01⁎ 0.04 2.73 8.68⁎⁎ 5.68⁎

0.98 (0.96–1.00)

−.03 (.01)

1.40 1.75 3.33 1.31 1.11 0.96

−.01 (.35) .20 (.39) 1.08 (.37) .55 (.55) .16 (.31) −.09 (.49)

−.10 (.22) .24 (.29) .49 (.21) .54 (.22) .24 (.34) .51 (.25) .30 (.21) −.42 (.31)

−.02 (.01) .34 (.32) .56 (.36) 1.20 (.36) .27 (.55) .10 (.29) −.04 (.46)

0.47 4.06⁎ 2.01 1.91

4.22⁎ 12.21⁎ 1.12 2.45 10.93⁎⁎ 0.25 0.13 0.01⁎

(0.75–2.61) (0.87–3.51) (1.63–6.79) (0.45–3.81) (0.63–1.95)

0.04 5.48⁎ 4.04⁎ 5.78⁎

6.18⁎ 9.83 0.00 8.71⁎⁎ 0.99 0.27 0.03 0.03

1.05 1.68 1.97 1.79 0.91 1.93 1.62

(0.65–1.70) (0.90–3.10) (1.26–3.10) (1.11–2.88) (0.39–2.14) (1.11–3.33) (1.01–2.60)

B (S.E.) −.02 (.01) .10 .51 .63 .41 .01 .70 .63 −1.35

(.27) (.35) (.26) (.28) (.47) (.30) (.26) (.39)

0.97 (0.95–0.99)

−.01 (.01)

1.00 1.22 2.93 1.73 1.17 0.85

.39 .20 .92 .53 .19 −.82

(0.51–1.99) (0.57–2.61) (1.44–5.99) (0.59–5.01) (0.64–2.13)

IPV = intimate partner violence; B = beta coefficient; S.E. = standard error; CI = confidence interval; vs. = versus. ⁎ p b .05. ⁎⁎ p b .01.

(.35) (.41) (.37) (.57) (.32) (.51)

Wald X2

Odds ratio (CI)

4.47⁎ 13.12 0.11 2.19 6.01 2.18 0.02 5.36 6.11 12.03

0.98 (0.97–1.00)

1.61 6.55 1.25 0.24 6.01 0.86 0.35 0.51

0.99 (0.97–1.01)

1.10 1.67 1.87 1.87 1.51 1.07 1.02

1.48 1.22 2.52 1.70 1.21 0.44

(0.64–1.87) (0.85–3.28) (0.85–3.28) (1.13–3.08) (0.87–2.59) (0.43–2.67) (1.11–3.67)

(0.75–2.92) (0.55–2.73) (1.21 –5.24) (0.55–5.23) (−.65 to 2.25)

F.L. Kraanen et al. / Journal of Substance Abuse Treatment 46 (2014) 532–539

537

Table 4 Logistic regression analyses for number of substance use disorders as predictor for any IPV, severe IPV perpetration and severe IPV victimization in male and female patients entering substance abuse treatment. Predictor

Male participants Age Number of SUDs 1 SUD vs. 2 SUDs 2 SUDs vs. 3 SUDs (Constant) Female participants Age Number of SUDs 1 SUD vs. 2 SUDs 2 SUDs vs. 3 SUDs (Constant)

Any IPV

Severe IPV perpetration

Severe IPV victimization

B (S.E.)

Wald X2

Odds ratio (CI)

B (S.E.)

Wald X2

Odds ratio (CI)

B (S.E.)

Wald X2

Odds ratio (CI)

−.02 (.01)

9.33⁎⁎ 12.54⁎⁎ 10.91⁎ 0.03 0.18

0.98 (0.97–0.99)

−.02 (.01)

0.98 (0.96–0.99)

−.02 (.01)

−.44 (.16) −.12 (.22) −.36 (.27)

0.64 (0.47–0.87) 0.89 (0.58–1.37) 0.70

−.37 (.17) −.31 (.24) −.85 (.30)

5.91⁎ 10.56⁎⁎ 4.59⁎ 1.69 7.98

0.98 (0.97–1.00)

0.63 (0.49–0.83) 1.04 (0.69–1.54) 0.90

11.54⁎⁎ 11.47⁎⁎ 8.01⁎⁎ 0.29 1.71

7.19⁎⁎ 6.45⁎ 5.99⁎ 0.10 1.85

0.98 (0.96–0.99)

−.03 (.01)

0.97 (0.95–0.99)

−.02 (.01)

−.57 (.24) −.26 (.40) .33 (.41)

0.57 (0.35–0.90) 0.77 (0.35–1.67) 1.39

−.36 (.25) −.23 (.41) −.26 (.42)

3.10 3.53 2.03 0.30 0.39

0.98 (0.96–1.00)

0.58 (0.37–0.90) 1.13 (0.53–2.44) 1.69

7.05⁎⁎ 8.75⁎ 5.71⁎ 0.45 0.63

−.46 (.14) .04 (.20) −.10 (.24) −.03 (.01) −.55 (.23) .13 (.39) .52 (.38)

0.69 (0.49–0.97) 0.74 (0.46–1.17) 0.43

0.70 (0.43–1.14) 0.80 (0.36–1.79) 0.77

IPV = intimate partner violence; B = beta coefficient; S.E. = standard error; CI = confidence interval; SUD = substance use disorder; vs. = versus. ⁎ p b .05 ⁎⁎ p b .01.

perpetration/victimization and severe IPV perpetration, but not severe IPV victimization.

4. Discussion The current study demonstrated that almost one third of the patients in substance abuse treatment were involved in any IPV (perpetration and/or victimization) in the year prior to intake. Further, almost a quarter of patients severely abused their partner, and 17.4% of patients were severely abused by their partner in the past year. For male patients, an alcohol use disorder in combination with a cannabis and/or cocaine use disorder was positively associated with any IPV (perpetration and/or victimization) and severe IPV perpetration; (combination of) other substance use disorders was associated with severe IPV perpetration compared to patients with only an alcohol use disorder. Substance use disorder diagnosis was not related to severe IPV victimization. For female patients, alcohol and cocaine use disorders were associated with any IPV (perpetration and/or victimization). The models for severe IPV perpetration and victimization were not significant. Additional analyses demonstrated that for males, the likelihood to be involved in any/severe past year IPV perpetration/victimization increased significantly in case patients had 2 substance use disorders compared to 1 substance use disorder but not if they had 3 or more substance use disorders in comparison to 2. For females, this was only found for any IPV (perpetration and/or victimization) and severe IPV perpetration. Results of Smith et al.'s (2012) study were thus partially replicated. In accordance with Smith et al., it was found that both alcohol and cocaine use disorders were significantly associated with IPV perpetration compared to only an alcohol use disorder. These results are also consistent with Pennings, Leccese, and De Wolff's (2002) review that suggested that both alcohol and cocaine use lead to elevated levels of dopamine and serotonin, which may lead to impaired impulse control and violent behavior. However, Smith et al. (2012) demonstrated that both alcohol and cannabis use disorders were negatively associated with IPV perpetration compared with only an alcohol use disorder, whereas the current study indicated that this specific combination of substance use disorders was positively associated with IPV perpetration compared to only an alcohol use disorder. On the other hand, alcohol and cannabis use disorders were also positively associated with severe IPV victimization. Since severe IPV perpetration and victimization overlap, it is inevitable that findings for IPV perpetration are dependent on findings for victimization (or vice versa). Differences in results between the two studies may be explained by the fact that the current study used a sample

seeking treatment for substance use problems whereas Smith et al.'s study used a general population sample. Also, it was noteworthy that the prevalence of IPV perpetration in substance abusers in the current study was somewhat lower than the prevalence rates that were found in previous studies. However, prevalence of IPV in the general Dutch population (Van der Veen & Bogaerts, 2010; Van Dijk, Flight, Oppenhuis, & Duesmann, 1997) is also lower than in, for example, the US population (e.g., Field & Caetano, 2005). Also, the majority of the studied sample (about 95%) was referred to outpatient treatment, in contrast to samples that were studied in previous (mainly US) studies that consisted mostly of inpatients (e.g., Chermack et al., 2008). Since the relationship between substance abuse and IPV in inpatients is stronger than in outpatients (Foran & O’Leary, 2008), this may also partially be responsible for the difference in results. Further, the current study used the J-IPV to assess IPV instead of the CTS2 that was used in previous research (e.g., Chermack et al., 2008). Compared to the CTS2 as ‘gold standard’, the J-IPV had a sensitivity of .80 to detect any IPV, indicating that the J-IPV missed 20% of patients that indeed were perpetrator/victim of any IPV. Although prevalence of IPV is lower in the current study than in previous studies, it is without doubt that IPV perpetration and victimization are more prevalent among substance abusers than in the general population. Furthermore, specific combinations of substance use disorders (alcohol in combination with cannabis and/or cocaine) appeared to be associated with IPV, particularly in males. However, the fact that these combinations are related to IPV does not imply a temporal or causal relationship between the use of these substances and IPV; personality factors might place individuals both at risk for abusing multiple substances and committing IPV (Hoaken & Stewart, 2003). Also, posttraumatic stress disorder is often associated with IPV perpetration (e.g., Jordan et al., 1992; Taft, Street, Marshall, Dowdall, & Riggs, 2007) and substance abuse (Driessen et al., 2008; Van Dam, Ehring, Vedel, & Emmelkamp, 2010), which may contribute to the high numbers of IPV in substance abusers as well (Dansky, Byrne, & Brady, 1999). Future studies should also assess personality traits and comorbid psychopathology that are often associated with IPV and substance abuse in order to control for these variables. In addition, it is noticeable that specific substance use disorders were found to be associated with IPV perpetration and victimization in male patients but not in female patients. Since males and females were analyzed separately and no interaction effects for gender were studied in one analysis, the results for males and females cannot be directly compared. Several limitations to this study should be noted. In the first place, IPV was assessed with the J-IPV. Although the J-IPV possesses good psychometric properties, it is not possible to distinguish between any

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IPV perpetration and any IPV victimization given the high rates of reciprocal IPV (over two third of the studied samples). However, although in many cases patients are both perpetrator and victim of any IPV, this is not true for all patients. Moreover, patients included in the any/severe IPV perpetration/victimization categories may not all have perpetrated or experienced IPV. Another limitation is that since patients with only an alcohol use disorder were used as a reference category, it is not possible to tell whether these patients were at increased risk for IPV. Since the study was conducted among patients referred to substance abuse treatment no healthy control subjects could be included. However, community studies demonstrated that patients with an alcohol use disorder were at increased risk for any IPV perpetration or victimization compared to patients without substance use disorders (e.g., Humphreys, Regan, River, & Thiara, 2005). Another limitation is that this study relied on self-report of participants' perpetration and victimization of IPV. Since IPV is a sensitive subject, participants possibly underreported IPV, which is not a specific problem for the J-IPV but for all self-report measures, including the CTS2. It is recommended that future research should involve partner reports as well. Further, although it was not the purpose of the present study, it would be interesting to assess other possible risk factors for IPV. Finally, future research should focus on the interaction between different substances and their relationship to IPV. Specifically, research should concentrate on temporal relationships between substance use and IPV, for example by assigning substance abusers in outpatient treatment to daily register substance use and IPV or by administering the timeline followback interview (TLFB; Sobell & Sobell, 1992). Several important clinical implications follow from the present study. This study demonstrated again that IPV perpetration and victimization are highly prevalent among substance abusers. Therefore, intake clinicians of substance use disorder treatment facilities should routinely ask about IPV, for example by administering the J-IPV, which only takes about 2 minutes. If patients score positive on the J-IPV, the CTS2 can be administered to obtain information regarding acts and frequency of IPV. If standard screening is not possible, clinicians should be particularly alert for IPV in patients who suffer from more than one substance use disorder, specifically in those who have an alcohol use disorder in combination with cannabis and/or cocaine disorders. Consequently, treatment of substance abusing IPV perpetrators should address both substance abuse and IPV as suggested by several researchers (e.g., Klostermann & Fals-Stewart, 2006; Kraanen, Emmelkamp, & Scholing, 2011; Leonard, 2001; Smith Stover, Meadows, & Kaufman, 2009; Stuart, 2005). Also, victims should be provided with safety planning or advocacy interventions (Ramsay et al., 2009). In addition, since IPV is often reciprocal (Archer, 2000, 2002), a treatment alternative is behavioral couples therapy, which showed some promising results (for a meta-analysis, see: Babcock, Green, & Robie, 2004).

Acknowledgments The present study was supported by the Royal Netherlands Academy of Arts and Sciences (KNAW) by the Academy Professorship awarded to Paul Emmelkamp.

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