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Quote: Domestic Violence before and after Alcoholism Treatment: A Two-Year Longitudinal Study Journal article by Christopher M. Murphy, Timothy J. O'Farrell, Valerie Van Hutton; Journal of Studies on Alcohol, Vol. 60, 1999 Journal Article Excerpt Domestic Violence before and after Alcoholism Treatment: A Two-Year Longitudinal Study(*). by TIMOTHY J. O'FARRELL , VALERIE VAN HUTTON , CHRISTOPHER M. MURPHY Domestic violence is a significant public health and mental health problem. One in six U.S. couples have an incident of physical assault each year (Straus and Gelles, 1986, 1990). Excessive alcohol use and alcoholism are associated with greater risk for domestic violence (Leonard, 1993). Over 50% of alcoholics have been violent to a female partner in the year before alcoholism treatment (Murphy and O'Farrell, 1996). The surprisingly few studies on domestic violence in clinical samples of alcoholics have been limited to cross-sectional descriptions of violence prevalence and correlates. O'Farrell and Murphy (1995) conducted an initial study of the natural history of domestic violence before and after alcoholism treatment in which they showed that a behavioral marital therapy (BMT) program for alcoholism reduced the risk of domestic violence for alcoholics. In the year before BMT, domestic violence was significantly greater--four to six times more prevalent and substantially more frequent--for the alcoholics than for a demographically matched, nonalcoholic comparison sample. Violence decreased significantly in prevalence and frequency in the year after BMT, and drinking status after treatment was significantly associated with domestic violence after treatment. Relapsed alcoholics had significantly elevated violence levels relative to nonalcoholic counterparts, whereas remitted alcoholics did not. In addition, the number of days drinking correlated significantly with the frequency of violent behaviors during the follow-up year. Although reduced domestic violence after alcoholism treatment is an exciting and encouraging finding, the use of only one follow-up measurement in the O'Farrell and Murphy (1995) study raises concerns about regression to the mean effects. In a community sample, considerable desistance in violence was observed during the first follow-up year of the study (Feld and Straus, 1990), but violence levels returned to near baseline in the second follow-up year (Kaufman Kantor, 1991). Therefore, at least two follow-up assessments are needed to determine whether posttreatment reductions in marital violence are stable or transitory. The present study examined the prevalence and frequency of domestic violence during the second year following alcoholism treatment. Of the original 88 married couples who completed pretreatment and 1-year follow-up assessments in the O'Farrell and Murphy (1995) study, 75 provided 2-year follow-up data on violence for the present study. Comparison rates of domestic violence for a demographically matched nonalcoholic sample were derived from a nationally representative survey of violence in American families (Gelles and Straus, 1985). Investigation of domestic violence rates in the second year after alcoholism treatment was deemed important for the following reasons. Domestic violence could decline during the first year after treatment, and then increase during the second year as a result of further alcoholism relapses or longstanding marital problems that were temporarily alleviated by BMT. Conversely, alcoholism treatment may have a lasting, and in some cases delayed, effect on domestic violence so that the violence rate might continue to decline significantly from the first year to the second year after treatment. Also, the 1-year follow-up results showed a strong relationship between alcoholism remission and desistance from domestic violence; it is very important both clinically and theoretically to determine whether this association is stable over a longer follow-up interval. Method O'Farrell and Murphy (1995) provides detailed methods of this study which are summarized here. Subjects and procedures The alcoholic sample was 75 couples with a newly abstinent alcoholic husband who were treated in a BMT program (O'Farrell, 1993) at the Veterans Affairs Medical Center in Brockton, Massachusetts. The nonalcoholic matched comparison sample provided a realistic, normative baseline against which to compare the levels of domestic violence experienced by alcoholics before and after BMT. The comparison sample came from matching alcoholic men and their spouses with demographically similar comparison groups of married individuals with no evidence of problem drinking drawn from the 1985 National Family Violence Re-Survey (Gelles and Straus, 1985). Subjects in the two samples were matched and did not differ on age (average for both samples = 45 years), years of education level (12.5), family income ($38,500) and years married (14). One couple in each sample was black and the rest were white. Husbands in the alcoholic sample were serious, chronic alcoholics as shown by: Michigan Alcoholism Screening Test (MAST; Seizer, 1971) mean ([+ or -] SD) scores (36.6 [+ or -] 10.5), mean years of problem drinking (13.3 [+ or -] 10.2) and mean alcohol-related hospitalizations (5.4 [+ or -] 9.6). The alcoholic patients and wives provided (1) drinking data before and after the BMT program and at quarterly intervals for 2 years after the end of BMT and (2) a questionnaire on marital violence in the previous 12 months at entry to the BMT program and at 1 year and 2 years after the end of BMT. Measures Domestic violence measure. The Conflict Tactics Scale (CTS), a widely used and well validated measure (Straus, 1990), provided two slightly different CTS indices for the two main purposes of the study. First, for all analyses within the alcoholic sample, a combined self and spouse report was used in which the husband was scored as committing a violent act if either the husband or wife reported that he had done so. Second, in contrasting the alcoholic and comparison samples, because only one member in a household was surveyed for the comparison sample, self and spouse reports for husband, to-wife violence were examined separately to provide (1) husbands who reported on their own behavior and (2) wives who reported on the behavior of their husbands. Drinking outcomes and remitted versus relapsed categories. Alcoholics and spouses were interviewed quarterly using the Time Line Follow-Back interview (TLFB; Sobell and Sobell, 1996), a method with established reliability and validity. On the basis of their drinking behavior during the first and second year after BMT, alcoholics were divided into remitted and relapsed groups using criteria adapted from other studies (e.g., Moos et al., 1990). In the first year after BMT, 37 of the 75 alcoholics were remitted and 38 relapsed; and in the second year after BMT, 34 were remitted and 41 relapsed. Results Change in violence from the year before BMT to the first and second years after BMT Changes in prevalence of violence. We compared prevalence of violence for the year before BMT with that for the first and second years after BMT using McNemar's test of change (Siegel, 1956). The prevalence of husband-to-wife violence was significantly decreased in both the first year and the second year after BMT, as compared with the year before BMT. The percentage of couples who experienced any violent act decreased from 61.3% in the year before BMT to 22.7% in the first year after BMT ([chi square] = 23.8, 1 df, N = 75, p [is less than] .001) and to 18.7% in the second year after BMT ([chi square] = 28.4, 1 df, N = 75, p [is less than] .001). The percentage experiencing severe violence(1) decreased from 24.0% in the year before BMT to 6.6% in the first year after BMT ([chi square] = 9.9, 1 df, N = 75, p [is less than] .01) and to 8.0% in the second year after BMT ([chi square] = 8.0, 1 df, N = 75, p [is less than] .01). Changes in frequency of violence. We used the Wilcoxon signed-ranks test, a nonparametric analysis, because data on frequency of violence was highly skewed. The frequency of violence was significantly decreased in both the first and second year after BMT, as compared with the year before BMT. The frequency of violent behaviors decreased significantly from over four violent acts (Mean [[+ or -] SD] = 4.3 [+ or -] 6.7) in the year before BMT to about one such act in the first (0.75 [+ or -] 1.8, z = -5.07, p [is less than] .001) and second (1.1 [+ or -] 3.6, z = -4.83, p [is less than] .001) years after BMT. Violence in the first and second year after BMT alcoholism treatment. There were no significant differences in the prevalence or frequency of violence between the first and second years after BMT. There was no evidence of an increase in violence during the second year after BMT, nor was there evidence of further reductions in violence during the second year after BMT. Comparison of marital violence among alcoholics and a matched nonalcoholic sample During the year before BMT. Column 2 of Table 1 presents data on violence by the alcoholics in the year before BMT and column 1 presents comparable data for the comparison sample. In the year before BMT, the alcoholics had a significantly higher prevalence of violence and frequency of violent acts than did their counterparts in the nonalcoholic comparison sample. TABLE 1. Husband to wife violence: Comparisons with demographically similar nonalcoholic subjects from the National Family Violence Re-Survey (Straus and Gelles, 1986) (N = 75) National survey subjects Husband self-report of violence Any violence (%) 8.0 Any severe violence (%) 0.0 Frequency of violent behaviors 0.1 [+ or -] 0.5 (Mean [+ or -] SD) Wife report of husband violence Any violence (%) 10.7 Any severe violence (%) 1.3 Frequency of violent behaviors 0.2 [+ or -] 0.7 (Mean [+ or -] SD) Alcoholics before BMT(a) Husband self-report of violence Any violence (%) 38.7([double dagger]) Any severe violence (%) 6.7(*) Frequency of violent behaviors 2.4 [+ or -] 5.5([double (Mean [+ or -] SD) dagger]) Wife report of husband violence Any violence (%) 48.0([double dagger]) Any severe violence (%) 24.0([double dagger]) Frequency of violent behaviors 3.5 [+ or -] 6.1([double (Mean [+ or -] SD) dagger]) Alcoholics Alcoholics in first year in second year after BMT(b) after BMT(c) Husband self-report of violence Any violence (%) 14.7 13.3 Any severe violence (%) 1.3 0.0 Frequency of violent 0.3 [+ or -] 1.2 0.8 [+ or -] 3.2 behaviors (Mean [+ or -] SD) Wife report of husband violence Any violence (%) 16.0 16.0 Any severe violence (%) 5.3 2.7 Frequency of violent 0.6 [+ or -] 1.9 0.5 [+ or -] 1.5 behaviors (Mean [+ or -] SD) (a) in the year before BMT, values of McNemar chi square (1 df, N = 75) for each violence prevalence score were: any violence husband report = 16.0, any severe violence husband report = 5.0, any violence wife report = 22.8, any severe violence wife report = 17.0. Wilcoxon's signed-rank test for analyses of violence frequency were: violence frequency husband report, z = -4.00; violence frequency wife report, z = -4.80. (b) in the first year after BMT, values of McNemar chi square (1 df, N = 75) for each violence prevalence score were: any violence husband report = 1.9, any severe violence husband report = 1.0, any violence wife report = 1.1, any severe violence wife report = 1.8. Wilcoxon's signed-rank test for analyses of violence frequency were: violence frequency husband report, z = -1.04; violence frequency wife report, z = - 1.29. (c) in the second year after BMT, values of McNemar chi square (1 df, N = 75) for each violence prevalence score were: any violence husband report = 1.1, any severe violence husband report = 0.0, any violence wife report = 1.1, any severe violence wife report = 0.3. Wilcoxon' s signed-rank test for analyses of violence frequency were: violence frequency husband report, z = -1.52; violence frequency wife report, z = -0.97. (*) p < .05; ([double dagger]) < .001. During the first year after BMT. Column 3 of Table 1 presents data on violence by alcoholics in the first year after BMT and column 1 presents comparison data. In the first year after BMT, the prevalence and frequency of violence by alcoholics were no longer significantly higher than among their counterparts in the nonalcoholic comparison sample. However, violence prevalence and frequency remained at least 1.5 times higher than that in the comparison sample. During the second year after BMT. Table 1 also shows violence by alcoholics in the second year after BMT (column 4) and comparison data (column 1). In the second year alcoholics' violence prevalence and frequency were no longer significantly higher than in the comparison sample, but prevalence of violence remained about 1.5 times higher than that in the comparison sample. Association between extent of violence and extent of alcoholics' drinking after BMT Comparison of remitted and relapsed alcoholics. Remitted alcoholics had a significantly lower prevalence and frequency of violence during both the first year and second year following BMT than did relapsed alcoholics. Extent of violence for relapsed and remitted, respectively, was: any violence--first year, 36.8% vs 8.1%, [chi square] = 16.3, 1 df, N = 75, p [is less than] .001; second year, 29.3% vs 5.9%, [chi square] = 23.5, 1 df, N = 75, p [is less than] .001; severe violence--first year, 13.2% vs 0.0%, [chi square] = 33.0, 1 df, N = 75, p [is less than] .001; second year, 14.6% vs 0.0%, [chi square] = 35.0, 1 df, N = 75, p [is less than] .001; and violence frequency--first year, 1.3 [+ or -] 2.6 vs 0.2 [+ or -] 0.9, z = -2.87, p [is less than] .01; second year, 1.9 [+ or -] 4.7 vs 0.1 [+ or -] 0.5, z = -2.63, p [is less than] .01. These differences did not simply reflect pretreatment levels of violence. Rank order data on frequency of violence showed relapsed were more violent than remitted in the first and second year after BMT, even after pretreatment violence was entered in an analysis of covariance (first year, F = 9.3, 1/72 df, p = .003; second year F = 7.3, 1/72 df, p = .008). Comparison of matched controls with remitted and relapsed alcoholics. Remitted alcoholics did not differ from matched controls, whereas domestic violence prevalence among relapsed alcoholics remained higher than among matched controls. Specifically, women's reports of male partner's violence were used to provide comparable data from the alcoholic and matched control samples. During the first year after BMT, none of the remitted alcoholics vs 13.5% of the comparison group were violent ([chi square] = 5.0, 1 df, N = 75, p = .025); in contrast, 31.6% of the relapsed alcoholics vs 7.9% of the comparison group were violent ([chi square] = 9.0, 1 df, N = 75, p = .003). During the second year after BMT, 2.9% of remitted alcoholics vs 8.8% of the comparison group were violent ([chi square] = 1.0, 1 df, N = 75,p = .32); in contrast, 26.8% of the relapsed alcoholics vs 12.2% of the comparison group were violent ([chi square] = 3.6, 1 df, N = 75, p = .058). Correlation of number of days drinking with violence frequency. There was a significant positive correlation between the number of days drinking by the alcoholic during the first and second year after BMT and subject's rank order on the frequency of husband-to-wife violence (first year after BMT, r = .48, N = 75, p [is less than] .001; second year after BMT, r = .40, N = 75, p = .001). Analyses to examine possible impact of sample attrition on study results The present sample consisted of 75 couples who provided 2-year follow-up data from the original sample of 88 couples who provided pretreatment and l-year follow-up data in the O'Farrell and Murphy (1995) study. For the most part, the 13 dropouts experienced serious drinking and marital problems during the second year of follow-up and were not completely cooperative with data collection efforts. However, the 13 cases who did not provide violence data at 24-month follow-up did provide TLFB drinking data. Therefore, we compared dropouts and completers on pretreatment characteristics and on available drinking, marital and violence scores at 1- and 2-year follow-up. Results showed dropouts, relative to completers, had greater violence in the first year after BMT and had other characteristics (e.g., worse violence and poorer marital adjustment at baseline, more drinking and more separations at follow-up) that suggest that domestic violence prevalence and frequency during the second year after alcoholism treatment may have been underestimated by the sample of 75 cases that provided complete data for the present study. We repeated study analyses for the entire sample of 88 cases in which we used four different estimates for the 13 dropouts' scores in the second year after BMT: (1) assume dropouts were violent, (2) use baseline violence scores, (3) use first-year violence scores, and (4) assume dropouts were nonviolent. These analyses had two conclusions. First, domestic violence prevalence and frequency during the second year after BMT may be underestimated by the present sample of 75 cases. Second, despite the possible underestimate, sample attrition did not appear to invalidate two basic conclusions of the present study, namely, that domestic violence in both the first and second year after BMT is significantly lower than in the year before BMT and is associated with the extent of the alcoholics' drinking, in that remitted alcoholics no longer had elevated domestic violence levels whereas relapsed alcoholics did. Discussion These results extend to a second year of follow-up our earlier findings on domestic violence reductions in the first year after BMT. In most respects second-year findings presented here parallel first-year results in O'Farrell and Murphy (1995). Violence continued to be significantly reduced during the second year after BMT as compared with the year before BMT. The extent of violence in the second year after BMT continued to be associated with the extent of the alcoholics' drinking: (1) relapsed alcoholics had greater violence than remitted alcoholics; (2) remitted alcoholics no longer had elevated domestic violence levels compared with matched controls, whereas relapsed alcoholics did; and (3) the frequency of violence was correlated with the number of days the alcoholic drank. The second-year findings differed from the first-year results presented by O'Farrell and Murphy (1995) in only one area. The first-year follow-up results showed that, despite significant reductions from the year before BMT, alcoholics' violence remained significantly elevated relative to matched controls. During the second-year follow-up, the alcoholic sample, when considered as a whole, not divided by drinking status, did not differ significantly on violence from the matched controls. This was true despite the fact that violence rates for the alcoholics were nearly double those for controls. Examination of the attrition from the first-year sample (N = 88) to the second-year sample (N = 75) showed that second-year violence likely was underestimated in the present study. This attrition affects the conclusion about comparisons of the alcoholics and matched controls just discussed. It would seem safer to conclude that alcoholics may still have had elevated second-year violence rates compared with controls. Nonetheless, the sample attrition did not appear to invalidate two basic conclusions of the present study. These conclusions are that domestic violence in both the first-and second-year after BMT (1) is significantly lower than in the year before BMT; and (2) is associated with the extent of the alcoholics' drinking, in that remitted alcoholics no longer had elevated domestic violence levels, whereas relapsed alcoholics did. Several important factors should be noted in considering the present results. First, the participants received a specialized, relationship-focused treatment for alcoholism. Further studies need to determine whether reductions in marital violence occur for alcoholics treated in programs that do not involve a marital therapy focus. Second, since the sample was almost exclusively white and consisted of treatment-seeking male alcoholics without current comorbid drug problems, the results may not generalize to other ethnic groups, female alcoholics, nonclinical samples, or polydrug-abusing individuals. Third, the alcoholic and comparison samples, although carefully matched on demographics, may have differed on relevant variables (e.g., marital adjustment) other than alcoholism that could account for the observed differences in domestic violence. Fourth, reduced violence among the remitted alcoholics and persistent violence among the relapsed alcoholics does not permit unequivocal interpretation that the continuing drinking caused the continued violence, since other variables may account for the variations in both drinking and violence. In addition, the direction of effects for the association between violence recurrence and alcohol relapse remains an interesting question, as the negative emotions associated with hostile and violent family conflict could precipitate relapse in some cases. Finally, we cannot conclude that the changes in violence were caused by BMT, since a control group without BMT was not included. Future studies examining larger samples, more typical individual treatment for alcoholism, more adequate comparison groups and factors in addition to drinking that may affect violence can improve our understanding of this important clinical problem. Acknowledgments We gratefully acknowledge assistance with data collection and data analysis from Greta Alter, Gina Byrnes, Keith Choquette, Deborah Gillis and Fay Larkin; and administrative support and practical assistance from Rogelio Bayog, Elizabeth Brown, Vivienne Esrig, Steven Gibson, Robert McCarley, William McCourt, Ming Tsuang, Barbara Van Wagner and Thomas Worobec. Note (1.) The Conflict Tactics Scale (CTS) has eight violence items: (1) threw something at the partner; (2) pushed, grabbed or shoved; (3) slapped; (4) kicked, bit or hit; (5) hit, or tried to hit, with something; (6) beat up; (7) threatened with a knife or gun; (8) used a knife or gun. Respondents rate each of the eight CTS violence items on a 7-point frequency scale (0 = never, 1 = once, 2 = twice, 3 = 3 - 5 times, 4 = 6 - 10 times, 5 = 11-20 times, 6 = over 20 times) for self and spouse behavior in the past 12 months. Items 4-8 are considered severe violence. References FELD, S.L. AND STRAUS, M.A. Escalation and desistance from wife assault in marriage. In: STRAUS, M.A. AND GELLES, R.J. (Eds.) Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families, New Brunswick, NJ: Transaction Publishers, 1990, pp. 489-506. GELLES, R.J. AND STRAUS, M.A. Physical Violence in American Families (computer file), 1985. 2nd release, Durham, NH: University of New Hampshire Family Research Laboratory (producer), 1988. Ann Arbor, MI: Inter-University Consortium for Political and Social Research (distributor), 1991. KAUFMAN KANTOR, G. Stressful life events, drinking and marital violence: A longitudinal analysis. Paper presented at the annual meeting of the American Society of Criminology, San Francisco, CA, 1991. LEONARD, K.E. Drinking patterns and intoxication in marital violence: Review, critique, and future directions for research. In: MARTIN, S.E. (Ed.) Alcohol and Interpersonal Violence: Fostering Multidisciplinary Perspectives. NIAAA Research Monograph No. 24, NIH Publication No. 93-3496, Rockville, MD: Department of Health and Human Services, 1993, pp. 253-280. MOOS, R.H., FINNEY, J.W. AND CRONKITE, R.C. Alcoholism Treatment: Context, Process, and Outcome, New York: Oxford Univ. Press, 1990. MURPHY, C.M. AND O'FARRELL, T.J. Marital violence among alcoholics. Curt. Direct. Psychol. Sci. 5(6): 183-186, 1996. O'FARRELL, T.J. A behavioral marital therapy couples group program for alcoholics and their spouses. In: O'FARRELL, T.J. (Ed.) Treating Alcohol Problems: Marital and Family Interventions, New York: Guilford Press, 1993, pp. 170-209. O'FARRELL, T.J. AND MURPHY, C.M. Marital violence before and after alcoholism treatment. J. Cons. Clin. Psychol. 63: 256-262, 1995. SELZER, M.L. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. Amer. J. Psychiat. 127: 1653-1658, 1971. SIEGEL, S. Nonparametric Statistics for the Behavioral Sciences, New York: McGraw-Hill Companies, 1956. SOBELL, L.C. AND SOBELL, M.B. Timeline Follow Back: A Calendar Method for Assessing Alcohol and Drug Use (User's Guide), Toronto: Addiction Research Foundation, 1996. STRAUS, M.A. The Conflict Tactics Scales and its critics: An evaluation and new data on validity and reliability. In: STRAUS, M.A. AND GELLES, R.J. (Eds) Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families, New Brunswick, NJ: Transaction Publishers, 1990, pp. 49-73. STRAUS, M.A. AND GELLES, R.J. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. J. Mart. Fam. 48: 465-479, 1986. STRAUS, M.A. AND GELLES, R.J. (Eds.) Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families, New Brunswick, NJ: Transaction Publishers, 1990. TIMOTHY J. O'FARRELL, PH.D.,([dagger]) VALERIE VAN HUTTON, PH.D., AND CHRISTOPHER M. MURPHY, PH.D.([dagger]) Harvard Families and Addiction Program, Harvard Medical School Department of Psychiatry and Veterans Affairs Medical Center, Brockton and West Roxbury, Massachusetts Received: February 24, 1997. Revision: September 4, 1997. (*) Portions of this article were presented at the Annual Convention of the American Psychological Association, Los Angeles, August 1995. This research was supported primarily by a grant from the Harry Frank Guggenheim Foundation. Additional support was provided by grants to the first author from the Office of Research and Development, Medical Research Service of the Department of Veterans Affairs, from the National Institute on Alcohol Abuse and Alcoholism (grant RO1 AA08637) and from the Smithers Foundation. ([dagger]) Correspondence should be addressed to Timothy J. O'Farrell, Ph.D., Harvard Families and Addiction Program (116B1), Harvard Medical Department of Psychiatry at the VA Medical Center, 940 Belmont Street, Brockton, MA 02301. Christopher M. Murphy is with the University of Maryland Baltimore Campus, Baltimore.3

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