Multidisciplinary cognitive-behavioral therapy training for the veterans affairs primary care setting.

OBJECTIVE: Current research highlights the need to embed evidence-based psychotherapies such as cognitive-behavioral therapy (CBT) within primary care settings. Few studies have examined CBT training procedures, and no studies have examined the impact of CBT training in the primary care setting. The current study sought to describe and assess the feasibility and effectiveness of a focused CBT training program for a diverse sample of primary care mental health providers in the Department of Veterans Affairs (VA). METHOD: A multidisciplinary group of 28 mental health clinicians from 6 VA medical centers and 15 community-based outpatient clinics received an intensive 1½-day CBT workshop, held in Houston, Texas, in May 2008, including didactic presentations, expert modeling, and small-group role plays. CBT experts also provided biweekly follow-up group telephone consultation calls for participants over 12 weeks to aid in development of CBT skills. Participant program evaluation surveys and self-reported CBT knowledge, ability, and utilization were measured preworkshop, postworkshop, and 3 months postworkshop. Analyses compared mean change scores at baseline to those at 3-month follow-up. Wilcoxon signed rank tests were completed, and Cohen d effect-size calculations were also computed. RESULTS: Statistical analyses found that participant self-reported CBT knowledge (P < .01, effect size [ES] = 0.49) was significantly improved postworkshop and maintained at 3-month follow-up. Self-reported abilities were also improved (P = .07, ES = 0.40). The potency of the training experience appeared to be enhanced by the multimodal nature of the program. CONCLUSION: Although challenges exist, focused and intensive training in CBT appears feasible for multidisciplinary mental health practitioners in the primary care setting.

Developing sexual violence prevention strategies by bridging spheres of public health.

Sexual violence (SV) is a significant public health problem with multiple negative physical and emotional sequelae for both victims and perpetrators. Despite substantial research and program activity over the past 20 years, there are few programs with demonstrated effectiveness in preventing SV. As a result, the field may benefit from considering effective approaches used with other risk behaviors that share risk factors with SV. The Division of Violence Prevention (DVP) at the Centers for Disease Control and Prevention (CDC) has taken several steps to identify and understand the breadth of risk factors for sexual violence and to delineate the implications of these factors in the development of effective prevention strategies. This report from CDC will highlight several risk factors that, although not traditionally included in SV prevention efforts, may be important areas on which to focus and may ultimately prevent youth from embarking on trajectories resulting in SV perpetration.

Characterizing aggression and its association to anger and hostility among male veterans with post-traumatic stress disorder.

OBJECTIVES: The basis for the associations among anger, hostility, aggressive behavior, and post-traumatic stress disorder (PTSD) remains unclear. We suggest classifying aggressive behavior may elucidate the associations among these factors. On the basis of diagnostic and neurobiological similarities between impulsive aggression (IA) and PTSD, we proposed that IA was the predominant form of aggression in PTSD and that anger and hostility would not significantly predict PTSD when IA was also included as a predictor. METHODS: We used cross-sectional self-report data obtained from two samples of male veterans (N = 136). RESULTS: Over 70% of veterans with PTSD reported IA compared to 29% of those without PTSD. IA, not anger, hostility, or premeditated aggression significantly predicted a diagnosis of PTSD. CONCLUSIONS: Associations between anger and PTSD may be unique to individuals with IA, and considering impulsive and premeditated aggressors separately may account for the heterogeneity found within samples of aggressive veterans with PTSD.

Intimate partner aggression perpetrated and sustained by male Afghanistan, Iraq, and Vietnam veterans with and without posttraumatic stress disorder.

Veterans with posttraumatic stress disorder (PTSD) consistently evidence higher rates of intimate partner aggression perpetration than veterans without PTSD, but most studies have examined rates of aggression among Vietnam veterans several years after their deployment. The primary aim of this study was to examine partner aggression among male Afghanistan or Iraq veterans who served during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and compare this aggression to that reported by Vietnam veterans with PTSD. Three groups were recruited, OEF/OIF veterans with PTSD (n = 27), OEF/OIF veterans without PTSD (n = 31), and Vietnam veterans with PTSD (n = 28). Though only a few comparisons reached significance, odds ratios suggested that male OEF/OIF veterans with PTSD were approximately 1.9 to 3.1 times more likely to perpetrate aggression toward their female partners and 1.6 to 6 times more likely to report experiencing female perpetrated aggression than the other two groups. Significant correlations among reports of violence perpetrated and sustained suggested many men may have been in mutually violent relationships. Taken together, these results suggest that partner aggression among Iraq and Afghanistan veterans with PTSD may be an important treatment consideration and target for prevention.

Male-to-female sexual aggression among Iraq, Afghanistan, and Vietnam veterans: co-occurring substance abuse and intimate partner aggression.

The current study examined the frequency and correlates of coercive sexual behaviors by male Iraq, Afghanistan, and/or Vietnam veterans recruited from a Veterans Affairs trauma recovery clinic (n = 92) toward their female partners. Men who reported sexual aggression in the past year (n = 37) compared to men who did not report sexual aggression in the past year (n = 55) more frequently reported impulsive aggression, dominating/isolating, and physically assaulting their partner, and were more likely to have a substance abuse diagnosis. Sexually aggressive men were significantly less likely than nonsexually aggressive men to have a diagnosis of depression. Posttraumatic stress disorder, an established risk factor for nonsexual partner aggression among veterans, was not associated with sexual aggression.

Considerations for the definition, measurement, consequences, and prevention of dating violence victimization among adolescent girls.

Violence experienced by adolescent girls from their dating partners poses considerable threat to their health and well-being. This report provides an overview of the prevalence and consequences of heterosexual teen dating violence and highlights the need for comprehensive prevention approaches to dating violence. We also discuss some considerations and future directions for the study and prevention of dating violence. We begin with a discussion of the definition of dating violence and also discuss measurement concerns and the need for evaluation of prevention strategies. Although women and men of all ages may be the victims or perpetrators, male-to-female dating violence experienced by adolescent girls is the main focus of this article. We incorporate research regarding girls' perpetration of dating violence where appropriate and as it relates to prevention.

Use of coercive sexual tactics across 10 years in at-risk young men: developmental patterns and co-occurring problematic dating behaviors.

Men's use of two coercive sexual tactics was tracked over 10 years in a sample of at-risk young men (N = 201). Patterns were identified for each tactic. For the tactic using drugs or alcohol to go further sexually, non-coercers (63%) and coercers (37%) were identified. For the tactic of going further sexually after the woman said "no," three patterns were identified-noncoercers (10%), low-level coercers who used the tactic five times or less over 10 years (42%), and high level coercers who used the tactic more than five times over 10 years (48%). The associations between coercive tactics and two dating behaviors-physical aggression toward a partner and risky sexual behaviors-were examined using multilevel linear modeling. For both coercive tactics, main effects and interaction effects with time occurred for physical aggression toward a partner. The most coercive men perpetrated the most physical aggression toward a partner between ages 18 and 22 years, but sexual coercion was unrelated to partner abuse between ages 22 and 27 years. Results suggest men vary in their use of coercive sexual tactics over time and the frequency of coercion varies based on tactic. Preliminary evidence suggests the use of coercive sexual tactics is associated with physical aggression toward a partner but not risky sexual behaviors, though the strength of the association varies over time.

Violence between therapy-seeking veterans and their partners: prevalence and characteristics of nonviolent, mutually violent, and one-sided violent couples.

Among male veterans and their female partners seeking therapy for relationship issues, three violence profiles were identified based on self-reports of physical violence: nonviolent, in which neither partner reported perpetrating physical violence (44%); one-sided violent, in which one partner reported perpetrating violence (30%); and mutually violent, in which both partners reported perpetrating physical violence (26%). Profiles were distinguished based on the veteran's psychiatric diagnosis, woman's age, and both partners' reports of the frequency and severity of violence. Men and women in mutually violent couples reported more verbal and physical aggression than did men or women in any other group. The three groups reported comparable rates of sexual aggression. Appraisals of marital satisfaction and intimacy were not different based on violence profile. No gender differences emerged in the self-reports of frequency and severity of verbal, physical, and sexual aggression.

Empathic deficits and alexithymia in trauma-related impulsive aggression.

Our long term interest is to develop a developmental model of impulsive aggression based on a confluence of social, psychological and biological features. This approach incorporates neurobiological research, which has identified language processing deficits as a unique characteristic of impulsive aggressors and extends it to include emotional deficits. As an initial test of this hypothesis, we examined whether empathy and alexithymia were associated with impulsive aggression. Regressions were performed to explore the associations among impaired empathy, alexithymia, impulsive aggression, verbal and physical general aggression. Among impulsive aggressive veterans (n=38) recruited from a VA trauma clinic, alexithymia predicted impulsive aggression and empathic deficits predicted verbal aggression. Neither emotional awareness deficit predicted general physical aggression in this middle-aged sample. Results suggested that empathic deficits were associated with general verbal aggression, but alexithymia was uniquely associated with impulsive aggression. Consideration of alexithymia in impulsive aggression has implications for its etiology, prevention and treatment.

Culture and Personality Among European American and Asian American Men.

Personality differences between Asian American (N = 320) and European American men (N = 242) and also among Asian American ethnic groups (Korean, Chinese, Japanese, Filipino, and mixed Asian) are examined on the Big Five personality dimension. Personality structures for Asian Americans and European Americans closely replicate established norms. However, congruence is greater for European American and highly acculturated Asian American men than for low acculturated Asian American men. Similar patterns are found for the construct loss of face (LOF). Asian American men with a high concern for LOF are less similar in their personality structure to European American men than Asian American men with low LOF concern. Mean differences are also found among Asian American and European American men, who differ significantly on Extraversion, Conscientiousness, Openness, and Neuroticism. Results indicate that acculturation and LOF are significantly associated with these four personality dimensions for both Asian American and European American men.

Initiation, desistance, and persistence of men's sexual coercion.

Patterns of sexually coercive behavior were examined among 266 Asian American and 299 European American men over 1 year. Noncoercer (n = 358), desister (n = 120), initiator (n = 39), and persistent (n = 48) sexually coercive groups were identified. The strongest predictor of sexual coercion was past sexual coercion. Persistent sexual coercers were higher than the other groups in delinquency and hostile masculinity and were nearly twice as likely to engage in laboratory sexual harassment. Loss of face attenuated self-reported sexual coercion and laboratory sexual harassment risk among Asian Americans and attenuated only laboratory sexual harassment risk among European Americans. These findings suggest that the heterogeneity of sexually coercive behavior and ethnicity are important research and clinical considerations.

Ethnicity, culture, and sexual aggression: risk and protective factors.

Explanatory models of sexual aggression were examined among mainland Asian American (n=222), Hawaiian Asian American (n=127), and European American men (n=399). The Malamuth et al. (N. M. Malamuth, D. Linz, C. L. Heavey, G. Barnes, & M. Acker, 1995; N. M. Malamuth, R. J. Sockloskie, M. P. Koss, & J. S. Tanaka, 1991) confluence model of sexual aggression, which posits impersonal sex and hostile masculinity as paths to sexual aggression, was consistently supported. Culture-specific moderators of sexual aggression were also identified. Whereas loss of face was a protective factor against sexual aggression in the Asian American samples, it generally was not a protective factor among European Americans. These findings are not a function of actual or perceived minority status. An implication is that theoretical models may need to be augmented with cultural constructs for optimal application in certain ethnic group contexts.

Validation of Acceptance of Coercive Sexual Behavior (ACSB): a multimedia measure of adolescent dating attitudes.

The psychometric properties of the Acceptance of Coercive Sexual Behavior (ACSB), a multimedia measure of adolescent dating attitudes, were examined. The ACSB is an interactive instrument that uses video vignettes to depict adolescent dating situations. Analyses of the measure's factor structure, internal consistency, test-retest reliability, and validity were conducted with separate samples of male (n = 106) and female (n = 114) high school students. Validity was evaluated in relation to subscales on the Sexual Attitudes Survey and self-reports of dating and sexual experiences. Factor analyses on the ACSB yielded two factors, Coercion and Consent. The ACSB demonstrated acceptable psychometric properties. Advantages of using a multimedia assessment of sexually coercive attitudes with adolescents are discussed.

The cultural context of sexual aggression: Asian American and European American perpetrators.

Attention paid to culture in theories of sexual coercion has been limited. This failure to include culture in these theories implies that culture does not have an important role in sexually coercive behavior. Recent conceptual and empirical work supports the existence of culture-specific models of sexual coercion. Sexual coercion has been characterized in much of the literature as an individual phenomenon. However, cultural norms are influential in collectivist cultural groups. Whereas European American men's sexual coercion is primarily determined by misogynous beliefs, Asian American men's sexual coercion is determined by a combination of misogynous beliefs and cultural considerations. These findings underscore the need to consider cultural context in the development of theoretical models and interventions for sexually coercive behavior.