JOINING FORCES

Joining Families

Volume 16, Issue 1 • Spring 2016

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

The How and Why of Intimate Partner Violence
An interview with L. Kevin Hamberger and Sadie Larsen
Biography— L. Kevin
Hamberger, PhD
Dr. Hamberger
is professor of family and community
medicine in the
Department of
Family and Community Medicine,
Medical Collegeof Wisconsin, andan affiliate of the
In This Issue
In this issue of Joining Forces Joining Families we explore developments
in intimate partner violence (IPV) research and practice. Our interview is with
L. Kevin Hamberger and Sadie E. Larsen on men’s and women’s experiences of
IPV. In a separate article, we highlight more of their research.
Building Bridges to Research describes meta-analysis, a statistical tool
used to obtain an estimate of a difference based on several studies. It isfrequently used in evidence-based research.
Our neuroscience article describes how child maltreatment increases
the risk for later adult disorders, such as depression, through epigenetic
mechanisms. Epigenetics is related to the “turning on or turning off” of genes
by the life experience of the individual.
The Website of Interest describes the US Preventive Services Task Force, apanel of experts in prevention and evidence-based medicine. We provide links
to their recommendations for IPV screening, depression screening, and aspirin
for the prevention of cardiovascular disease and cancer.
Contents.Featured Interview: L. Kevin Hamberger and Sadie Larsen.............................. 1
Intimate Partner Violence and Trauma: Research of L. Kevin Hamberger
and Sadie E. Larsen..................................................................................... 4
Building Bridges to Research: Meta-Analysis Used to Investigate PTSD
Diagnostic Criteria....................................................................................... 7
Screening for Intimate Partner Violence and the Recommendations of the
U.S. Preventive Services Task Force......................................................... 10
Influence of Child Maltreatment on Genes Related to Health Outcomes........ 11
Websites of Interest....................................................................................... 12

MCW Injury Research Center. Since 1982, hehas conducted treatment and research programswith domestically violent men and women anddeveloped and evaluated health care provider
training programs to deliver violence prevention
and intervention services to patients. He was
Principal Investigator (PI) on a recently completed CDC-funded project to evaluate the impactof a health systems change model of intervention
to prevent and end intimate partner violence inprimary care settings.

Biography — Sadie E. Larsen, PhD

Dr. Larsen graduated from the clinical/community psychology program at the University of
Illinois at Urbana-Champaign and completed
a postdoctoral fellowship in PTSD at the VA
Boston Healthcare System. She now works as a
psychologist at the Clement J. Zablocki VA Medical Center. She is an Assistant Professor at the
Medical College of Wisconsin. Dr. Larsen has along-standing interest in gender-related violence
and recovery from trauma. She has worked withvictims of such violence in various capacities,
from crisis hotline work to therapy and research.
She is currently researching prevention and treatment of PTSD.



Dr. McCarroll: Much of your research has
been on clinical samples of intimate partner
violence (IPV) victims and perpetrators. Bothof you have published on men’s and women’s
experiences of IPV, screening for IPV, IPV
treatment, and the relationship of trauma
to IPV, particularly as related to treatment.
Another approach to understanding IPV is
research on community samples. Could you
Continued on page 2

In clinical samples,
women tend to use
violence more in
reaction to theirpartner’s violence
whereas men tend toinitiate it.

explain the differences between research
performed on clinical versus community
samples?
Dr. Hamberger: In research on IPV, adistinction is usually made between community-based sampling versus clinical samples.
Clinical samples are a very narrow part of
the total population. They consist of people
who reach out for help, either on their own
or because someone else thought that there
was sufficient distress or problems occurring in their lives that they needed to seek
help. They are a special part of the general
population. Community samples are often
convenience samples such as college students, community dwelling people who arerecruited for a particular study, or they might
be part of a random selection to represent a
broad cross section of society.
Community-based samples are often
broader and more representative of thecommunity in general than clinical samples.
Therefore, research based on such samples isviewed as being more generalizable and one
is more able to make inferences that mightlead to theory building and theory testing.
Clinical samples are fairly narrow and datafrom those samples does not necessarily
generalize to the broader community. The

JOINING FORCES
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email:
James.McCarroll.ctr@usuhs.edu
Joining Forces Joining Families
is a publication of the U. S.
Army Installation Management Command and theFamily Violence and Trauma
Project of the Center for the
Study of Traumatic Stress(CSTS), Bethesda, Maryland
20814-4799, tel. 301-2952470. CSTS is part of the
Department of Psychiatry of
Uniformed Services University of the Health Sciences,which is our nation’s federal
medical school.

2 • Joining Forces/Joining Families

Editorial Advisor
LTC Ricky J. Martinez. PhD, MSC, USA
Family Advocacy Program Manager
Installation Management Command
Department of the Army
Editorial Consultant
Joshua C. Morganstein, MD
Commander, US Public Health Service
Assistant Professor/Assistant Chair andScientist
Center for the Study of Traumatic Stress
Uniformed Services University
Department of Psychiatry

other side of the argument has also been made,that data from broad community samples do
not necessarily generalize and apply to clinicalsamples. So, they may be two separate parts of
the whole picture.
Dr. McCarroll: One of the questions you
addressed in your recent papers is the age-old
question of whether women are as violent asmen. You pointed out differences as well as
similarities in men’s and women’s use andexperiences of violence (Hamberger & Larsen,
2015; Larsen & Hamberger, 2015). One result
was that men’s and women’s uses of violence
are quite different.
Dr. Larsen: It is hard to boil down our two
giant papers into a short answer. In those two
papers we were dealing exclusively with clinicalsamples. One of the common findings in community samples is that men and women seemto endorse using violence at pretty similar rates
and that is part of what gives rise to the question of whether women are as violent as men.
But, mutual abuse is not necessarily mutual.
When you examine men’s and women’s experiences of IPV, you often find that they are quite
different and not really mutual. We have foundthat the result actually depends on how you ask
the question. Part of the finding of equal rates
of violence might be sort of an artifact of how
the question is asked. If you just ask men andwomen “Have you hit your partner in the lastyear?” about equal rates of them will say “Yes.”
But, if you get a little more specific and ask if
it was not joking or horseplay, then the rates
start to look different and you see that men
actually use more violence than women. So, a
lot of what we pick up might be not what wewould actually think of as violence. We would
say that both men and women use violence, butthey seem to use it for largely different reasons.
There is a statement in the paper to the effectthat when violence is used, women get the worst
of it. It affects women much more in financial
costs, physical injury, fear, and feelings of being
controlled.
Dr. Hamberger: Let me just speak moregenerally to that. What we found in the reviewof the literature is that women and men in
intimate partner relationships use violence. We
start with that as a basic conclusion; there is no
denying that. We then looked at some of the different parameters of violence such as whether
they initiate violence at the same rate or if it isreactive. The studies that have been done seem
Continued on p. 3
Spring 2016

An interview with L. Kevin
Hamberger and Sadie
Larsen, from page 2

Batterer treatment isevolving. Many men
who batter grew up
in violent households
and were abused as
children. They carry thelegacy of trauma withthem. People are now
starting to think about
how to address thetrauma issues as partof the overall treatment
package.

http://www.CSTSonline.org

to suggest that in clinical samples, womentend to use violence more in reaction to theirpartner’s violence whereas men tend to initiate
it. That was borne out in some straightforward
questions of who uses violence first and inindirect ways by looking at the arrest recordsof the partners of individuals who are arrested.
For example, when women were arrested theyfound that their male partners had much longer arrest records for prior domestic violence
than the women who were arrested and thereverse was also true. When the men were arrested the women partners had shorter priorarrest records than the men, which suggested
that women were more reacting to partner
violence than initiating it. Other studies ofrecidivism seem to indicate that even in dualarrested couples that when they followed themfor up to five years and followed their police report activity for new domestic violence, women
were more likely to show up in subsequent police reports as victims whereas men were more
likely to show up as perpetrators.
When we looked at motivation for violence, a fuzzy picture emerged. I published apaper in 2005 in which it seemed pretty clearthat women’s motivations tended to be morearound self-defense and retaliation and men’s
motivations tended to be more around control(Hamberger, 2005). In our more recent review,
we still seemed to see more of that retaliation/
reactiveness in women’s motivation, but there
did not seem to be as much of a gender difference in terms of a motivation of control. That
raised some questions about the whole issue ofcontrol.
Dr. Larsen: That is one of our other ongoing projects, looking at the concept of control.
It is difficult to define and measure. It is talked
about a lot, but it is not necessarily measured.
There were not many papers that we could
include in our review that looked at control
mechanisms. We are taking a little more in
depth look at that right now. Control has a lotof different aspects such as what actions aretaken and how those actions are perceived.
Violence may be used by both men and womenand yet it may not mean the same thing. That
was one of our large, overall findings. Just looking at participation rates does not necessarily
get at “What does this violence do or mean tothe people involved in it?”Dr. Hamberger: Injury inflicted is different
from injury sustained. This is a complex issue.
Based on arrests in single incidents, womenare more likely to inflict an injury using aweapon whereas men tend to use hands, feet,or head butt. In injury sustained data, womenshow more injuries than men, but this is usuallybased on a longer time frame (e.g., 12 months)
than a single incident. Other methodologicalissues come into play in interpreting injury reports according to whether they are self-reports
or based on contacts with the criminal justicesystem.
We also looked at gender differences inemotional abuse tactics. If you look at an overall
score on a questionnaire, men and women scorepretty much the same. Again, it looks like gender symmetry, but when we looked at genderdifferences in items, men tended to make lethal
threats or try to control their partner’s activities and autonomy or their partner’s children
whereas women tend to yell and shout.
Dr. McCarroll: You have also conducted
research on screening for IPV in medical
settings. Your program Health Care Can
Change from Within, was a systems-levelintervention to determine if clinic proceduresof screening and a brief intervention leadto different outcomes for abused women.
(Ambuel et al., 2013)
Dr. Hamberger: Two clinics were intervention sites and two were usual care controls.
Everyone in the intervention clinics was trained
about IPV, but only the family practice residents and physicians and nurses conducted IPVscreening. In addition to training the clinic staff,
the intervention also consisted of provision ofpatient education materials for IPV prevention,and the development of clinic policies to facilitate all staff collaborating to identify IPV. The
usual-care clinics did not display educational
materials and did not have written IPV policies
and procedures, did not screen specific groupsof patients for IPV, and were not collaboratingwith local IPV agencies.
Dr. McCarroll: In your results, you showedthat the intervention group had increased
IPV inquiry, discussion, and disclosure thanthe usual care group. Both groups adopted
more safety behaviors and experienced lessviolence.
Dr. Hamberger: Ours was a fairly small
study, but our results are not inconsistent withwhat larger studies have found. Screening does
not necessarily result in less violence or better
quality of health compared to no screening. But,
importantly, there is a methodological issue opContinued on page 8
Joining Forces/Joining Families • 3

Intimate Partner Violence and Trauma: Research of
L. Kevin Hamberger and Sadie E. Larsen
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

Hamberger and Larsen’s2015 review papers
present (1) the methodsof violence (the how),and (2) the motivations(the why).

Drs. Hamberger and Larsen reviewed
research published between 2002-2013 on
men and women who experienced intimate
partner violence (IPV) (Hamberger & Larsen,
2015; Larsen & Hamberger, 2015). Both ofthese articles focus on gender differences in theperpetration, motivation, and impact of IPV inclinical samples and extend an earlier literature
review (Hamberger, 2005). Why only in clinicalsamples? In general, there have been two approaches to research on IPV: samples of large
populations and clinical samples. The authors
argue for the use of clinical samples in research
for two major reasons. First, they are likely to
be of interest to policy makers as well as clinicians since these are the people who are most
likely to come in contact with law enforcement,
legal, social service, and medical providers. Second, there is substantial morbidity and mortality associated with clinical cases of IPV.
The first review presents: (1) the methodsof violence (the how), (2) the motivation (thewhy), (3) the context and risk factors (theenvironmental and situational variables), and(4) the physical and psychological consequences of injury (Hamberger & Larsen, 2015).
While there were many specific and sometimes
conflicting results of the research, the authors
concluded that both men and women are active participants in IPV, but women’s physicalviolence appeared to be more often in response
to violence initiated against them. Women werealso more highly victimized, more injured,and more fearful of their partners. Men were
the predominant perpetrators of sexual abuse.
The authors suggested that adopting a gendersensitive approach in working with clinicalpopulations will be beneficial in understanding
the problems, formulating interventions, anddeveloping policies.
The second paper described the costs
related to abuse, criminal and legal factors,
recidivism, substance abuse, and psychopathology (Larsen & Hamberger, 2015). This paper
also extended the earlier literature review(Hamberger, 2005) by focusing on the context,
risk factors, and consequences of men’s andwomen’s experiences of violence, both as perpetrators and as victims. Overall, this review

4 • Joining Forces/Joining Families

reported that women incur more costs related
to abuse than men, are less likely to be prosecuted, and more likely to be granted a restraining order. However, women as perpetrators
have more psychopathology with the exceptionof antisocial personality disorder. While men
and women were equally likely to be arrested
for IPV in a given incident (though men makeup about 80% of total IPV arrests), men were
found to have more extensive criminal histories
and had higher recidivism. Gender differencesin these factors are complex and generalization
can be difficult. For example, findings on substance abuse were conflicting and no conclusion
was presented. As was concluded in the earlier
paper (Hamberger & Larsen, 2015), this review
also found that men and women have different experiences of IPV. Due to the findings that
IPV experiences differ by gender, the authors
recommended that clinical assessment must be
in-depth to understand how IPV functions in
the relationship and how it impacts the parties
involved. Thus, assessment should be based onclient needs with an appreciation of gender differences.
Screening for IPV has been a prominent
research subject as well as a policy conundrum. Prompts for screening by family practiceresidents to inquire about IPV led to a dramaticincrease in documented IPV inquiry (Hamberger, Guse, Patel, & Griffin, 2010). While thisstudy did not document violent victimization, it
did find increased inquiry rates among primarycare physicians.
Recent studies have found that routine
screening for IPV did not lead to improved
women’s health or recurrence of partner violence (Klevans et al., 2012; MacMillan et al.,2009). However, these authors suggested that
evaluation of services for women after identification of IPV remains a priority. Dr. Hamberger
acknowledges the difficulties in routine screening for IPV: time constraints, lack of protocols
and policies, and departmental regulations(Hamberger, Rhodes, & Brown, 2015). Hamberger and his colleagues suggest incorporating IPV screening with a broader system-level
model in which both screening and long-term
Continued on page 5
Spring 2016

Intimate Partner Violence
and Trauma: Research of L.
Kevin Hamberger and Sadie
E. Larsen, from page 4

Men and women havedifferent experiencesof intimate partner
violence (IPV). Clinicalassessment must
understand how
IPV functions in therelationship. Assessment
is based on client needs
with an appreciation ofgender differences.

http://www.CSTSonline.org

IPV services are needed (Ambuel et al., 2013).
This model requires: (1) on-site IPV expertise,(2) saturation training (all staff members in aunit), (3) unit-based policies and procedures
supporting the organization’s commitment to
the issue, (4) collaboration with local advocates and IPV experts, (5) quality improvement strategies and primary prevention withina health care system such as posted signage
and pamphlets for patients (Hamberger et al.,2014). This model is directed toward intervention as a part of on-going clinical care to
decrease IPV and improve women’s health. Asof this writing, research supporting this type ofintervention was lacking. There will be a needto track harms as well as to identify the mostappropriate outcome variables. Among theseoutcomes could be safety and feelings of support from the care provider as well as reducing
health care costs (Hamberger et al., 2014).
The effect of the neighborhood on IPV is arelatively new area of inquiry, but lacks theoretical and conceptual models (Beyer, Wallis, &Hamberger, 2015). This literature review discusses social disorganization theory, the process by which social disadvantage and residential instability disrupt social bonds and limit
collective activity to maintain social control
increasing the likelihood of deviant behaviors.
IPV differs from other types of violence in that
it is often hidden from public view and one
cannot assume that community members willrecognize IPV or respond to it. Social isolation
may be a protective measure and social support
may be negative in communities that encourage IPV. This article asks many questions that
could be the subject of further research andalso suggests practice and policy implicationsof possible community efforts to reduce IPV.
Dr. Larsen’s research career includes both
IPV and responses to trauma. She participatedin a study of medical organizational responses
to IPV through the support of community
councils, organizations made up of groups andindividual community members to address acomplex social issue (Allen, Larsen, Javdani,& Lehrner, 2012). The organizational environment plays a powerful and central role inshaping providers’ behaviors. Twelve healthcare organizations participated in this studyof the moderating effects of the organizational
context on changing the response to IPV. Those
providers in organizations that supported
screening engaged in screening more frequently (though providers at all organizations
tended to personally support screening). The

council played a critical role in these health caresettings by bringing about screening, providing supports in the form of model policies, andtraining at the administrative and individual
provider levels.
In addition to IPV, Dr. Larsen’s research has
also focused on a variety of traumatic events.
The nature of the stressor in the diagnosis of
PTSD has evolved over time. Dr. Larsen examined 22 studies to determine whether posttraumatic stress symptoms (PTSS) differed according to whether the stressors were congruent
with the diagnosis (e.g., extreme events that are
traditionally viewed as traumatic such as combat and IPV) or not congruent (e.g., events thatare traditionally viewed as stressful life events
such as sexual harassment, divorce, chronic
illness, racial discrimination) (Larsen & Pacella,2016). She found that PTSS were significantly
greater following a congruent trauma, but that
there was only a small difference in PTSS between congruent and non-congruent traumas.
A similar study, one on recovery from a
stressful or traumatic event, asked 107 women
to describe a traumatic event and how it affected them (Larsen & Berenbaum, 2014). One
week after the end of the study, women reported
significantly lower levels of negative affect.
Effects were greatest for those with the highest
levels of depression at the time of the interview.
They concluded that participation in a trauma
or stress-focused event is not harmful andmay be beneficial, especially among depressed
participants. This was thought to occur becauseinterviews may be more beneficial when they
allow for more emotional processing than is
likely in surveys. However, she suggested thatfurther research could better determine thedifferences between the experiences of participating in interviews and surveys. In this samegroup of participants, she studied the relationship between trauma responses and posttraumatic growth to see if emotion regulation strategies could be helpful in recovery from trauma(Larsen & Berenbaum, 2015). Participants
completed questionnaires measuring emotion
regulation, meaning making, distress and posttraumatic growth (PTG). Emotional processing
had a significant indirect positive effect on PTG
through its effect on meaning making. Emotion
suppression positively predicted distress, but
not PTG. Meaning making negatively predicteddistress and positively predicted PTG.
Another study of PTSS was conducted todetermine if participating in trauma-focusedContinued on page 6
Joining Forces/Joining Families • 5

Intimate Partner Violence
and Trauma: Research of L.
Kevin Hamberger and Sadie
E. Larsen, from page 5

There is concern in
Veterans Affairs (VA)
about young returning
veterans who do notseek care, particularly
mental health care, anda need to understandthe differences in those
who seek care andthose who do not.

therapy (prolonged exposure, cognitive
processing therapy (CPT), and CPT withouta written trauma narrative) would exacerbate symptoms or increase drop out (Larsen,
Wiltsey-Stirman, Smith, & Resick, 2016). Whilea small minority of participants experienced
symptom exacerbation (depending on the typeof trauma-focused therapy), they experienced
clinically significant improvements by the endof therapy. The authors concluded that thesetreatments are safe and effective even for those
who experience temporary symptom increases.
There is concern in Veterans Affairs (VA)
about young returning veterans who do notseek care, particularly mental health care, anda need to understand the differences in those
who seek care and those who do not (Averill,
Eubanks Fleming, Holens, & Larsen, 2015). In
this review paper, they report that both groups
have high rates of screening positive for PTSD
and younger veterans fear stigma related tomental health treatment. They recommended
that research needs to study relationship status
and expressed concerns about veterans ofsexual minority status (lesbian, gay, bisexual,and transgender) as subjects of trauma. Further
study of PTSD on these issues will greatly
enhance services for veterans.
The research of Drs. Hamberger and Larsen
has greatly enriched the understanding of current topics facing victims of trauma, whether
related to IPV or are militarily-related.

References

Allen, N. E., Larsen, S. E., Javdani, S., & Lehrner,
A. L. (2012). Council-based approaches to reforming the health care response to domestic
violence: promising findings and cautionary
tales. American Journal of Community Psychology, 50(1-2), 50–63. doi: 10.1007/s10464011-9471-9
Ambuel, B., Hamberger, L. K., Guse, C. E.,
Melzer-Lange, M., Phelan, M. B., & Kistner, A.
(2013). Healthcare Can Change from Within:
Sustained improvement in the healthcare response to intimate partner violence. Journal of
Family Violence, 28(8), 833–847. doi: 10.1007/
s10896-013-9550-9
Averill, L. A., Eubanks Fleming, C. J., Holens, P.
L., & Larsen, S. E. (2015). Research on PTSD
prevalence in OEF/OIF Veterans: expanding
investigation of demographic variables. European Journal of Psychotraumatology, 6, 27322.
doi: 10.3402/ejpt.v6.27322
Beyer, K. M., Wallis, A. B., & Hamberger, L.
6 • Joining Forces/Joining Families

K. (2015). Neighborhood environment andintimate partner violence: a systematic review.
Trauma Violence Abuse, 16(1), 16–47. doi:
10.1177/1524838013515758
Hamberger, L. K. (2005). Men’s and women’s useof intimate partner violence in clinical samples:
Toward a gender-sensitive analysis. Violence
and Victims, 20(2), 131–151.
Hamberger, L. K., Ambuel, B., Guse, C. E., Phelan,
M. B., Melzer-Lange, M., & Kistner, A. (2014).
Effects of a systems change model to respondto patients experiencing partner violence inprimary care medical settings. Journal of Family
Violence, 29(6), 581–594. doi: 10.1007/s10896014-9616-3
Hamberger, L. K., Guse, C. E., Patel, D., & Griffin, E. (2010). Increasing physician inquiry
for intimate partner violence in a family
medicine setting: Placing a screening prompt
on the patient record. Journal of Aggression,
Maltreatment & Trauma, 19(8), 839–852. doi:
10.1080/10926771.2010.522950
Hamberger, L. K., & Larsen, S. E. (2015). Men’sand women’s experience of intimate partner
violence: A review of ten years of comparative
studies in clinical samples; Part I. Journal of
Family Violence, 30(6), 699–717. doi: 10.1007/
s10896-015-9732-8
Hamberger, L. K., Rhodes, K., & Brown, J. (2015).
Screening and intervention for intimate partner
violence in healthcare settings: creating sustainable system-level programs. Journal of Womens
Health (Larchmt), 24(1), 86–91. doi: 10.1089/
jwh.2014.4861
Klevans, J., Kee, R., Triack, W., Garcia, D., Angulo,
F. R., Jones, R., & Sadowski, L. S. (2012). Effectof screening for partner violence on women’squality of life. Journal of the American Medical
Association, 308(7), 681–689.
Larsen, S. E., & Berenbaum, H. (2014). The effect ofparticipating in a trauma- and stressful eventfocused study. Journal of Clinical Psychology,
70(4), 333–340. doi: 10.1002/jclp.22029
Larsen, S. E., & Berenbaum, H. (2015). Are specificemotion regulation strategies differentiallyassociated with posttraumatic growth? Journalof Aggression, Maltreatment & Trauma, 24,
794–808.
Larsen, S. E., & Hamberger, L. K. (2015). Men’s andwomen’s experience of IPV Part II: A review of
new developments in comparative studies inclinical populations. Journal of Family Violence,30(8), 1007–1030. doi: 10.1007/s10896-0159730-x
Continued on page 10
Spring 2016

BUILDING BRIDGES TO RESEARCH

Meta-Analysis Used to Investigate PTSD
Diagnostic Criteria
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD
Meta-analysis is astatistical procedure forobtaining an estimateof a treatment effectbased on combining
the results from many
independent studies.

When many studies are
statistically combined inmeta-analysis, significant
effects can be foundthat were previously notdetected in individual
studies.

http://www.CSTSonline.org

Meta-analysis in clinical research, is a statistical procedure for obtaining an estimate of atreatment effect based on combining the resultsfrom many independent studies. It is part ofdeveloping clinical procedures due to its ability
to analyze results from multiple and sometimes conflicting studies (Haidich, 2010). As
described by Haidich, it is a statistical method
for analysis.
Research evidence becomes stronger as inascending a pyramid. The lowest level is animaland laboratory studies. (Some might say thatthe single observation or anecdote is the lowest
level of eviadence.) However, ascending Haidich’s hierarchy, the following levels of strengthof evidence are case reports, case-control
studies, cohort studies, randomized controlled
trials, systematic review, and, at the top, metaanalysis.
Meta-analysis begins with a literaturesearch to identify applicable studies. Studies
that are selected have important characteristics
such as the avoidance of inclusion or exclusion
biases, strong statistical methodology, including outcomes such as odds ratios and meandifference estimation. Haidich concludes thatmeta-analysis has been extremely useful in developing evidence-based medicine, but it is not
foolproof. Some results have been contradictedby later studies and by other meta-analyses
and no single study will provide all the answers
for understanding risk factors, the response totreatment, or other factors affecting disease.
Many studies have been done to attempt
to answer questions about clinical procedures.
There may many good studies, but with varying and sometimes conflicting results. They
may have different study populations, different
methodologies, different measures, and different outcomes. Some studies may not even finda statistically significant effect. However, whenmany studies are statistically combined inmeta-analysis, significant effects can be foundthat were previously not detected in individual
studies. Meta-analysis is a systematic review
of research studies whose goal is to produce asingle estimate of the procedure under study.
As a result of its power, it is part of developing

clinical procedures due to its ability to analyze
results from multiple and sometimes conflicting
studies (Haidich, 2010).
Dr. Larsen used meta-analysis in her review
of 22 studies in which two types of traumas
were defined for posttraumatic stress symptoms(PTSS), traumas that were DSM-congruent andthose that were incongruent (Larsen & Pacella,2016). A congruent trauma is one that fits thedefinition for PTSD (American Psychiatric
Association, 2013). It is a trauma event that isextreme and involves actual or threatened deathor serious injury (e.g., combat) and a negative
emotional response such as fear or horror. An
incongruent trauma is less restrictive than the
DSM criteria for PTSD. Incongruent traumas
include events that might better be describedas stressors (e.g., divorce). The purpose of her
review and meta-analysis was to determine
whether PTSS differed in studies of events
satisfying the DSM criteria (DSM-congruent)
to other studies involving an event that was
DSM-incongruent to determine whether PTSS
differed in studies using these two different
criteria.
As a result of her analysis, she found a small,but statistically significant difference between
the congruent and incongruent traumas suchthat there were higher PTSS symptoms for
persons with PTSD-congruent trauma thanincongruent trauma. The stressors in PTSD arecomplex. She suggested that while the DSM
criteria for PTSD generally capture events leading to higher levels of PTSS. Her use of metaanalysis allowed her to find significant differences between these two types of responses totraumatic events.

References

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Arlington, VA: American Psychiatric Association.
Haidich, A. B. (2010). Meta-analysis in medical
research. Hippokratia, 14(Suppl 1), 29–37.

Continued on page 10

Joining Forces/Joining Families • 7

An interview with L. Kevin
Hamberger and Sadie
Larsen, from page 3

Is the intervention fromthe research protocol
resulting in less violence
for both groups or is it
the effectiveness of thescreening and clinicbased intervention
relative to usual care?

erating here that has to be sorted out. Whether
they are in the intervention group or in thecontrol condition, if somebody reports new violence the research protocols call for providing
a brief intervention right then and there. Thismight consist of some emotional support, giving them some community resource information and safety information. Essentially what
happens is that people in both the intervention
condition and in the control condition end up
getting an intervention and so the intervention
effects are hard to tease out.
Is the intervention from the research
protocol resulting in less violence for bothgroups or is it the effectiveness of the screening
and clinic-based intervention relative to usual
care? We really cannot say at this point. The
research protocol calls for brief intervention
in the event of reports of new violence overtime for women in both groups. We also think
there is at least one other possible and plausible explanation for the failure of the study toshow group differences in violence reduction.
Participants in both groups were interviewed
up to 5 times over the 18-month follow-up,
during which time participants were asked
about changes in violence, new violence, use of
a number of specific safety behaviors, as wellas the brief intervention noted previously inthe event of report of new violence. We believethat the heavy exposure to questions of safety
behaviors constituted an inadvertent, unintentional intervention to which all participants
were exposed. This suspicion was supported byresponses provided in the post-participationinterview. Several women, including some inthe usual care group, noted that the repeatedquestions about safety, as well as questions
about violence, led them to to think about theirpersonal life circumstances and to make somechanges accordingly.
We addressed this finding by calling for
further study of the impact of actual research
processes on participants. For example, regularstudy follow-up with questions about violence
may be experienced as a positive intervention by research participants, even those in acontrol condition. We want to develop different ways to conduct follow-up to reduce thelikelihood of confounding the method with theintervention.
Dr. McCarroll: What is your thinking about
universal screening? Some have argued
against universal screening in favor of case8 • Joining Forces/Joining Families

finding (Klevans et al., 2012; MacMillan et al.,2009; Wathen & MacMillan, 2012) .
Dr. Hamberger: I am for universal screening. I do not think that research argues strongly
against that. I am not aware of any good, solid
research that shows that we can identify specificrisk factors that are highly sensitive and appropriately specific to domestic violence andthat, if we see those, we are going to get all of
the domestic violence. However, I am a fan ofcase finding as well. It is a combination. It isappropriate during annual visits to ask our patients about intimate partner violence. If in theongoing care of any given patient certain factors
stand out, like depression, anxiety, difficulty
sleeping, stress, then it is appropriate to explorethat with questions about intimate partner violence. To me, it is a both and issue, not an either
or issue.
Dr. McCarroll: What do you think are the mostsignificant barriers to having a good outcome
for abused women?
Dr. Larsen: If there is not training and somewhere to refer people after screening, it makes
people reluctant to do the screening. That canbe one of the barriers, but as we see more integration, it becomes easier to follow-up on thesekind of concerns. This fits with the move toward
more integrated health care in which behavioral
health is much more a part of the primary care
team.
Dr. McCarroll: What should treatment be for
perpetrators and victims?
Dr. Hamberger: Treatment of perpetrators ismorphing and evolving. Anger management has
not been traditionally viewed as an appropriate
treatment for batterers. The argument goes thatbattering is something more than anger. It may
be a problem of power and control in whichanger is often used as a tool to accomplish that.
It is not that a perpetrator is necessarily not incontrol of their anger. That is the traditional
argument against anger management. However,the data show that men who batter tend tohave more anger expression problems as well as
hostility problems than men who do not batter.
Not to address some aspect of anger seems tomiss the boat, but it may not be the whole package. We are also becoming increasingly sensitive to the idea that many men who batter werethemselves abused as children. They grew up inviolent households and they carry the legacy ofContinued on page 9

Spring 2016

An interview with L. Kevin
Hamberger and Sadie
Larsen, from page 8

Mutual abuse is notnecessarily mutual.
Violence may be usedby men and women andyet it might not mean thesame thing. “What does
this violence do or mean
to the people involved?”

trauma with them into their adulthood. That
has been largely ignored in batterer treatment
until very recently. People are now starting tothink about how to address the trauma issues
as part of their overall treatment package.
There are still strong elements of accountability. The person who is violent is responsible,
but we need to look at some other aspects ofthese people’s lives and help them deal withsome of the pain that they have been carrying
with them as well as helping them to stop their
violence.
Dr. McCarroll: That makes great sense. Is
there anything new or different in victim
treatment?
Dr. Larsen: It tends to be pretty variable.
You have to meet the person where they are,depending on whether they are wanting toleave the relationship or not. It might involvesafety planning, it might involve motivational
interviewing, and it might involve trauma-focused treatment, so it depends on the individual situation. There is some thinking about
adapting batterer treatments for women andwhat that should look like, which is not all thatclear.
Dr. McCarroll: What should treatment look
like for women who are batterers or who findthemselves in batterer treatment programs?
Should it be the same as men in batterer
treatment programs or does there need to
be an adaptation of the program for women
specifically?
Dr. Larsen: It should look a little bit different although there is a subset of women
who probably use violence in similar ways as
men do. For some women, traditional batterer
treatment might be appropriate and for other
women it might not be. For instance, if their
violence is mainly in response to violence ordefensive violence, treatment might need tolook different.
Dr. McCarroll: There is more in the literature
now about emotional abuse as something that
affects health and well-being.
Dr. Hamberger: We see an interaction between emotional and physical abuse every day
in clinical practice. Victims routinely tell methat even though their partner ended his physical violence, his continued emotional abuse isjust as, or even more damaging, psychologically, than the physical violence. In relationships
where the physical violence has ended, ongoing

http://www.CSTSonline.org

emotional abuse and violence assumes thefunction of controlling and stifling the victim’s
autonomy because the emotional violencealways suggests the possibility of renewedphysical violence, and also plays on the victim’s
vulnerabilities. Treatment must address ending both physical and emotional abuse andviolence.
McCarroll: Thank you both for your work andyour time.
Dr. Larsen: Thank you. It has been a pleasure.
Dr. Hamberger: A lot of fun.

References

Ambuel, B., Hamberger, L. K., Guse, C. E.,
Melzer-Lange, M., Phelan, M. B., & Kistner, A.
(2013). Healthcare Can Change from Within:
Sustained improvement in the healthcare
response to intimate partner violence. Journal of Family Violence, 28(8), 833–847. doi:
10.1007/s10896-013-9550-9.
Hamberger, L. K. (2005). Men’s and women’s
use of intimate partner violence in clinicalsamples: Toward a gender-sensitive analysis.
Violence and Victims, 20(2), 131–151.
Hamberger, L. K., & Larsen, S. E. (2015). Men’sand Women’s experience of intimate partner
violence: A review of ten years of comparative
studies in clinical samples; Part I. Journal of
Family Violence, 30(6), 699–717. doi: 10.1007/
s10896-015-9732-8
Klevans, J., Kee, R., Trick, W., Garcia, D., Angulo,
F. R., Jones, R., & Sadowski, L. S. (2012). Effectof screening for partner violence on women’squality of life. Journal of the American Medical Association, 308(7), 681–689.
Larsen, S. E., & Hamberger, L. K. (2015). Men’sand women’s experience of IPV Part II: A
review of new developments in comparative studies in clinical populations. Journalof Family Violence, 30(8), 1007–1030. doi:
10.1007/s10896-015-9730-x
MacMillan, H. L., Wathen, C. N., Jamieson, E.,
Boyle, M. H., Shannon, H. S., Ford-Gilboe, M.,. . . McNutt, L.-A. (2009). Screening for intimate partner violence in health care settings.
Journal of the American Medical Association,
302(5), 493–501.
Wathen, C. N., & MacMillan, H. L. (2012). Healthcare’s response to women exposed to partner
violence. Journal of the American Medical Association, 308(7), 712–713.

Joining Forces/Joining Families • 9

Screening for Intimate Partner Violence and the
Recommendations of the U.S. Preventive Services
Task Force
There are screening
instruments that
can identify current
and past abuse or
increased risk forabuse as well asinterventions suchas counseling, home
visits, information
cards, referrals tocommunity services,and mentoring
support.

Intimate Partner Violence
and Trauma: Research of L.
Kevin Hamberger and Sadie
E. Larsen, from page 6

By James E. McCarroll, PhD
In January 2013, the U.S. Preventive Services Task Force (USPSTF) recommended thatclinicians screen women of childbearing age(14-46) for intimate partner violence (IPV) andprovide or refer women who screen positive tointervention services (Moyer, 2013). (See Websites of Interest for more information on the
USPSTF.) This recommendation was given a
B Grade indicating that the Task Force recommends the service.
The task force reported that there are available screening instruments that can identify
current and past abuse or increased risk forabuse as well as interventions such as counseling, home visits, information cards, referrals tocommunity services, and mentoring support(Moyer, 2013). Counseling usually provides
information on safety and community resources. Home visits, in addition to providing
counseling, may include emotional support,
education on problem-solving strategies, andparenting support. The Task Force found no
direct evidence about harm from screening,although they did note some potential harms:
shame, guilt, self-blame, fear of retaliation or
abandonment by perpetrators, and repercussion of false-positive reports.
In addition to clinicians in primary careand specialty clinics, screening can also identify
women victims of IPV through screening
in other health care setting such as pediatricclinics (Dubowitz, Prescott, Feigelman, Lane, &Kim, 2008). A screening instrument for parents
bringing in children less than 6 years old forchild health supervision, found that 12% of
mothers answered at least one of the screening
questions positively. Following a positive screen,a social worker would express empathy, attempt
to clarify the situation, and discuss options suchas a safety plan, crisis intervention, and information on a hotline and shelter. Risks to thechild were assessed as well as the need to reportto child protective services.
The Task Force recognized that further research is needed. Among these are further studyof post-screening interventions, computerized
screening and intervention, legal requirements,
underlying medical conditions, and dependence
on perpetrators. There was a lack of evidence
on screening men for IPV as well as for womenover childbearing age.

Larsen, S. E., & Pacella, M. L. (2016). Comparing the effect of DSM-congruent traumas
vs. DSM-incongruent stressors on PTSD
symptoms: A meta-analytic review. Journal ofAnxiety Disorders, 38, 37–46. doi: 10.1016/j.
janxdis.2016.01.001… McNutt, L.-A. (2009). Screening for intimate partner violence in health care settings.
Journal of the American Medical Association,
302(5), 493–501.

Larsen, S. E., Wiltsey-Stirman, S., Smith, B. N., &Resick, P. A. (2016). Symptom exacerbations
in trauma-focused treatments: Associations
with treatment outcome and non-completion.
Behavior Research and Therapy, 77, 68-77. doi:
10.1016/j.brat.2015.12.009
MacMillan, H. L., Wathen, C. N., Jamieson, E.,
Boyle, M. H., Shannon, H. S., Ford-Gilboe, M.,

10 • Joining Forces/Joining Families

References

Dubowitz, H., Prescott, L., Feigelman, S., Lane,
W., & Kim, J. (2008). Screening for intimate
partner violence in a pediatric primary careclinic. Pediatrics, 121(1), e85-91. doi: 10.1542/
peds.2007-0904
Moyer, V. A. (2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task ForceRecommendation Statement USPSTF. Annals
of Internal Medicine, 158(6), 478–487.

Meta-Analysis Used to Investigate PTSD
Diagnostic Criteria, from p. 7
Larsen, S. E., & Pacella, M. L. (2016). Comparing the effect of DSM-congruent traumas vs.
DSM-incongruent stressors on PTSD symptoms: A meta-analytic review. J Anxiety Disord,38, 37–46. doi: 10.1016/j.janxdis.2016.01.001

Spring 2016

Influence of Child Maltreatment on Genes Related to
Health Outcomes
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, and Robert J. Ursano, MD

Epigenetics is thestudy of changes inorganisms caused bymodification of theexpressions of genes
rather than changes in
the genes themselves.

Since the landmark studies on the effects
of adverse childhood experiences (ACEs) on
health (Felitti et al., 1998), much more researchhas been conducted. As this area of research
has rapidly developed, studies of epigenetics
have looked at mechanisms that might be associated with the development of mental healthsymptoms and disease outcomes following
childhood maltreatment.
What is epigenetics? It is the study ofchanges in organisms caused by modificationof the expressions of genes rather than changes
in the genes themselves. Genes are segments of
DNA inherited from parents and are the basisof inherited characteristics. Gene expression is
the mechanism by which genes interact withthe environment and other factors to produce
the observable behavioral and biological outcomes characteristic of an individual. (Theseobservable changes are called the phenotype.)
Epigenetic mechanisms switch genes on or off(gene expression) through biochemical processes. Epigenetic changes and the outcomesof these changes are complex and influenced
by many environmental and biological factors. Environmental factors include stress,
brain function, and behavior. Social adversity,
particularly through parent-offspring interaction, is thought to alter a wide variety of genes
which regulate the stress response.
A study of epigenetic mechanisms of
disease risk in maltreated and non-maltreatedfound that maltreated children may be at higher risk for health problems in later life (Yanget al., 2013). Ninety-six abused or neglectedchildren who had been removed from theirparents were compared with 96 demographically matched children. There was an average of
17% differences in epigenetic modifications between the maltreated children and the controls.
These genes were associated with a wide varietyof biological processes related to diseases,
including cancer, were identified. The authors
concluded that epigenetic mechanisms in maltreated children may be involved in conferringrisk for many adult health problems. Thus, childmaltreatment is a preventable risk factor for
numerous adult health problems.
There are many limitations to epigenetic
research in its current state. Not everyone
who has been maltreated is affected and many
hypotheses remain to be tested. Regardless ofthe challenges, among the goals of this researchis to improve treatment, particularly for thosewith ACEs. Further research will help to identify those most at risk, optimal prevention andintervention strategies for maltreated children,
and ways to reverse epigenetic changes resulting
from early maltreatment.

References

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J.
S. (1998). Relationship of childhood abuse andhousehold dysfunction to many of the leading
causes of death in adults. Am J Prev Med, 14(4),245–258.
Yang, B. Z., Zhang, H., Ge, W., Weder, N., DouglasPalumberi, H., Perepletchikova, F., …Kaufman,
J. (2013). Child abuse and epigenetic mechanisms of disease risk. Am J Prev Med, 44(2),101-107. doi: 10.1016/j.amepre.2012.10.012

Gene expression is the mechanism by which genes interact with theenvironment and other factors to produce the observable behavioral andbiological outcomes characteristic of an individual. (These observablechanges are called the phenotype.)

http://www.CSTSonline.org

Joining Forces/Joining Families • 11

Websites of Interest
Created in 1984, the U.S. Preventive Services Task Force(USPSTF) is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task
Force makes evidence-based recommendations about clinical preventive services such as screenings, counseling, andpreventive medications. All recommendations are publishedon the Task Force’s website and some are also published ina peer-reviewed journal. Their website provides extensive
documentation of screening tests, interventions, suggestions
for practice, resources, research needs and gaps, and references.
The USPSTF assigns one of five letter grades (A, B, C, D,or I) to its recommendations. The grade is accompanied bya definition and suggestions for practice. A and B grades arerecommended. C, D, and I are either not recommended orrecommended with caveats.
As noted in the article on screening in this issue of JFJF,
the USPSTF recommended that clinicians screen women ofchildbearing age for intimate partner violence and provide
or refer women who screen positive to intervention services.
In January 2016, the Task Force recommended depression
screening in adults for the general population and for major
depressive disorder in adolescents ages 12–18.
The Task Force currently has recommendations on 96
preventive health services. Grade recommendations are
given for each. In many cases, there is more than one recommendations in which services are recommended for one
group and not for another. For example, for Alcohol Misuse:
Screening and Behavioral Counseling Interventions in Primary Care is recommended for adults, but not for persons
under age 18. Some recommendations are classified as Inactive, often because evidence may not be current. The website
also includes information about services currently being
evaluated by the USPSTF. Much additional information canbe found on the webpage such as announcements on new
topics, public comments, new staff members, final researchplans and final recommendations. This information can inform the clinical practices of healthcare personnel as well as
provide general information for healthcare decision-making.

12 • Joining Forces/Joining Families

Website References
The Home Page of the USPSTF:

http://www.uspreventiveservicestaskforce.org/
A, B, C, D and I Grade Definitions:
http://www.uspreventiveservicestaskforce.org/Page/
Name/grade-definitions
All USPSTF Recommendations:
http://www.uspreventiveservicestaskforce.org/
BrowseRec/Index
Recommendations for Intimate Partner Violence
Screening:
http://www.uspreventiveservicestaskforce.org/Page/
Document/UpdateSummaryFinal/intimate-partnerviolence-and-abuse-of-elderly-and-vulnerable-adultsscreening
Recommendations for Depression Screening:
http://www.uspreventiveservicestaskforce.org/
BrowseRec/Search?s=depression
Recommendations for Aspirin to Prevent 		
Cardiovascular Disease and Cancer:
http://www.uspreventiveservicestaskforce.org/Announcements/News/Item/final-recommendationstatement-aspirin-use-for-the-primary-prevention-ofcardiovascular-disease-and-colorectal-cancer
Announcements on Topics and Information about 		the USPSTF:
http://www.uspreventiveservicestaskforce.org/Announcements/News/Index/announcements

Spring 2016