Joining Forces

Joining Families

Volume 10, Issue 4 • September 2008

R e a l W o r l d R e s e a r c h f o r F a m i l y  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

Domestic Violence and Alcohol Misuse
An Interview with Christopher Murphy, PhD, by James E. McCarroll, PhD
Christopher Murphy, PhD

Christopher Murphy, PhD, is Professor of
Psychology at the University of Maryland, Baltimore County. He also directs the New Behaviors
Program at the Domestic Violence Center ofHoward County, Maryland. This Center consistsof comprehensive clinical training, service, andIn This Issue
Recently the media has drawn attention to serious family violence episodes
in our military community. Alcohol is a contributor to family violence. This issueof Joining Forces Joining Families (JFJF) focuses on the relationship between
domestic violence and alcohol use. Our interview is with Chris Murphy, PhD,of the University of Maryland Baltimore County. Dr. Murphy shares his insights
into violence and alcohol based on his experience in coordinating a community counseling program for domestic violence offenders. Other articles in thisissue are related to themes discussed by Dr. Murphy including a review of thestages of change model and a brief discussion of motivational interviewing.
Both concepts are commonly used in addiction and violence interventions andare widely applicable to changing maladaptive behaviors. We continue our
focus on violence and neuroscience with a review of a study relating the geneenvironment interaction to child abuse and adult PTSD. Our regular statistics
article presents a brief discussion of meta-analysis, a technique often used in
the behavioral sciences to estimate the effect of an intervention across a wide
range of studies investigating the same outcome.
Contents
Domestic Violence and Alcohol Misuse............................................................1
Alcohol and Interpersonal Violence..................................................................3
How People Change........................................................................................4
Building Bridges to Research: Meta-Analysis..................................................5
Child Abuse and Adult Posttraumatic Stress Symptoms: A Gene byEnvironment Interaction..................................................................................6
CSTS Website Updated...................................................................................6
Website of Interest..........................................................................................8

research programs focusing on perpetrators of
intimate partner violence. Dr. Murphy’s research
focuses on cognitive-behavioral and motivational
interventions for abusive behavior in intimate
adult relationships, factors that predict successful response to partner violence treatment,
emotional abuse in relationships, and the links
between intimate partner violence and the use ofalcohol and drugs. His work has been supported
by grants from the National Institute of Mental
Health and the National Institute on Alcohol
Abuse and Alcoholism. Dr. Murphy has authoredmore than 50 articles and book chapters on the
topic of intimate partner violence.
Dr. McCarroll: Please tell us about your centerfor domestic violence counseling and yourresearch on the relationship between domestic
violence and alcohol use.
Dr. Murphy: I have an appointment at the
University of Maryland, Baltimore County(UMBC) and I also help coordinate a community-based counseling program for domestic
violence offenders in Howard County, Maryland. About 80 to 100 abusive individuals comethrough our counseling program each year. My
clinical work has been mainly in domestic violence treatment. I also collaborate with people
in the VA system whose primary expertise is in
substance abuse.
Dr. McCarroll: People can be referred fortreatment for violence or for alcohol abuse.
How well does each program screen for theother problem and how well do they work
together?
Dr. Murphy: Surveys in both of those areas
have shown that there is tremendous variation
Continued on page 2

Stable remission ofdrinking is a major
protective factor against
further domestic abuse.

in the extent to which each program assesses
for the other problem. There are some theories that help to explain why this is the case.
In domestic violence, it has traditionally beenthought that substance use is viewed as an
excuse rather than a contributing factor andcertainly not a cause of violence. Because ofthat, some domestic violence programs haverejected the idea that they can do much about
the substance abuse or they have said that substance abuse is not something that they handle
in their program.
In the substance abuse field, there is a traditional belief that once the addiction is cured,
all other aspects of one’s life will start gettingback on track.
Dr. McCarroll: How would you advise aclinician working in the domestic violence
field to assess for the involvement of alcohol
misuse or abuse in domestic violence?
Dr. Murphy: There are several methods
that are very helpful. One is to use a generalscreening tool such as the AUDIT (Alcohol
Use Disorders Identification Test).1 [Editor’snote: The CAGE is also used for screening
for problem drinking.2] Although the AUDIT

Joining Forces
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email: jmccarroll@usuhs.mil
EditorJohn H. Newby, MSW, PhD
Email: jnewby@usuhs.mil
Joining Forces Joining Families
is a publication of the U. S.
Army Family Morale, Welfare
and Recreation Commandand the Family Violence andTrauma Project of the Centerfor the Study of TraumaticStress (CSTS), Bethesda,
Maryland 20814-4799, tel.
301-295-2470. CSTS is a partof the Dept. of Psychiatry,
USUHS, and a partnering
center of the Defense Centersof Excellence (DCoE).

2 • Joining Forces/Joining Families

Editorial Advisor
LTC Ben Clark, Sr., MSW, PhD
Family Advocacy Program Manager
Headquarters, Department of theArmy
E-mail: Ben.Clark@fmwrc.army.mil
Editorial Consultants
David M. Benedek, MD, LTC, MC, USA
Associate Professor and Scientist
Center for the Study of Traumatic Stress
Uniformed Services University of the
Health Sciences
dbenedek@usuhs.mil
Nancy T. Vineburgh, MA
Director, Office of Public Education
and Preparedness
Center for the Study of Traumatic Stress
Email: nvineburgh@usuhs.mil

detects early signs of alcohol dependence, wehave found that it misses a lot of people who
were intoxicated at the time of an abuse incident. The approach I take is to go over details ofconflicts where there has been abuse and ask the
person whether they had had anything to drinkor were using any drugs at that time. We also
ask how often they drink and how much they
typically drink on weekdays and weekends toscreen for unhealthy levels of alcohol consumption.
Dr. McCarroll: If you find somebody who hasa high level of drinking, but they were notdrinking during the incident, what do you dowith that information?
Dr. Murphy: It is still valuable for them tohave some type of intervention for a coupleof reasons. First, they might be doing damage
to themselves or others through that level ofdrinking. Second, their drinking may interferewith their getting benefits from domestic violence counseling.
Dr. McCarroll: Is the person who drinks
moderately more likely to be involved indomestic violence than one who does notdrink?
Dr. Murphy: There is no good evidence tothat effect. It is binge drinking and chronicallyhigh levels of alcohol consumption that are associated with domestic violence. There are twodifferent patterns of drinking among those withserious alcoholism: stable and unstable drinking. Unstable drinking applies to people withserious alcohol problems who do not drink thesame amount every day, or may not drink every
day, but who drink quite excessively at times.
They also tend to drink outside the home.
Stable alcoholic individuals tend to drink athome, every day, in roughly the same amount.
We have found that domestic violence is morecommon among those with unstable drinking
patterns.
In our studies of persons with severe alcohol
problems we have found that if they are able toachieve stable recovery or remission from theirproblem drinking, their domestic violence rates
substantially decline and their level of risk looks
fairly similar to demographically matched people in the population who do not have alcohol
problems. This suggests that stable remissionof drinking is a major protective factor against
further domestic abuse.
Continued on p. 7
September 2008

Alcohol and Interpersonal Violence

In a study of partnerviolent and nonviolent
alcoholic men, thepartner-violent
alcoholic men had
more antisocial
personality traits,
greater alcohol problem
severity, greateruse of other drugs,
higher relationshipdistress, andstronger beliefs in therelationship between
alcohol drinking andrelationship problems.

http://www.CSTSonline.org

By James E. McCarroll, PhD
intervention that emphasizes sobriety, teaches
The research of Dr. Murphy and colleagues
communication skills, and increases positive
has focused on the relationship of alcohol con- activities has strong research support in imsumption to interpersonal violence (IPV). The
proving relationships and decreasing domestic
studies reviewed here examine many of theviolence (O’Farrell, Murphy, Stephan, Falsrisk factors associated with
Stewart, & Murphy, 2003).
IPV and alcohol misuse.
In a study of partnerReferences
Alcoholics in remission had
Chase KA, O’Farrell TJ,
violent and nonviolent
about the same prevalence
Murphy CM, Fals-Stewart
alcoholic men, the partW, & Murphy M. (2003).
of violence (15%) as thener-violent alcoholic
Factors associated withmen had more antisocial
non-alcoholic comparison
partner violence among fepersonality traits, greater
male alcoholic patients andsample.
alcohol problem severtheir male partners. J. Stud.
ity, greater use of other
Alcohol, 64:137–149.
drugs, higher relationshipdistress, and stronger beliefs in the relationMurphy, C. M., O’Farrell, T. J., Fals-Stewart, W.,ship between alcohol drinking and relationship& Feehan, M. (2001). Correlates of intimate
partner violence among male alcoholic
problems. Relationship distress and alcohol
patients. Journal of Consulting and Clinicalproblem severity were independently associPsychology, 69, 528–540.
ated with partner violence (Murphy, O’Farrell,
Fals-Stewart, & Feehan, 2001). The number ofMurphy CM, Winters J, O’Farrell TJ, Fals-Stewart
drinks consumed by the alcoholic husband in
W, & Murphy M. (2005). Alcohol consumpthe 12 hours prior to a physical assault incition and intimate partner violence by alcoholdent was significantly higher prior to violent
ic men: Comparing violent and non-violent
compared to non-violent conflicts (Murphy,
conflicts. Psychology of Addictive Behaviors,
Winters, O’Farrell, Fals-Stewart, & Murphy,
19:35–42.
2005).
O’Farrell TJ, Fals-Stewart W, Murphy M, & MurIn another study, rates of domestic viophy CM. (2003). Partner violence before andlence by alcoholic men were compared before
after individually based alcoholism treatment
and after alcohol treatment. In the year before
for male alcoholic patients. Journal of Consulttreatment, 56% of the alcoholic men had been
ing and Clinical Psychology, 71:92–102.
violent toward their female partner (O’Farrell,O’Farrell TJ, Murphy CM, Stephan SH, FalsFals-Stewart, Murphy, & Murphy, 2003). After
Stewart W, & Murphy M. (2004). Partner viotreatment, partner violence in the alcoholic
lence before and after couples-based alcoholsample decreased to 25%, but remained higher
ism treatment for male alcoholic patients: The
than the comparison group (14%). Among alrole of treatment involvement and abstinence.
coholics whose alcoholism remained in remisJournal of Consulting and Clinical Psychology,
sion, the prevalence of violence was reduced to
72:202–217.
a level (15%) that was nearly identical with the
non-alcoholic comparison sample.
Greater drinking by wives prior to violent
For additional reading on alcohol andconflicts has also been observed. Women indomestic violence in the Army, see:
addiction treatment programs reported a highBell NS, Hartford T, McCarroll JE, & Senier L.
level of both victimization and perpetration(2004). Drinking and spouse abuse amongof violence. They committed more violent acts
U.S. Army soldiers. Alcoholism: Clinical andExperimental Research, 28:1890–7.
and were more likely to commit severely violent acts than the men in these couples (Chase,
Bell NS, Harford TC, Fuchs CH, McCarroll JE, &O’Farrell, Murphy, Steward, & Murphy, 2003).
Schwartz CE. (2006). Spouse abuse and alcoFinding successful treatment for substance
hol problems among white, African American,
abusers has also been a focus of the researchand Hispanic U.S. Army soldiers. Alcoholism:of Dr. Murphy and colleagues. Recent studies
Clinical and Experimental Research, 30:1721–
have found that behavioral couples therapy, an
1733.
Joining Forces/Joining Families • 3

How People Change
By James E. McCarroll, PhD

The stages ofchange model has
five components:
precontemplation,
contemplation,
preparation, action,and maintenance.

Dr. Murphy, in his interview in this issue
through ambivalence and commit to change.
of JFJF, noted the applicability of the stages of
The components of motivational interviewing
change model of Prochaska and DiClemente
are: (1) a focus on increasing motivation forto family violence and addiction counselingchange, and (2) consolidating commitment(Prochaska & DiClemente,(Miller & Rollnick, 2002).
1983; Prochaska, DiCleMotivational interviewing
The stages of change model ismente, & Norcross, 1992).
consists of a supportive
flexible. Most individuals do not
The purpose of theirand empathic counselingstudies was to understandstyle, a directive method
progress through the changes inand describe how people
for resolving ambivalence,a linear fashion, but in a spiral inintentionally change their
exploration of the clibehavior with and without
ent’s own arguments forwhich relapse occurs.
psychotherapy. The stages
change, and reflectiveof change model has fivelistening (Hettema, Steele,
components: precontemplation, contempla& Miller, 2005). A recent comprehensive review
tion, preparation, action, and maintenance.
of motivational interviewing and meta-analysis
The model has now become a classic wayof studies of MI concluded that the evidenceof conceptualizing how individuals initiatebase for MI is strong in the areas of addictionchanges in behavior.
and health behavior (Hettema, Steele, & Miller
The stages of change model is flexible and(2005). When used as a brief intervention
considers that most individuals do not progadded to other treatment approaches, MI apress through the changes in a linear fashion,
pears to improve outcomes, but its effectivenessbut in a spiral in which relapse occurs. The
is highly variable across providers, populations,spiral suggests that those who relapse do nottarget problems, and settings (Hettema, Steele,
revolve in endless circles, but learn from their& Miller, 2005).
mistakes as they progress. The stages represent
a time dimension that allows understanding of References
when shifts in attitudes and behaviors occur.
Hettema J, Steele J, & Miller WR. (2005). Motivational interviewing. Annual Review of ClinicalThe processes of change aspect of the model
Psychology, 1:91–111.
addresses how the changes occur. Ten examplesof types of intervention leading to change are
Miller WR. (1983). Motivational interviewing
given by the authors (Prochaska, DiClemente,with problem drinkers. Behavioural Psycho& Norcross, 1992). Among these are conscioustherapy, 11:147–172.
ness-raising, self-reevaluation, and helping
Miller WR & Rollnick S. (2002). MotivationalIrelationships. Importantly, for assessment andinterviewing: Preparing People for Change.
treatment of behaviors requiring change is the
New York: Guilford.
integration in their model of both the stages
Prochaska JO & DiClemente CC. (1983). Stages
and the processes of change. A practical impliand processes of self-change of smoking:cation of this approach is that prevention andtoward an integrative model of change.
treatment programs that address clients andJournal of Consulting and Clinical Psychology,
communities with only action-oriented pro51:390–395.
grams are likely to not appeal to people whoare not ready for the action stage of change.
Prochaska JO, DiClemente CC, & NorcrossSpecifically, the model requires that assessJC. (1992). In search of how people change.
ment address the stage of a client’s readinessAmerican Psychologist, 47:1102–1114.
for change and provide an intervention that isRogers CR. (1959). A theory of therapy, personalappropriate for that stage.
ity, and interpersonal relationship as develMotivational interviewing (MI) grew out
oped in the client-centered framework. Inof the style of non-directive therapy pioneered
Psychology: A Study of a Science, P Koch (Ed.),
by Carl Rogers (Rogers, 1959). Miller (1983)
3:184–256. New York: McGraw-Hill.
is credited with developing motivational
interviewing as a way to help people work

4 • Joining Forces/Joining Families

September 2008

Building Bridges to Research
Meta-Analysis
By James E. McCarroll, PhD, David M. Benedek, MD, and Robert J. Ursano, MD

Meta-analysis
is a statisticaltechnique that allows
investigators toanalyze the results ofa number of studies
at one time.

http://www.CSTSonline.org

Meta-analysis is a statistical technique thatallows investigators to analyze the results of anumber of studies at one time. It is frequently
used in social science research when many studies have been conducted on the same question
using the same or similar measures. Based on
the aggregation of data from the studies in theanalysis, the investigator may draw conclusions
about whether the phenomenon or intervention of interest has consistently shown the sameor similar results.
There are many different models for metaanalysis and many cautions on how to conduct
the analysis to avoid a misleading conclusion
due to biases in study selection and analytic
techniques (Egger, Smith, & Phillips, 1997).
Ideally, the research selects only studies withthe same objectives and outcome measures.
However, the selection of studies ultimately has
elements of subjectivity requiring the investigator to be aware of biases due to different aspectsof the studies selected for analysis. Critical formeta-analysis is that the outcome measures
have to be expressed in a standardized form topermit comparison across studies. Outcomescan be either continuous (such as degree ofchange on a measure) or dichotomous (characteristic present or absent). For estimates ofthe outcome in studies involving continuous
measures, the differences are measured in the
difference between the mean in the treatmentgroup and the controls or other comparisongroup. Sometimes these differences are also
expressed in units of standard deviation. Whenthe outcome is dichotomous, the odds ratio(or relative risk) is used as the measure of theoutcome result.
Another approach to meta-analysis was
suggested by Greenland (1998) who reviewed
meta analysis from the epidemiologic point ofview. He noted the approach that may be taken
when investigators have used non-experimental
data to make inferences about causes of theoutcomes investigated. Why does he stress themeta-analysis of non-experimental data? Thisis because in experimental research wherecontrols are applied to confounders and othersources of variability, causal relationships
between antecedent variables and outcomes ofinterest are more likely to be observed.

In Greenland’s summary of the meta-analysis of non-experimental data, there are two primary objectives: (1) to find an overall summary
effect (such as an average) across studies, and(2) to identify and estimate differences among
the variables in the analysis. The first is called
the synthetic approach and the second is called
the analytic approach. The synthetic approach
can be misleading or lead to wrong conclusions
if the investigator does not also pursue some
aspect of the analytic approach to determine
whether there is systematic variation acrossstudies. Finally, no meta-analysis can compensate for systematic error that affects all studies
in the analysis.
In synthetic studies, the major outcomesought is the effect size. Effect size is a generalterm in statistics that refers to the difference inoutcome between groups that have received anintervention compared to those who received
no intervention. For example, the difference inheight between adult men and women is readily visible and does not require measurement ina large population. This would be considered alarge effect size.
For pre-teen children, the difference between the height of boys and girls may not be
so obvious and the differences would constitute a small effect size. However, it is not the
only outcome that should be produced whenanalyzing quantitative data. At a minimum, theconfidence interval of the effect size is requiredin order to understand the meaning of the effect size observed.
Meta-analysis was used to examine whether
motivational interviewing (MI) was more effective than no intervention in reducing alcohol
consumption, and whether MI is as effective
as other interventions (Vasilaki, Hosier, & Cox,
2006). The data for their review consisted of
22 randomized trials of MI interventions. The
effect size observed was greater than 0.60, considered a moderate result (Cohen, 1988), when
the follow-up period was 3 months or less anddependent drinkers were excluded. When MI
was compared to studies in which anotherintervention was applied, the effect size was
0.43. Applying Greenland’s second requirement
for a meta-analytic review, the authors comContinued on p. 6
Joining Forces/Joining Families • 5Child Abuse and Adult Posttraumatic Stress Symptoms:
A Gene by Environment Interaction
By James E. McCarroll, PhD and David M. Benedek, MD

Research suggeststhat individuals with acertain genetic makeup
when subjected to earlychild abuse are more
likely to develop PTSS
as adults than persons
without this genetic
pattern.

JFJF strives to report new developmentsin the neuroscience of family maltreatment.
Here, we briefly summarize an article which
relates the interaction between a gene (FKBP5)
and the environment (child maltreatment) tothe development of adult posttraumatic stresssymptoms (PTSS) (Binder, Bradley, Liu, et al.,2008). Genes have many variations. In thisstudy, some forms (alleles) of the FKBP5 gene
were associated with adult PTSS symptoms
while other alleles of the gene appeared to beprotective against the development of PTSS.
Specifically, four types of the FKBP5 geneinteracted with the severity of abuse as a childto predict the level of adult PTSS symptoms.
This gene by environment interaction was significant after controlling for age, sex, levels of
non-child abuse trauma, genetic ancestry, anddepression (frequently found in combination
with PTSS). A hypothesized mechanism for

Meta-Analysis, from page 5

Although meta-analysis
is a powerful analytic
method, it is not
foolproof.

mented on qualitative aspects of their study.
They concluded that while brief MI is effective,
there are complex factors that could influence
its long-term outcome and that future researchshould concentrate on possible predictors suchas age, gender, employment status, marital
status, mental health, and other variables.
In conclusion, although meta-analysis is a
powerful analytic method, it is not foolproof.
The reader of a meta-analytic paper claiming
benefit of a treatment or other intervention
should pay attention to the methodology andespecially to whether the author has provided
qualitative data and commented on the limitations of the analysis.

this observed result was that certain variationsin the FKBP5 gene may alter sensitization of thestress-response pathway during development
and place individuals who have had significant child abuse at risk for PTSS. This study
involves complex genetic and neurochemicalmechanisms that are not well understood andrequires replication before the findings become
widely accepted. Nevertheless, it suggests that
individuals with a certain genetic makeup whensubjected to early child abuse are more likely todevelop PTSS as adults than persons without
this genetic pattern.

Reference
Binder EB, Bradley RG, Liu W, et al., (2008). Association of FKBP5 Polymorphisms and childhood abuse with risk of posttraumatic stressdisorder symptoms in adults. Journal of theAmerican Medical Association, 299:1291–1305.

References
Cohen J. (1988). Statistical Power in the Behavioral Sciences. Hillsdale, NJ: Erlbaum.
Egger M, Smith GD, & Phillips AN. (1997). MeatAnalysis: Principles and procedures. British
Medical Journal, 315:1533–1537.
Greenland S. (1998). Meta-analysis. In Modern
Epidemiology. KJ Rothman & S Greenland(Eds.). Philadelphia: Lippincott-Raven,
643–673.
Vasilaki EI, Hosier SG, & Cox WM. (2006). The
efficacy of motivational interviewing as abrief intervention for excessive drinking: A
meta-analytic review. Alcohol & Alcoholism,
41:328–335.

CSTS Website Updated
The website of the Center for the Study of Traumatic Stress (CSTS) has
been redesigned and reorganized. Three bars on the left-hand side of the site
provide navigation to all aspects of the site. About Us, Trauma and Disaster,and About You now serve as a gateway to the comprehensive information on
the site. A search function has been added to make finding resources faster andmore efficient. We’ve even shortened our URL to CSTSonline.org. Please visit,
check it out, and send comments and suggestions to nvineburgh@usuhs.mil.

6 • Joining Forces/Joining Families

September 2008

Dr. Christopher Murphy Interview, from page 3

However, risks may still exist. One risk is the limited successof alcohol treatment. People with antisocial personalities andlonger histories of substance abuse tend to have poorer outcomes in addiction treatment. They might have continued riskfor partner violence because they are less likely to remit in theirsubstance abuse. It is also possible that even when they overcome their substance abuse they will continue to be controllingor abusive in their relationships due to generalized tendencies
toward anger and violence.
Dr. McCarroll: What are some differences between the
populations seen in domestic violence treatment and those inalcohol treatment?
Dr. Murphy: The vast majority of people in domestic violence treatment are court-mandated whereas alcohol programs
have tended to be primarily voluntary or have a mix of mandated and voluntary clients. In actual practice, a lot of people
in court for alcohol problems do not get referrals for domestic
violence even when there is evidence or testimony that they
have both problems.
However, when domestic violence offenders are referredto addiction treatment programs, those programs would notalways view the domestic violence client’s drinking problems
as warranting substance abuse services. For example, domestic
violence offenders may not have many negative consequencesof their substance abuse other than its negative effects on theirfamily relationships. Also, substance abuse programs do notnecessarily gather information from the relationship partner
about substance abuse and violence.
Dr. McCarroll: What are the goals of most substance abuseprograms?
Dr. Murphy: Abstinence is the goal for people with significant substance dependence disorders. Once they have a certain
level of alcohol problems, it is unlikely that they could drink in
a controlled fashion. There are also binge drinkers who come todomestic violence programs. They may get into trouble when
they binge drink, but not have symptoms of alcohol dependence. Non-abstinence might be a reasonable goal for thoseindividuals if they can regulate their drinking and have harmreduction as a goal.
Dr. McCarroll: Do you find common barriers to treatment inmost domestic violence offenders?
Dr. Murphy: The first barrier is blaming the partner for thedifficulties and problems and being very frustrated and angry
at the system that put them there. Clients feel like they havebeen railroaded or they did not get a chance to have their partof the story heard by the police or the courts. It is often very
hard for them to look at their own behavior.
Dr. McCarroll: Many states mandate lengthy domestic
violence treatment programs, six months and more. In the

http://www.CSTSonline.org

military, that option is limited by the frequency and lengthof deployments. What is the length of time necessary for aneffective treatment for violence and for alcohol abuse?
Dr. Murphy: In substance abuse, some brief interventions
have good outcomes, particularly motivational enhancement therapy where the goal is to stimulate the individual
to a self-directed change process. [See articles in this issue of
JFJF entitled How People Change for more on motivational
interviewing and the stages of change model.] In the domestic
violence field, we are still struggling to clearly identify effective interventions. There is a general clinical sense that we needto see people at least for a few months to try to understandtheir problems and to give them some skills to supplant their
abusive behavior. There is not much evidence to suggest that a
one-year program is better than a six-month program or that asix-month program is clearly better than a three or four-monthprogram.
Dr. McCarroll: What is the distinction between motivational
therapy and cognitive behavioral therapy?
Dr. Murphy: Motivational therapy is less directive thancognitive behavioral therapy. It uses more reflective listening and focuses on the issues of why someone would want tochange, the barriers to change, developing a plan for change,and stimulating movement through the stages of change. A
lot of the original motivational interviewing is based on theProshaska and DiClemente five stages of change.3 Motivational
interviewing emphasizes a self-directed change process.
Cognitive behavioral therapies tend to focus on the active
ingredients of change. Once someone is motivated to change,
they need to alter their thought processes and to learn new behaviors, for example strategies to handle relationship disagreements and conflicts more constructively.
We have studied motivational therapy as an early intervention for domestic violence offenders. A lot of clients are resistant when they show up for treatment and hostile toward thesystem and the treatment providers. We need a clinical strategy
to get them past that initial resistance and hostility in order toopen them up to some of the subsequent interventions that are
more cognitive and behavioral. You may have the best cognitive behavior therapy in the world, but people are not going tobenefit if they do not practice the listening and communication
skills taught in the treatment.
Dr. McCarroll: Can you use the stages of change model inboth the domestic violence and alcohol fields?
Dr. Murphy: Yes. It was originally developed in the addictions field. The model fits well for stopping smoking. It gets
more complicated when you apply it to domestic abuse because
you have another person involved in the relationship and acomplex set of behaviors that might involve control, emotional
abuse, physical assault, and other kinds of difficulties so it is
not as simple to conceptualize as smoking.
Continued on p. 8
Joining Forces/Joining Families • 7

Websites of Interest

There are many websites containing helpful information for practitioners on the prevention of alcohol misuse.
Preventive services are an important part of the Army
Family Advocacy Program (FAP). Prevention of alcohol
misuse can have a dramatic effect on rates of domestic
violence (See interview with Dr. Chris Murphy). The U.S.
Preventive Services Task Force (USPTF) in 2004 published recommendations for primary care interventions
for alcohol problems.1, 2 The USPTF found that important
outcomes can result from screening and behavioral counseling to reduce alcohol misuse by adults. 3■■ Screening in primary care settings can identify patients
whose levels or patterns of alcohol consumption do
not meet criteria for alcohol dependence, but do placethem at risk for increased morbidity and mortality.
■■ Brief behavioral counseling with follow-up can
produce small-to-moderate reductions in alcohol
consumption that are sustained over 6- to 12-month
periods or longer.
■■ Interventions can lead to positive health outcomes 4 ormore years later.
■■ Screening and behavioral counseling can reduce
alcohol-related morbidity.
The U.S. Department of Health and Human Services
maintains a webpage for the Agency for Healthcare Research and Quality (http://www.ahrq.gov/clinic/). This
website has a very wide variety of sources of informationof interest to the Army Family Advocacy Program (FAP)
community as well as all clinical services providers. To findthis article and others of interest go to Preventive Services, then to Recommendations, and then to Injury andViolence. Under Mental Health Conditions and Substance
Abuse is the entry entitled “Alcohol Misuse.” At this pointis a summary of the finding that screening in primarycare settings can accurately identify patients who are athigh risk for increased morbidity and mortality.
Other entries on this page are Screening for Family
Violence, Depression Screening in Adults and Children,and others such as obesity, exercise, and pregnancy.
These pages may be especially helpful to providers as
they present a succinct statement of the problem, theevidence considered, and the recommendation, all in a
way that can be easily presented to clients.

References
1. http://www.americanheart.org/downloadable/heart/110
5390918119HDSStates2005Update.pdf
2. http://www.cdc.gov/nchs/data/hdasd/sr13_156t12.pdf
3. Soiberg LI, Maciosek MV, & Edwards NM. (2008).
Primary care intervention to reduce alcohol misuse.
American Journal of Preventive Medicine, 34:143–152e3.

Dr. Christopher Murphy Interview, from page 7

Dr. McCarroll: Do you think that a clinician can function
effectively addressing both violence and alcohol misuse?
Dr. Murphy: Yes. It would require evaluation of someof their assumptions. People in the domestic violence fieldmight have to reevaluate some of their thoughts that substance abuse is just an excuse for violence by acknowledging
that it might contribute directly to people’s bad judgment
and impulsive behavior. People on the substance abuse side
might have to reevaluate the extent to which they believe thatfamily relations may play a role in someone’s addiction andnot just think that all their clients’ problems are as simple as asecondary consequence of their substance abuse. A lot of theclinical and counseling skills would be very similar in boththese areas.
8 • Joining Forces/Joining Families

Dr. McCarroll: Thank you for your insights.
Dr. Murphy: You are welcome.

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2. Buchsbaum, Buchanan, Centor, Schnoll, & Lawton. (1991).
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ratios. Annals of Internal Medicine, 115:774–777.
3. Prochaska JO, DiClemente CC, & Norcross JC. (1992). In searchof how people change. American Psychologist, 47:1102–1114.
September 2008