This study examined whether partner aggression was reduced in the first and second year after, as compared with the year before, BCT for married or cohabiting female alcoholic patients. Partner aggression measures included male-perpetrated and female-perpetrated prevalence of elevated verbal aggression, overall violence, and severe violence and frequency of verbal aggression, overall violence, and severe violence. Results supported predictions that partner aggression and violence would decrease after BCT, and that clinically significant violence reductions to the level of a non-alcoholic comparison sample would occur for patients whose alcoholism was remitted after BCT.
In the year before BCT, over two-thirds of women engaged in violence toward their male partners and a similar proportion were victimized by their male partners. Severe violence also was high with 50% female perpetration and 22% female victimization prevalence. Before BCT alcoholic women and their male partners had a fourfold or greater increased risk of partner aggression on all measures studied when compared to the matched nonalcoholic sample.
Female-perpetrated aggression in the first and second year after BCT decreased significantly from pre-treatment levels. Further, women who were remitted after BCT had aggression levels similar to the comparison sample, suggesting that these violence reductions were clinically significant. These predicted reductions in women's aggression occurred for all measures studied.
Male-perpetrated aggression followed the same pattern of predicted results with a few exceptions. Male aggression was significantly reduced in the first and second year after BCT except for year-1 prevalence and frequency of severe violence. Male aggression also returned to the level of matched controls when the female partner was remitted except for year-1 prevalence and frequency of verbal aggression. These minor differences in results for female versus male aggression were not predicted, but it seems reasonable that reductions in the woman's drinking may reduce the woman's aggression somewhat more than the man's aggression.
A final prediction was that couples in which the alcoholic women were remitted after BCT would have lower aggression than their counterparts in which the woman had relapsed. Although results were all in the predicted direction, strength and consistency of support for the hypothesis varied. Women's and men's aggression was generally lower for remitted than relapsed cases, but in year-2 some measures only approached significance or were significant only when adjusted for attrition. Severe violence showed an exception to the general pattern, in that men's prevalence and frequency of severe violence in both years and women's frequency of severe violence in year-2 did not differ as a function of the women's remission status.
The prevalence of female-to-male overall violence illustrates the general pattern of study results. In the year before BCT, 68% of female alcoholic patients had been violent toward their male partner, nearly 5 times the comparison sample rate of 15%. In the year after BCT, violence decreased significantly to 31% of the alcoholic sample. Among remitted alcoholics in the year after BCT, violence prevalence of 22% did not differ from the comparison sample and was significantly lower than the rate among relapsed patients (38%). These results support the hypothesis that women's recovery from alcoholism after BCT is associated with reductions in risk of female-to-male partner violence to a level that is similar to the nonalcoholic population.
Results for the second year after BCT were similar to the first year. In addition, the year-2 results showed that posttreatment reductions in violence were stable rather than transitory. Year-2 partner aggression remained significantly reduced from baseline levels and aggression did not increase from the first to the second year after BCT.
The present results replicate and extend earlier studies in a number of ways. First, violence prevalence of over two-thirds in the year before BCT is of similar magnitude to the 50-60% past year violence prevalence noted in other studies of women with alcoholism (e.g., Chermack et al, 2001
; Drapkin et al, 2005
). Second, the present results replicate the findings of Fals-Stewart et al (2006)
showing significant reductions in partner violence among women with alcoholism in the year after BCT. The present study extended the Fals-Stewart et al study by including a 2-year follow-up and a non-alcoholic comparison sample, thus showing that violence reductions were maintained in the second year after BCT and that clinically significant violence reductions to the level of a non-alcoholic comparison sample occurred for patients whose alcoholism was remitted after BCT. Finally, present results show that findings of substantially reduced violence associated with abstinence in the 2 years after BCT in 2 studies of male alcoholic patients (O'Farrell et al, 1999
) generalizes to women alcoholic patients as well. The pattern of results is remarkably similar for the studies of male and female alcoholic patients.
The current study had several strengths. To date, this study provides the longest follow-up period assessing women with alcoholism and their male partners on IPV following BCT. It replicates the one previous published study showing reductions in IPV for women with alcoholism following BCT (Fals-Stewart et al, 2006
), and expands upon these findings by showing maintenance of reduction in IPV for two years following treatment. Also, this study is the first that we are aware to compare women with alcoholism and their male partners to a demographically, case-matched non-alcoholic community sample both prior to and following treatment. This strategy helps to gauge the meaningfulness of clinical gains after BCT allowing for comparison of the treatment sample to individuals from the community who do not exhibit alcohol problems (Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999
Limitations of this study should also be noted. First, although study attrition was modest over the course of the two year follow-up period, various data substitution procedures showed that the lack of a predicted difference between remitted and relapsed patients on some measures might have been due to attrition. Second, due to the naturalistic study design, the declines in IPV following BCT cannot be casually attributed to specific procedures of the BCT intervention. Although use of multiple follow-up assessments and a case control sample helps to offset some confounds, this study did not have a no-treatment or alternative treatment control and therefore the causal role of BCT in producing reductions in IPV remains unclear. Third, the mechanism of action whereby IPV was reduced after BCT was not examined in the present study. Fourth, since partner data was not obtained in the community sample, we were unable to compare different violence assessment methods (e.g., highest report of either partner versus partner collateral report) and how these might have impacted the results. Fifth, we did not collect data on reasons for refusal or willingness to take Antabuse or accept abstinence as a goal of treatment. Therefore, we are unable to determine in what ways study participants differ from those that chose not to participate. Finally, the comparison sample was collected in 1985, a number of years before the alcoholic sample was collected, raising the possibility of cohort or history effects on the comparison analyses. However, it seems unlikely that such effects would invalidate conclusions of the present study, given that IPV prevalence estimates from national surveys in 1992 (Straus & Kaufman Kantor, 1994
) and 1995 (Cunradi, et al, 1999
) differ from the 1985 sample used in the present study by less than 1% for female-perpetrated and 1-2% for male perpetrated violence.
Although the current study offers some advancement into the understanding of IPV following alcoholism treatment for women and their male partners, there is a clear need for additional research. The current study did not investigate the mechanisms of action that might be associated with reductions in violence following BCT. The finding that reductions in IPV were found even among the relapsed group suggests that there may be avenues other than reducing substance use through which BCT impacts IPV. Future research is needed to see if the BCT procedures aimed at improving communication and conflict resolution might have an impact on reducing IPV in addition to the BCT procedures for supporting sobriety. In addition, future research should examine the association between partners' substance use and violence on a day-by-day basis to better understand the temporal and possible causal ordering of these variables. Expanding the model to include male partner substance use may help to further explain situations that lead to violence. Future studies should also examine the degree to which polysubstance dependence and relapse to substances other than alcohol might contribute to IPV. In addition, it will be important for future research to better contextualize the occurrence of the IPV among women with alcoholism and their partners by assessing factors such as whether or not verbal arguments over drinking and problems related to drinking escalated to violence, who initiated the violence, and whether or not the reported violence was in self-defense. This issue speaks to the need for future research to use alternative methods for measuring violence that go beyond simply summing the frequency of a specific violent behavior. Results from the current study are based upon a sample that was primarily White. Future studies of BCT should seek to incorporate individuals from other racial backgrounds and examine the degree to which race and ethnicity might impact treatment outcomes including IPV. Finally, future research should examine whether other predisposing factors, such as antisociality or history of abuse victimization, might increase risk for IPV among women seeking alcoholism treatment and their partners.