Transcript Violence Against Women: Techniques in Screening, Assessment

Violence Against Women:
Techniques in Screening,
Assessment & Basic Interventions
Fran Danis, PhD
Sara Plummer, PhD
Pei-ling Wang, PhD
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Agenda
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Review of Domestic Violence Dynamics
Screening Techniques
Risk Assessments
Basic Interventions including:
– Safety Planning
– What Not to Do
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Statistics & Prevalence
• Nearly ¼ adults disclosed childhood sexual abuse, and
1/10 were physically abused as children.
ACE Study, Felitti et al., 1998
• Approximately 1/3 of women and men witnessed
domestic violence as children.
Strauss, 1992
• Nearly 33% of women experience physical and/or
sexual abuse in an intimate relationship
The Commonwealth Fund 1998
• 1/5 teenage girls will experience an incident of dating
abuse before graduating high school Journal of the American Medical Association
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Center on Violence Against Women and Children
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• Power and Control Wheel
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Physical Health Effects
• Physical Injury (Facial, fractures, dental, neurological, soft
tissue, internal, “falls”)
• Chronic Pain (Back, abdominal, chest, head) (Goldberg &
Tomlanovich ’85; Campbell et. al. ’00)
• Chronic Irritable Bowel Syndrome (Drossman et. al., ’90; ’96)
• Eating Disorders (McCauley, 1995)
• Hypertension (Rodriguez, 1989)
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Mental Health Impact
• Depression 10 - 43% pop; 32 - 70% clinical
(9.3% non abused)
• Post Traumatic Stress Disorder 2 - 12% pop;
31 - 68% clinical
• Alcohol Abuse 4 - 16% pop; 23 - 44% clinical
• Drug Abuse 5 - 16% pop; 23 - 44% clinical
(2% non abused)
• Eating Disorders (McCauley et.al.1995)
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Why Do Men Hit?
• Learned behavior: Home, Community,
School, Culture
• Because they can…risks do not outweigh
the rewards
• Male privilege
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Figure 1. Ecological Model of Factors Associated with Partner Abuse
Society
•Norms granting
men control over
female behavior
•Acceptance of
violence as a way to
resolve conflict
•Notion of
masculinity linked
to dominance, honor,
or aggression
•Mass
Media/Culture
Community
Relationship
•Poverty, low
socioeconomic
status,
unemployment
•Rigid gender
roles
•Associating
with delinquent
peers
•Male control of
wealth and
decision-making
in the family
•Marital conflict
•Isolation of
women and
family
Individual
Perpetrator
•Being male
•Witnessing marital
violence as a child
•Narcissistic
personality
•Being abused as a
child
•Alcohol use
Source: Adapted from Heise 1998 (210)
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Population Reports/CHANGE
Domestic Violence is not caused by:
• Illness
• Genetics
• Alcohol or drugs
• Out-of-control behavior
• Anger
• Stress
• Behavior of the victim
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Why Do Women Stay?
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CASH: Economic Dependence
KIDS: Children & Fear of Loss of Children
HOPE: Promises of Change
LOVE: He doesn’t always beat her
FEAR: of Death or Threats to family, kids,
VOWS: Marriage vows are not be broken
PETS: Threatens to harm family pest
Sham(e): Societal Attitudes: Stigma & Shame
Loss: Not ready to face loss of the relationship
No Place To Go/ Resources
Traditional Value System
Isolation
WOMEN DO LEAVE EVERY DAY
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Strengths of Survivors
• Assessment skills
• Protective of children
• Informal support
networks
• Perseverance
• Endurance
• Connection with others
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Loyalty
Love for others
Creativity
Courage
Humor
Persistence
Spirituality
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Why Should We Screen?
• Abused women tend to use health care, mental
health, and social services more than women
who are not abused.
• The majority of abused women who disclosed
abuse within these settings were
screened/assessed by a professional.
• Approximately 75% of patients and 88% of
victims/survivors state that health care
providers should ask about history of abuse.
• Can save her life: suicide & homicide risk
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Center on Violence Against Women and Children
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What Do We Know About Suicidality & Domestic
Violence?
• Of women who reported prior suicide attempts, 81% had
been victims of partner abuse at some point (Abbott et. al,
1995).
• Rates of Suicidality among abused women range from 4.6%
- 77% across 13 studies as compared to 4.9% for nonabused women
• 22% of women sexual assaulted within a relationship
reported threatening or trying to commit suicide compared
to 4.2% of not-sexually abused women.
• Women reporting sexual assault were 5.3 times more likely
to report threatening or attempting suicide (McFarlane et.
al, 2005)
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• Outpatient mental health services study: physical abuse
experienced as an adult was significantly related to
increased rates for lifetime suicide attempts (Kaplan et. al,
1995).
• Strong association between partner abuse and PTSD
• Strong connection between PTSD & Suicide attempts
• Individuals with PTSD were 15 more times likely than
individuals without PTSD to have attempted suicide
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Post Traumatic Stress Disorder
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
Diminished interest or participation in events,
detachment, restricted range of affect
• Sense of foreshortened future…
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If I can’t have you…
National Violent Death Reporting System
• For 7 states in 2003 & 13 in 2004
• 65 homicide/suicide incidents
• Most victims (58%) were current or former
intimate partner of perpetrator.
• Among all male perpetrators of intimate
partner homicide, 30.6% committed suicide.
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Risk Factors for Murder-Suicides
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GUNS: 81% of murder-suicides used guns
Prior domestic violence against the victim
Prior threats with a weapon
Prior threats to kill her
Estrangement from the perpetrator
A stepchild in the household
Marriage vs. cohabitation
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Universal Screening for DV
• Ask all females aged 14+ each time (for health care
providers; at intake for mental health and with
every new intimate
• Screener should be knowledgeable about the
dynamics of domestic violence; trained in safety
and autonomy and cultural competency
considerations
• Ideally, screening should be conducted by someone
who has established some trust
• Be face to face & forms: asking vs. forms
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Basic Screening Principles
• Be direct, behaviorally based questions
• Be non-judgmental
• Be confidential: no family, friends, partners
around
• Limits of confidentiality should be discussed
beforehand
• Use professional interpreters not members of
family especially children and adult partners
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Screening Questions
• Framing Statement: Because violence is so common in many
people’s lives, I’ve begun to ask all my clients/patients
about it
– Are you in a relationship with a person who physically
hurts or threatens you?
– Have you ever been hit, kicked, slapped, pushed, or
shoved by your boyfriend, husband, partner?
– Do you ever feel afraid of your partner?
– Has your partner ever forced you to have sex when you
didn’t want to?
– Do you feel isolated or controlled by your partner?
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Screening Questions
• Have you ever been abused/assaulted by
someone you know?
• Have you ever been abused/assaulted by
someone who was a stranger to you?
• Has someone you dated or been married to:
– Ever call you names or put you down?
– Made you feel afraid or intimidated?
– Ever made you concerned for your safety, or the
safety of your loved ones?
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Center on Violence Against Women and Children
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Show Screening Video
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Risk Assessments
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Use of Strengths Perspective
Facilitate Safety & Resiliency
Danger Assessment Instrument (Campbell)
Taiwan Intimate Partner Violence Danger
Assessment (TIPVDA) Pei-Ling Wang
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Resilience Research:
• Resiliency research recognizes a complex interaction of
individual attributes (e.g., intelligence, easygoing
temperament), family milieu (e.g., safe and secure
connections), and social interactions (e.g., positive peer
relations) in promoting well-being (Masten, 2001).
• Resilient persons are viewed by researchers as having
“self-correcting” tendencies that promote their positive
adaptation in overcoming risk factors (e.g., domestic
violence).
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Wolin & Wolin (1993)
Resilience Research
• Research with Adult Children of Alcoholics
• Broadened the definition of resilience to
include: the individual attributes that
develop as a result of finding ways to survive
adversity.
• People who have survived traumatic
situations are considered resilient because
they have enduring strengths that developed
as means to protect themselves from their
adversity (e.g., domestic violence).
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The Wolins’
Seven Themes of Resilience
• Insight, independence, initiative, relationships,
creativity, humor, and morality.
• Using these resiliencies as guidelines helps
practitioners to identify and support the
strategies battered women use to manage their
traumatic experiences.
• Domestic violence literature on coping and
quotes from the author’s research with battered
women (Anderson, 2009) provide additional
clarification and examples for each theme.
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The Strengths Perspective
• Practicing from a strengths perspective
means practitioners believe that the
strengths and resources to resolve a difficult
situation lie within the client and his or her
environment.
• Discovering these strengths, then is central to
guiding the assessment process.
• The identification and rediscovery of a
client’s individual and environmental
resources occurs through the use of a
strengths assessment.
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Strengths Assessment
• A strengths assessment gathers information
on the client’s history of functioning (e.g.,
“What have I used in the past?”), present
status (e.g., What’s going on today? What’s
available now?”), and desires for the future
(e.g., “What do I want?”), in different life
domains:
– housing/transportation, vocational/educational,
financial/insurance, family/relationships, health,
social support, spirituality, and leisure time
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Adding Resilience Research to a Strengths
Assessment for Domestic Violence Survivors
• Incorporating resiliency research into a strengths
assessment, provides opportunities to uncover
additional strengths and broaden the focus of
the strengths assessment to include the life
domain of trauma.
• Exploring the pain and trauma that one has
experienced can help to unravel how one
survived and prevailed, which may become
significant strengths to be used in present
circumstances.
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Strengths
Assessment
What have I used in the past? What’s going on
today? What do I want?
Life Domain Trauma: Domestic Violence
Insight
What signs/cues in your abuser alerted you to
danger? Such as did you figure out what was
likely to set off an abusive incident?
Did you sense that something was not right about
the violence even though your abuser made
excuses for it?
Did you ever challenge the name-calling or
reasoning of your abuser?
Did you try to avoid or divert the violence towards
yourself? Towards other family members?
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Independence Did you find a place or an activity that provided an
escape from the abuse?
Did you ever defy your abuser in a way that
surprised you? Such as, did you ever physically or
verbally challenge the abuser?
What ways did you protect yourself and other family
members from the abuser? Such as, did you make
plans to escape the violence?
Did you seek out additional education and skills that
would provide a means for leaving?
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Initiative
Did you avoid him or topics in an attempt to divert
the violence?
Did you hide money, valuables, important papers, car
or house keys?
Did you try to find ways to improve safety? Such as
changing locks, hiding or removing weapons?
Did you try to avoid him or leave the home to get
away from your abuser?
In what ways did you try to make the relationship
nonviolent? Such as, did you try and talk your
abuser out of the violence?
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Relationships Were there ways you defied being isolated?
Did you ever tell someone about the violence?
Did you seek out help from family members, friends?
Did you talk to them about protecting yourself and
your children?
Did you send your children to stay with family?
Did you seek out help from professionals (e.g., the
police, health and mental health services, battered
women’s services) for yourself?
Did you seek out religious or spiritual support?
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Creativity
& Humor
Did you ever find ways to get away from what you
were feeling through the use of art, music, or humor?
Morality
Did you try to be different (e.g., nonviolent) from
how your abuser acted?
Did you ever fight and try to protect others from the
abuse?
How is service to others a part of your life?
Did you ever risk of your own security or safety to
do what is right?
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Assessing Abuse
• Identifies an individuals’ history of
abuse/trauma
– Types of abuse
– Severity of abusive behaviors
– Frequency of abusive incidents: Use calendar
– If abuse was ever disclosed to others
– Others’ responses to disclosures of abuse
• Individuals (Friends, Family, Co-workers, Doctors,
Clergy)
• Systems/Agencies (Police, DYFS, Community agencies)
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Center on Violence Against Women and Children
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Assessment Questions
– What types of abuse were perpetrated?
• Use questions that reflect specific behaviors
– When was the first incident?
– What was the worst incident?
– How often has abuse occurred?
– Does anyone else know about the abuse?
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Center on Violence Against Women and Children
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Danger Assessment
Dr. Jackie Campbell (2003)
• Has violence increased in severity or frequency in past year,
6 months, month?
• Does he own a gun?
• Have you left him after living together during the past year?
• Is he unemployed?
• Has he ever used a weapon against you or threatened you
with a lethal weapon?
• Does he threaten to kill you?
• Has he avoided being arrested for domestic violence?
• Do you have a child that is not his?
• Has he ever forced you to have sex when you didn’t want to?
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Does he ever choke you?
Does he use illegal drugs?
Is he an alcoholic or problem drinker?
Does he control most of all of your daily activities?
Is he violently and constantly jealous of you?
Have you ever been beaten by him while you were pregnant?
Have you ever threatened or tried to commit suicide?
Has he ever tried or threatened to commit suicide?
Does he threaten to harm you or the children?
Do you believe he is capable of killing you?
Does he follow you, spy on you, leave threatening notes,
destroy your property?
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TIPVDA
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Role Play Exercises
General instructions
• What red flags do you identify?
• What are your clients’ strengths?
• What is your intervention plan?
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Case Study 1: Mary
Mary is a 23 year old pregnant woman with a broken leg.
She is accompanied by her boyfriend, who stares at her
whenever she is asked how she broke her leg. She claims she
slipped and fell down the stairs. Mary has a 2 year old son
from a previous relationship who is at home being watched
by a friend of her boyfriend. When her boyfriend steps
outside to smoke a cigarette, Mary confides in you that her
boyfriend is very jealous and questions whether the baby is
his. Mary is worried about how she will manage with her
broken leg because none of her family likes her boyfriend
and she has no friends left of her own.
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Case Study 2: Linda
Linda is a 25 year old mother of a 7 year old son who
is acting out in school. The school social worker has
told you that he is aggressive with other children,
bullies them through threats, disrespectful of his
teacher. Linda feels she does the best she can but
that she is just tired all the time. Her husband
refuses to allow her to work outside the home; she
is not allowed to see her family or friends without
his permission. She describes her husband as king
of the castle.
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Case Study 3: Amber
• Amber is a 19-year-old college sophomore seeking counseling for
concerns about her boyfriend. This is her first serious relationship and
she really wants it to work out. Her boyfriend is a fifth year senior. She
met him 2 weeks ago and he has told her that she is the only woman
who really understands him. His previous girlfriends, he said, didn’t
really understand him and took advantage of him. He recently decided
to change his major, and wants Amber to transfer with him to a school
several hundred miles away. She likes being at State University because
she has a lot of friends here and her parents are only 2.5 hours away.
Her boyfriend has never hit her, but last week while they were working
through campus, she said hi to a guy she knew from high school. Her
boyfriend grabbed her by arm very tightly and pulled her away. He
seemed very angry and wanted to know whom that guy was and if you
had had an affair with him. He wanted her to know, she was his girl now.
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Debriefing Questions
• How did it feel to ask these questions?
What was the most difficult?
• How did you validate the client’s experience
and feelings?
• Did you agree with the clients’ decisions?
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What We Should Say To
Abused Women
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It’s not your fault.
You don’t deserve this.
You are not alone.
I respect you and your decisions.
I am concerned for your safety.
If you want to talk, I’ll be here for you
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Understanding Victims’ Responses
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Avoidance
Minimizing
Isolation
Internalizing
Escape
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Compliance
Lying
Emotional Numbing
Aggression/
Retaliation
Center on Violence Against Women and Children
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Basic Interventions
• Safety Planning
• Taiwan Services
• Services that can do further harm
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Intervention at Every Level
• Prevention Model
– Primary
• Education on healthy relationships to reduce the risk
of victimization
– Secondary
• Screen and assess for abuse, discuss impact of trauma
on individual’s health and well-being
– Tertiary
• Assess for lifetime exposure, and provide appropriate
resources and referrals
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Center on Violence Against Women and Children
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Basic Intervention- Do’s
• Be patient, compassionate and non-judgmental
• Encourage the individual to tell their story by
using open-ended questions
• Assure the client that the abuse is not their fault
• Confirm that they are not alone
• Provide information, resources, and make
referrals as appropriate
• Document observations/disclosures of abuse,
and follow-up provided
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Center on Violence Against Women and Children
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Basic Intervention- Don'ts
• Don’t blame the victim
– For not leaving
– For not stopping the abuse
– For antagonizing the perpetrator
• Don’t be judgmental
• Don’t pry into the conversation when the
individual isn’t ready to talk
• Don’t be in-sensitive
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Center on Violence Against Women and Children
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Initial Safety Planning
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Is the individual in immediate danger?
Is the perpetrator present in your facility?
If not, is the perpetrator likely to appear?
Does the perpetrator have access to weapons?
What is the survivor’s initial plans?
What resources/support do they have access to?
Connect the individual to resources and options
Center on Violence Against Women and Children
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Understand Abuse Survivor’s
Perspective
• Batterer-generated risks
• Life-generated risks
• What risks does she face if she stays or if she
leaves?
• How do those risks affect her plans?
• What are her past and current safety plans?
August, 2005
MCADV - Advocacy in Practice
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Build a partnership with the survivor
• Review her analysis of risks to herself
and her children
• Work with her to strengthen her safety
plan
August, 2005
MCADV - Advocacy in Practice
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Local Resources
• Domestic Violence Services
• Sexual Assault Services
– SANE Program- Sexual Assault Nurse Examiner
• Division of Youth and Family Services
• Children & Adolescent Services
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Center on Violence Against Women and Children
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Items to Take When Leaving
• Important Papers:
Birth, Passports, Credit
Cards, Banking
Information
• Medical records: self &
children
• Prescription
Medications
• Address Books
• School Records for
Children
• Favorite toys
• Pets
• Important phone
numbers: people they
can stay with, work &
school
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Contraindicated Interventions
• Couples/marriage counseling
• Divorce mediation
• Anger Management Programs
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