Violence Against Women: Techniques in Screening, Assessment & Basic Interventions

1. Violence Against Women: Techniques in Screening, Assessment & Basic Interventions Fran Danis, PhD Sara Plummer, PhD Pei-ling Wang, PhD

2. Agenda • Review of Domestic Violence Dynamics • Screening Techniques • Risk Assessments • Basic Interventions including: • Safety Planning • What Not to Do

3. 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 Center on Violence Against Women and Children 3

4. Power and Control Wheel

5. 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)

6. 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)

7. Why Do Men Hit? • Learned behavior: Home, Community, School, Culture • Because they can…risks do not outweigh the rewards • Male privilege

8. Figure 1. Ecological Model of Factors Associated with Partner Abuse Individual Perpetrator Society Community Relationship • 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 • Poverty, low socioeconomic status, unemployment • Associating with delinquent peers • Isolation of women and family • Rigid gender roles • Male control of wealth and decision-making in the family • Marital conflict • Being male • Witnessing marital violence as a child • Narcissistic personality • Being abused as a child • Alcohol use Source: Adapted from Heise 1998 (210) Population Reports/CHANGE

9. Domestic Violence is not caused by: • Illness • Genetics • Alcohol or drugs • Out-of-control behavior • Anger • Stress • Behavior of the victim

10. Why Do Women Stay? • 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

11. Strengths of Survivors • Assessment skills • Protective of children • Informal support networks • Perseverance • Endurance • Connection with others • Loyalty • Love for others • Creativity • Courage • Humor • Persistence • Spirituality

12. 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 Center on Violence Against Women and Children 12

13. 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 non-abused 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)

14. 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

15. Post Traumatic Stress Disorder • 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…

16. 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.

17. Risk Factors for Murder-Suicides • 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

18. 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

19. 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

20. 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?

21. 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? Center on Violence Against Women and Children 21

22. Show Screening Video

23. Risk Assessments • Use of Strengths Perspective • Facilitate Safety & Resiliency • Danger Assessment Instrument (Campbell) • Taiwan Intimate Partner Violence Danger Assessment (TIPVDA) Pei-Ling Wang

24. 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).

25. 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).

26. 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.

27. 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.

28. 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

29. 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.

35. 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) Center on Violence Against Women and Children 35

36. 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? Center on Violence Against Women and Children 36

37. Danger AssessmentDr. 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?

38. 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?

39. TIPVDA

40. Role Play Exercises General instructions • What red flags do you identify? • What are your clients’ strengths? • What is your intervention plan?

41. 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.

42. 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.

43. 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.

44. 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?

45. What We Should Say To Abused Women • 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

46. Understanding Victims’ Responses • Avoidance • Minimizing • Isolation • Internalizing • Escape • Compliance • Lying • Emotional Numbing • Aggression/ Retaliation Center on Violence Against Women and Children 46

47. Basic Interventions • Safety Planning • Taiwan Services • Services that can do further harm

48. 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 Center on Violence Against Women and Children 48

49. 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 Center on Violence Against Women and Children 49

50. 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 Center on Violence Against Women and Children 50