Family violence: Screening and risk assessment in family support services

1. Family violence: Screening and riskassessment in family support services Towards a holistic approach Elly Robinson & Lawrie Moloney FRSA conference, 3-5 November 2010, Melbourne

2. Background and definitions Based on Australian Family Relationships Clearinghouse Briefing No. 17 (released October) Why this paper? Challenges around defining family violence Acknowledge Lawrie’s input and knowledge of family violence. Paper was in response to a request from funding body about whether a short screening tool (or set of 3-4 questions) existed that could be used in all services.Debate regarding definitions, prevalence etc likely to continue, but we proceed based on the following propositions: 1.Family violence is a significant problem, which is associated with a broad range of poor outcomes for children and for other family members. 2.There is general consensus that useful definitions of family violence must encompass the range of ways in which violence is expressed and the range of ways in which one individual seeks to control the life of another. Clearly violence is not just physical and just as clearly, significant fear can be engendered by attitudes and behaviours that are not necessarily obvious to the naïve or untrained observer. 3.Whilst not all violence is gendered, for a variety of reasons, the role that gender plays in the institutionalisation and maintenance of violence is one that cannot be ignored. We proceed on the basis of these propositions for the remainder of this paper.Acknowledge Lawrie’s input and knowledge of family violence. Paper was in response to a request from funding body about whether a short screening tool (or set of 3-4 questions) existed that could be used in all services.Debate regarding definitions, prevalence etc likely to continue, but we proceed based on the following propositions: 1.Family violence is a significant problem, which is associated with a broad range of poor outcomes for children and for other family members. 2.There is general consensus that useful definitions of family violence must encompass the range of ways in which violence is expressed and the range of ways in which one individual seeks to control the life of another. Clearly violence is not just physical and just as clearly, significant fear can be engendered by attitudes and behaviours that are not necessarily obvious to the naïve or untrained observer. 3.Whilst not all violence is gendered, for a variety of reasons, the role that gender plays in the institutionalisation and maintenance of violence is one that cannot be ignored. We proceed on the basis of these propositions for the remainder of this paper.

3. Challenges for family services Family Law Evaluation (Kaspiew et al, 2009) Majority of individuals accessing family support services are struggling with impact of violence, particularly post-separation services Other Australian studies e.g. Brown et al, 1998; Moloney et al, 2007 in family law court applications, allegations of violence in majority of cases Both physical and emotional abuse Both physical and emotional abuse

4. Screening and assessment Attention on screening and assessment as a result More questions than answers Who should be conducting screening and assessments? Who is being screened/assessed, and for what? How should family violence be screened/assessed? This paper explores these issues

5. Terminology “Screening” and “risk assessment” are commonly conflated in the literature For this paper: Screening – identification of victims of family violence occurs. Routine screening = all clients Risk assessment – ongoing efforts to assess the degree of harm or injury likely to occur 1. Conflation means that in the literature there is a common lack of distinction between the two terms, making it difficult to compare studies or make conclusions.1. Conflation means that in the literature there is a common lack of distinction between the two terms, making it difficult to compare studies or make conclusions.

6. Who should screen/assess? Little guidance in literature regarding one or two worker model Two separate workers may generate efficiencies or fragment effort Trust may not be present with a second worker Delay between screening and assessment What skills are needed? Can screening be “neatly concluded”? Little said about whether best approach is to separate out tasks of screening and assessment and have them undertaken by different people, or whether one worker should do both. Framework for Screening, Assessment and Referrals in FRCs and FRAL provides guidance around establishing a “first point of call” worker, who screens whether a client requires a more in-depth assessment (normally by another worker) or if needs can be met through information provision or early referral elsewhere. Trust or rapport that led to revelation in screening may not necessarily be repeated with another worker – can’t assume second worker can simply build on first worker’s efforts. Could be argued that beginning a screening process brings ethical and professional obligations to ensure that risks at this stage are acted upon then and there. Other issues addressed in the paper that we don’t have time for today, for example, need for ongoing training in family violence and use of tools. Raises questions about skills needed for screening and assessment – e.g. ability to support or “hold” clients and simultaneously not engage in deeper conversation about their concerns. Jo Spangaro & co – screening can be a therapeutic experience, but may also be traumatising and increase risk if not handled well. Issues addressed in family law by Jaffe, Crooks & Bala (2007) – safety concerns need to be given higher prominence at early stages of intervention, when adequate information needed to evaluate safety of children and adults. Little said about whether best approach is to separate out tasks of screening and assessment and have them undertaken by different people, or whether one worker should do both. Framework for Screening, Assessment and Referrals in FRCs and FRAL provides guidance around establishing a “first point of call” worker, who screens whether a client requires a more in-depth assessment (normally by another worker) or if needs can be met through information provision or early referral elsewhere. Trust or rapport that led to revelation in screening may not necessarily be repeated with another worker – can’t assume second worker can simply build on first worker’s efforts. Could be argued that beginning a screening process brings ethical and professional obligations to ensure that risks at this stage are acted upon then and there. Other issues addressed in the paper that we don’t have time for today, for example, need for ongoing training in family violence and use of tools. Raises questions about skills needed for screening and assessment – e.g. ability to support or “hold” clients and simultaneously not engage in deeper conversation about their concerns. Jo Spangaro & co – screening can be a therapeutic experience, but may also be traumatising and increase risk if not handled well. Issues addressed in family law by Jaffe, Crooks & Bala (2007) – safety concerns need to be given higher prominence at early stages of intervention, when adequate information needed to evaluate safety of children and adults.

7. Strengths and weaknesses Strengths and weaknesses in the institutionalisation of screening and assessment procedures: Positive - formalise the process of determining issues; increase the chances that services offered are appropriate. But – no tool is 100% accurate (could there ever be? – false positives and negatives) Risk assessment doesn’t equate to “completion” – ongoing assessment needed. False positives – that violence occurred when it didn’t False negatives – that violence did not occur, when it did Sensitivity – measure of how likely it is that the tool will pick up the presence of FV when it is actually present. Specificity – measure of how likely the tool will pick up the absence of FV when it is actually absent. Ideally should be both, and even if both high, will still get false positives and negatives. there is danger in indiscriminately applying a screening test to a large population where the prevalence rate of the disease is very low – as you will end up with higher false positive rate. Once assessment is done, the risk is that it is seen as “completed” and that no further assessment needs to occur, whereas from a statistical point of view, future violence is possible. Needs to be ongoing – this is well established but may seem counterintuitive, esp. to novice practitioner.False positives – that violence occurred when it didn’t False negatives – that violence did not occur, when it did Sensitivity – measure of how likely it is that the tool will pick up the presence of FV when it is actually present. Specificity – measure of how likely the tool will pick up the absence of FV when it is actually absent. Ideally should be both, and even if both high, will still get false positives and negatives. there is danger in indiscriminately applying a screening test to a large population where the prevalence rate of the disease is very low – as you will end up with higher false positive rate. Once assessment is done, the risk is that it is seen as “completed” and that no further assessment needs to occur, whereas from a statistical point of view, future violence is possible. Needs to be ongoing – this is well established but may seem counterintuitive, esp. to novice practitioner.

8. Screening tools – what is used? At present, no answer to most effective tool or most appropriate length of time to take Many studies are from broader health care settings FRC & FRAL Framework Promotes use of three broad questions, fourth if contact is related to setting up a joint session Possible issues with approach 1. Do you have any reason to be concerned about your own safety or the safety of your children? Do you have any other concerns about your children’s wellbeing at the moment? Do you have any reason to be concerned about the safety of anyone else? How do you think your partner/ex-partner would answer these questions? (optional) 2. Understandable compromise to establishing presence or absence of safety across broad domains – violence, child abuse, self-harm – but what the gain in covering broad ground, they lack in directness. But – further questions undermines the brevity and focused nature of screening. Inherent tension between brevity and comprehensiveness, or effectiveness – balance can be partially informed by a careful consideration of what practitioner needs to know before proceeding. 1. Do you have any reason to be concerned about your own safety or the safety of your children? Do you have any other concerns about your children’s wellbeing at the moment? Do you have any reason to be concerned about the safety of anyone else? How do you think your partner/ex-partner would answer these questions? (optional) 2. Understandable compromise to establishing presence or absence of safety across broad domains – violence, child abuse, self-harm – but what the gain in covering broad ground, they lack in directness. But – further questions undermines the brevity and focused nature of screening. Inherent tension between brevity and comprehensiveness, or effectiveness – balance can be partially informed by a careful consideration of what practitioner needs to know before proceeding.

9. Screening tools – what is used? NSW Health – direct questions on violence: Within the last year have you been hit, slapped or hurt in other ways by your partner or ex-partner? Are you frightened of your partner or ex-partner? If yes: Are you safe to go home when you leave here? Would you like some assistance with this? 62-75% eligible women screened in 2003-06, 6-7% family violence. Why was screening not undertaken – presence of partner or others main reason. Separate assessments of individuals in FDR offers the opportunity to avoid this barrier to use of screening. Also problems with increased workloads with screening, lack of protocols and training around use of tools. Other problems include that use of tool itself does nothing to protect woman, nor is there convincing evidence about long-term benefits for clients as a result of using the tool (Braaf & Sneddon, 2007).Why was screening not undertaken – presence of partner or others main reason. Separate assessments of individuals in FDR offers the opportunity to avoid this barrier to use of screening. Also problems with increased workloads with screening, lack of protocols and training around use of tools. Other problems include that use of tool itself does nothing to protect woman, nor is there convincing evidence about long-term benefits for clients as a result of using the tool (Braaf & Sneddon, 2007).

10. Risk assessment Differentiated by degree to which professional judgment and more formal tools used. Three approaches: Unstructured (clinical) decision making Actuarial decision making Structured professional judgment Unstructured – where assessment based on professional discretion, intuition or gut feeling, justified by qualifications or experience Actuarial – tools used based on evidence-based risk factors associated with the outcomes of risk, in this case FV. Risk determined via scale or matrix. SPJ – attempts to bridge the two – guidelines used to conduct assessment, but also includes information gathering, communicating options, implementing violence prevention strategies.Unstructured – where assessment based on professional discretion, intuition or gut feeling, justified by qualifications or experience Actuarial – tools used based on evidence-based risk factors associated with the outcomes of risk, in this case FV. Risk determined via scale or matrix. SPJ – attempts to bridge the two – guidelines used to conduct assessment, but also includes information gathering, communicating options, implementing violence prevention strategies.

11. Risk assessment Many tools in circulation, including those developed independently by services, but few evaluated Kropp (2008) four hold promise, but only moderate associations with recidivism: Danger Assessment Domestic Violence Screening Inventory Ontario Domestic Assault Risk Assessment Spousal Assault Risk Assessment Won’t go into detail on these tools, but more info in paper. Won’t go into detail on these tools, but more info in paper.

12. Frameworks Tools often discussed within a broader framework Most frameworks support structured judgment approach FRC & FRAL framework Common Risk Assessment Framework (Vic) FRC & FRAL framework – favours SPJ, but also recognises the high level of skills and knowledge needed regarding family violence to make use of this appraoch Victorian Family Violence Common Risk Assessment Framework (Department for Victorian Communities) draws on three elements to determine risk – victim’s own assessment, evidence-based risk indicators and professional judgment. Family Safety Framework (SA) – professionals are encouraged to act on professional judgment, even though use of a common actualrial assessment tool is proposed.FRC & FRAL framework – favours SPJ, but also recognises the high level of skills and knowledge needed regarding family violence to make use of this appraoch Victorian Family Violence Common Risk Assessment Framework (Department for Victorian Communities) draws on three elements to determine risk – victim’s own assessment, evidence-based risk indicators and professional judgment. Family Safety Framework (SA) – professionals are encouraged to act on professional judgment, even though use of a common actualrial assessment tool is proposed.

13. How good are victims at assessing risk? Risk assessment should be informed by victim assessment Reasonably accurate predictor of reassault, both in isolation and by improving predictive value of other tools But – use with caution. 3. Women at greatest risk may be the ones who communicate a feeling of safety, may have some uncertainty but not enough to take precautions Also denial or fear may lead to risk minimisation.3. Women at greatest risk may be the ones who communicate a feeling of safety, may have some uncertainty but not enough to take precautions Also denial or fear may lead to risk minimisation.

14. What is being measured? Tools may aim to elicit risk without clearly identifying: The nature of the risk, such as reassault or lethality. The type of violence, such as physical or sexual violence. The severity, frequency or imminency of violence. Without information on validity and reliability, may be difficult to know what is being measured, and to what extent. Validity – was the tool actually measuring what it was supposed to, i.e. family violence? Reliability – that the same thing will be measured each time it is used with the same subjects under the same conditions – “repeatability”Validity – was the tool actually measuring what it was supposed to, i.e. family violence? Reliability – that the same thing will be measured each time it is used with the same subjects under the same conditions – “repeatability”

15. Tailored tools Family support services have shown great initiative to create own tools Approach supported, as long as underlying principles remain consistent. Flexible approach gives credence to different circumstances, cultural profiles and other factors Range of frameworks offer items and tools to draw upon, e.g. FRC & FRAL Framework.

16. In summary – key dilemmas How do we know that the screening and/or assessment tool is measuring what it is supposed to? How do we ensure there is a consistent use of an organisation’s chosen tools between practitioners, now and over time? How do issues such as rates of refusal to answer questions, or inability to answer questions, impact on tool evaluation? How do we measure whether screening and/or assessment is making a difference? What is used to measure a “difference”? Referral? Re-assault rates?

17. In summary – key dilemmas Regarding routine use of screening (Spangaro, 2007): Does screening reduce abuse? Does screening cause harm? What outcomes can be expected? NSW Health pilot study Overwhelming majority of women okay or relieved about being asked specific questions about domestic violence.

18. Is it the tool that is important? Consensus on best tool for the job ambitious. Macro level analysis of issues needed? Rather than tools, the minimum, necessary steps to ensure client safety. Service specific checklist? Similar to those used by pilots and surgeons (Gawande, 2010).

19. Is it the tool that is important? If the focus remains on tools, current imperfections can be reduced in two ways: Provision of quality, ongoing staff training and supervision Sharing of information regarding the effectiveness and limitations of existing evaluation frameworks, including issues of validity and reliability.

20. Conclusions Clinical practice and research currently hindered by the following: Screening and assessment tools not always considered separately in research Few tools have been tested independently for validity and reliability No gold standard currently exists (though we can’t wait for one either) Little research undertaken on risk assessment for family violence relative to violent and general criminal recidivism.

21. Conclusions Comprehensive summary of existing tools outside the scope of paper, but needed? Projects underway in Australia Mediator’s Assessment of Safety Issues and Concerns (MASIC) Family Relationship Centre research – Townsville, Rockhampton, Mackay Jenn McIntosh & US researchers piloting screening tool for use in FRCs and other FDR contexts. Focus of research is on identifying prevalence, characteristics and impacts of reported violence on clients attending the FRC for FDR.Jenn McIntosh & US researchers piloting screening tool for use in FRCs and other FDR contexts. Focus of research is on identifying prevalence, characteristics and impacts of reported violence on clients attending the FRC for FDR.

22. Acknowledgements This presentation is based on AFRC Briefing No. 17, Family Violence – Towards a holistic approach to screening and risk assessment in family support services. http://www.aifs.gov.au/afrc/pubs/briefing/b017/index.html Thanks to Lawrie Moloney, Margaret Anderson, Malia Dewse, Tibor Mokany and all the service providers and practitioners who provided key information and examples of tools. Elly Robinson, elly.robinson@aifs.gov.au