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System Assessment of Risk: Keeping Women and Children Safer

This study by Jacquelyn Campbell PhD aims to address the critical issue of intimate partner femicide, offering insights into risk factors, missed opportunities for prevention, and the impact on children witnessing these events.

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System Assessment of Risk: Keeping Women and Children Safer

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  1. System Assessment of Risk: Keeping Women and Children Safer Jacquelyn Campbell PhD RN FAAN Anna D. Wolf Chair and Professor Johns Hopkins University School of Nursing Multi City Intimate Partner Femicide Study Funded by: NIDA/NIAA, NIMH, CDC, NIJ VAWA R01 DA/AA1156

  2. INTIMATE PARTER HOMICIDE • In Canada – 30-40% of women killed – Killed by husband, partner, BF or EX – Stats Canada (vs. 7-10% of men) (US – 40-50% vs. 5-8% of men – hand count) • 3:1 Ratio of women killed by intimate partners vs. men in Canada (ranges from 3-5:1 over past 20 years) • Canada – Hx of DV: 62% spousal femicides; 67% male (Stats Canada ‘04) - DV against female partner; 71% Ontario DR • More at risk when leaving or left (Wilson & Daly ‘93; Campbell et. al. ‘01) 79% spousal homicides (Ont DR): during,1st 3 mos, 1st year • Women far more likely to be victims of homicide-suicide (29% vs. .1% in US; 29.3% vs. 2.9% in Canada) • Aboriginal and immigrant women more at risk (NYC) • IPV 21% of aboriginal (M & F) vs. 7% nonaboriginal in Canada) • 44-47% of women killed seen in health care system before killed (Sharps, Campbell ’02; Wadman & Muelleman ‘99)

  3. Number of Canadian Individuals Killed 2000 – 2006 Data from Brian Vallee, The War on Women, (2007)

  4. 32% Witnessed Femicide; 58% Witnessed Attempts 43% & 37% Found Mother Received Counseling 60% - all children of actuals; only 28% of attempteds 56% & 40% of children who witnessed femicide & attempts 57% & 54% of children who found the body 71% & 76% of mothers abused 22% & 27% threats to take children if she left 20% & 13% threats to harm children if she left 8% fathers reported for child abuse – both actuals & attempteds “He Killed My Mommy” – Lewandowski, Campbell et. al. JFV ’04: kids in the homes of women killed or almost killed

  5. DISRUPTION OF CHILDREN AFTER HOMICIDAL EVENT • Moved from home • To mother’s kin • To father’s kin • Split between mother’s and father’s kin • With others (e.g. foster home) Femicide 86% 40% 12% 5% 14% Attempted 25% 16% 6% 0% 2%

  6. SERVICES FOR CHILDREN WITNESSING INTIMATE PARTNER HOMICIDE • Vary city to city • Private - Victim Assistance Funds • Public - Specialized City Agency • Services offered but no follow-up • Coordination with school fragmented • Custody issues • Nothing systematic for attempted homicides

  7. VICTIMS Police Contacts - 66% of stalked & battered women Any Medical Visit - 56% 27% ED; 25% mental health Shelter Contacts - 4% of battered women Substance abuse Tx - 6% PERPETRATORS Prior Arrest - 56% of batterers (32% of non) Canada – 30% of spousal femicides – prior police contact Mental Health System - 12% but 36% described as having “poor mental health Canada - 17% – “suspected” mental/developmental disorder Substance Abuse Tx - 6% (but 48% with drug &/or alcohol px) Reported Child Abuse – 8.6% MISSED OPPORTUNITIES FOR PREVENTION - 83% of Cases – National Femicide Study (Sharps, Campbell et al, 2001; Stats Canada ’04, ‘05)

  8. MISSED OPPORTUNITIES:PERPETRATORS

  9. ATTEMPTED & ACTUAL VICTIMS SEEN IN SYSTEM

  10. Spousal Homicide in Canada • BF-GF category increasing – rest decreasing • Same sex intimate homicides – 6 since ’97 vs. approx 75 per year heterosexual • Atlantic – lowest rate of spousal homicide in Canada, Alberta, Sascatchewan highest – BC & Manitoba tied for 3rd • Rates: Sascatchewan -.76/100,000 spouses, Alberta .62; Atlantic Region - .35/100,000 spouses; BC – .53 = average of 13 per year ‘99-’03 (10 femicides • If approximately 8-9 attempted femicides for each femicide = 80 – total of at least 90 attempteds & actuals each year • Therefore, approximately 120-150 children each year affected by mother’s murder or attempted murder – prior DV • Ontario Death Review – 21% of spousal homicides – custody or access disputes; overall 10 of 342 women killed were pregnant when killed & 7 of 10 killed by partner or ex

  11. CANADIAN INTIMATE PARTNER HOMICIDE RATE 1974-06 (’91 – first inclusion of BF-GF) (F 3-5 X M) Rate per million couples – 57% decline *BF-GF increased in ‘04 Source: Homicide Survey, Canadian Centre for Justice Statistics

  12. U.S. INTIMATE PARTNER HOMICIDE RATE DECLINE 1976-02 FBI (SHR, 1976-02; BJS ’05, ‘07) FEMALE MALE 2004, 05 - no ex’s

  13. INTIMATE PARTNER FEMICIDE BY PERPETRATOR IN TEN CITIES (N= 311) (female partner perpetrator – Glass et al 2004 – Canada: 6 since ‘97) EX-BF OTHER EX-SPOUSE BOYFRIEND SPOUSE

  14. Decline in Intimate Partner Homicide and Femicide - US • Decline in male victimization in states where improved DV laws and services - resource availability (Browne & Williams ’89; ‘98) • Exposure reduction - increased female earnings, lower marriage rate, higher divorce rate (Dugan, Nagin & Rosenfeld ‘97) • Gun availability decline (Wilt ‘97; Block ‘95; Kellerman ‘93, ‘97- gun increases risk X3)

  15. Rates of Spousal Homicide Using Firearms 40% of female; 21% of male (Stats Canada ‘03)

  16. U.S. INTIMATE PARTNER HOMICIDE RATES & DOMESTIC VIOLENCE SERVICES 1976-9 (Resources per 50 million - Dugan, Nagin & Rosenfeld ‘03)

  17. Spousal Homicide by Relationship Status – Canada 96-05 (*vs. 14% in all Canada)

  18. CANADIAN RATE OF SPOUSAL HOMICIDES IN DIFFERENT TYPES OF RELATIONSHIPS, 96 – 06 Rate per 1,000,000

  19. “Prediction is very hard to do - especially if it is about the future” Yogi Berra

  20. Overview of Issues • High demand for both lethality & reoffending risk assessment by criminal justice, advocacy, victim service, & health systems • Other risk assessment instruments used for general probation purposes - accuracy with batterers for repeat IPV in dispute • Low base rates • Relatively young science in intimate partner violence & risk assessment particularly • 4 interacting parts to consider - instrument, risk assessor, perpetrator & one specific potential victim (vs. sexual assault or mental health – MacArthur study) • Fears that risk assessment will be used to limit service to victims • High stakes with either false negatives or false positives

  21. Overlapping Concerns Similar; Not the same Lethality Assessment Risk Assessment Safety Assessment

  22. Risk Prediction 4 Quadrant Model (Webster et. al. ‘94) Combination of Sensitivity & Specificity = ROC Curve (Receiver Operating Curve)

  23. ROC Curve Analysis – DA Calibrated on Actual Femicides – Tested w/Attempteds - 90% Campbell et al JIPV ‘08

  24. Navy (DoD) FAP Victim & Offender -reoffend Evaluation not finished Risk & Safety & safety (FA, MP, health) (Stith, Milner ’02-’04) DV Mosaic (20) (deBecker) Computerized/Victim (criminal .65 under ROC justice) - lethality risk system severe re-assault DVSI- R (Kirk Williams) Offenders (criminal justice) .71% under ROC short – reoffending (Williams & Grant, ’06) K-SID (Gelles & Lyon) Offender – reoffend (CJ) Some evaluation data O.D.A.R.A. (Z. Hilton) Offender - reoffend – (CJ) 77% under ROC (’04) PSI (Duluth) Victim & offender - both Process evaluation (advocates & criminal justice) (CDC) - no outcomes PAS (D. Dutton) Offender – intervention programs, Cross sectional prevention validation good SARA (Kropp et al) Offender (criminal justice) - Most data published B-SAFER reoffending best if perp. psych exam Danger Assessment Victim- Lethality (Advocates, Health) .69% under ROC (Campbell) reassault; .90% att. hom Existing Risk Assessment Scales

  25. Risk Factors for Femicide-Suicide in Abusive Relationships: Results From a Multisite Case Control Study Jane Koziol-McLain, Daniel Webster, Judith McFarlane, Carolyn Rebecca Block, Yvonne Ulrich, Nancy Glass, Jacquelyn C. Campbell Violence & Victims (Springer), Volume 21, Number 1, February 2006

  26. Femicide – Suicide Cases (32% of femicide cases in study – 29.3% -Canada; 29% -US) • No significant difference in proportion of prior physical DV – 77% w/o suicide (n = 210) ; 72% with suicide (n = 100) & similar characteristics – proportions of forced sex, choking, stalking • < abuse during pregnancy (14% vs. 30%) • 50% illicit drug use – not significantly more than abused • Approximately same proportion victim > 50 yo (w/o suicide 7%; with suicide 11%) • Little evidence of “mercy” killings or suicide pacts – one case with a suicide note suggesting such – family disputed motive • Prior DV – 32% in older women vs. 79% in younger but close to same as in older women killed w/o suicide as with suicide & 49% of older women afraid of partner

  27. Femicide – Suicide cases • Significant explanatory power for same femicide – suicide risk factors. • Unemployment – slightly different profile • Partner access to gun – used in 61% of homicide/ suicides vs. 28% w/o • Same proportions in Quebec (Lund & Smorodinsky ‘01) • Threats with a weapon • Forced sex • Step child in the home • Highly controlling perpetrator – especially if estranged • Estrangement • (52% of femicides w/suicide 56% w/o) & leaving “trigger” 31% vs. 33%)

  28. Femicide- Suicide • Unique to femicide – suicide: • Partner suicide threats – history of poor mental health – higher proportion to mental health care provider • In another study, majority of married femicide perpetrators failed to receive treatment for depression or received inappropriate anti-anxiety medications (Cohen, 2004). • Married • Somewhat higher education levels (unemployment still a risk factor), more likely to be white, Hispanic, Asian vs. African American • Children more likely to be killed along with female partner

  29. Intimate Violence Risk Assessment Validation Study – J. Campbell, C. O’Sullivan & J. Roehl – NIJ #2000WTVX0011 • N = 782 women who had accessed system through calling police, civil court, shelter or hospital ED’s – NY & CA • Relatively severely abused – 43% severe abusive tactic from CTS last 6 mos • 60% retention from Time 1 – more severely abused. employed & Latina less like to return • 38% foreign born; 28% African American; 48% Hispanic/Latina

  30. NIJ “RAVE” study • Women randomly assigned to 2 of 4 risk assessment methods • Also CTS, WEB scale, HARASS • Also 40 other items hypothesized to increase risk • Also 2 items to assess victim’s perceived risk • Recontacted 6 – 12 months later – interviewed by phone • Also a criminal justice record check for violent crime & DV offenses • Women – especially those who saw themselves at high risk took many impressive protective actions – all kinds • Their accuracy of perception of re-assault – significantly better than chance but

  31. ROC curve analysis (excluding 27 victims w/no exposure to abuser) with potential confounders • Chance - .50 • Any & severe re-assault – all significant at <.01 • DA - .694; .714 • DV-MOSAIC .618; .665 • DVSI - .650; .664 • K-SID - .639; .657 • Victim perception .635; .627 • Instruments/method improved on victim assessment • But none of approaches without serious margin of error

  32. Impact of the questionnaire • Repeat of self-perceived risk questions: not significant • Did answering these questions (CTS, 2 risk questionnaires, self-protective questions) change your view or thinking about his behavior? • No effect - 64% • More abusive or dangerous than I thought – 29% • Less abusive or dangerous than I thought – 7% • Do you think you will do anything differently in the future as a result of answering these questions (such as taking more safety precautions, or fewer; spending more or less time with him, etc.)? 61% yes

  33. Women’s Statements After Risk Assessment Process (NIJ RAVE study) • “I never knew – this makes me much more resolved to not go back” • “I’m gonna’ go get that permanent thing (PO) – I wasn’t gonna’ go through the hassle before but now I surely will” • “Damn…. He is really dangerous, isn’t he? I keep foolin’ myself about that – now I know I gotta do something” • “I knew he was scary but no one believed me – I’m going to keep pushing now” • From a woman in Alberta after doing the DA “It was like filling in a piece of a puzzle – I could finally see the whole picture"

  34. % taking protective actions during follow-up by victim perception of risk of serious harm.

  35. Effects of protective actions on severere-assault during follow-up

  36. Effects of protective actions on minor-moderate re-assault during follow-up

  37. Effects of protective actions on stalkingduring follow-up

  38. Conclusions re: protective actions’ effects on re-assault • Going to shelter at T1 significantly reduced risk of severe and moderate assaults • No voluntary contact with abuser during follow-up reduced risk of moderately severe assaults • Arrest at T1 reduced severe assaults • OP/RO reduced moderate assaults • Some protective actions at T2 likely to be response to assaults during follow-up • Places she thinks he can’t find her – often after a while, someone tells

  39. 75% children in common with abuser 52% - abuser having visits w/ children 51% of visits by court order Unsupervised – 73% Supervised – 27% 24%: Physical abuse, threats or intimidation during exchange for visits Visitation during Follow-Up

  40. GENERAL PRINCIPLES FOR RISK ASSESSMENT IN DV • More sources of information the better – “gold standard” for information is victim – without information from victim, cutoffs for lethality risk problematic – criminal record check important • Perpetrators will minimize perpetration • Few independent evaluations of current instruments – use any cutoffs with caution – DVSI or ODARA best if criminal justice records only & SARA with psych evaluation • Instrument improves “expert judgment” – but clinician wisdom important also • Never underestimate victim’s perceptions (Weisz, 2000; Gondolf, 2002) but often minimize victimization – therefore victim assessment of risk not enough if low • Need for DV identification and risk assessment as part of psychiatric practice

  41. Implications for Policy & Safety Planning • Clinical assessment (psychiatry, psychology) needs specific DV training • How to ask about DV as part of suicidality assessment • Batterer intervention - she needs to stay gone until he completes & his attendance monitored • Employment issues – especially for African American and aboriginal men • Protective order for stalking - or use stalking laws • Issues with various “risk” lists included in safety planning • Supervised visitation & other means of keeping her safe during visitation exchanges

  42. Implications for Policy & Safety Planning • Engage women’s mothering concerns & skills (Henderson & Erikson ’97 ‘93; Humphreys ‘93; Sullivan et. al.‘00) • If she says she’s going to leave, cannot leave face to face • Importance of forced sex & stepchild variables – not on most risk assessment instruments • Make sure she knows entire range of shelter services • Be alert for depressed/suicidal batterer • Batterer intervention programs working with partners

  43. Policy/Practice/Research Implications • Need for substance abuse Tx in abusive men – concurrent with batterer intervention? Combination programs? New models needed with rigorous evaluations • Need for collaborations btw. researchers & clinicians in substance abuse, health, criminal justice, forensic psychiatry and advocacy – for advances in risk assessment – research and policy

  44. Gun Issues • Get the gun(s) out!!! • Judges need to order removal of all guns – specify in search warrants & PO’s • Canada better about guns in general than US but still issues

  45. Future Directions • “Danger Assessment is a Process not a Product” (B. Hart) • Field developing rapidly – watch literature • Differentiating lethality & reoffending risk - different batterer typologies may explain differences (Holtzworth-Munroe) • Strategies for working with victims important – to increase their realistic appraisal and to determine risk factors not available from criminal record checks or from perpetrators never previously arrested – e.g. as part of batterer intervention programs • Assessing safety – protective strategies as well as danger – implications for interventions • Two parallel processes – reoffending risk for criminal justice cases; danger (lethality) – e.g. DVSI risk for victim safety planning

  46. Offenders in CJ or BIP Or MH or SA Tx Ideal Process Model First Responders B-SAFER or MD Lethality Assessment Women in Shelters Or Health Care System Risk Assessment Partners of Men in System Danger Assessment & Safety Assessment Judicial System System Safety Audit – Including Fatality Reviews

  47. Also with RAVE data – 3 item version of DA – submitted for publication • Outcome of those 666 who took DA & full data on return - N = 400 • Predicting those seriously re-assaulted – life threatening – seriously choked, shot or knifed or head injury with loss of consciousness (15% of total)

  48. 3 item version – acceptable validity for severe re-assault (ROC .79) • Violence increasing in severity &/or frequency over past year • Used a weapon on you/threatened with a weapon • Woman believes he is capable of killing her If one of 3 – 94% sensitivity but only 29% specificity If two yeses of 3 – 81% sensitivity & 56% specificity Either way – outperforms women’s perception of risk by itself

  49. Policy/Practice Possibilities • Use 3 item version in ED, protective order hearings, child custody etc. • If 2 of 3, do full DA and proceed based on results • If 1 of 3, tell her has one of 3 highly predictive risk factors for serious assault/homicide – highly recommend further immediate advocacy – call with her • If none of 3, proceed with normal referral/ procedural processes

  50. Never forget who it’s for - “please don’t let her death be for nothing – please get her story told” (one of the Moms)

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