Teaching package on domestic violence

1. Teaching package on domestic violence Name of presenter and institution

2. Introductions What would you like to get out of the workshop?

3. Aims and objectives • To be aware of the different types of violence • To be able to Identify risk factors for violence • To be able to recognize patients presenting with a variety of signs and symptoms due to violence • To gain understanding of all potential victims of abuse including children and the elderly • To be able to recognize and identify culture as a separate category of risk • To be able to know how to proceed with a case using a trauma informed approach once a patient discloses that they have violence concerns • To be aware of local support services including the immediate priority of a safety plan after disclosure of violence • To be aware of the role of  men and boys in prevention and treatment • To be aware of resources for survivors of violence • To be aware of screening tools for domestic violence • To have an awareness of the long term needs of abuse survivors

4. Outline of the presentation • Definition of domestic violence (DV) • Common risk factors forDV • Those who are affected by DV • Signs and symptoms of violence • Children and the elderly • Cultural factors • Preventative programmes

5. Group activity In groups consider three questions What is domestic violence and what different forms may it take? List commonly found factors in cases of domestic violence List all those who may be victims of domestic violence

6. Definition of domestic violence • Domestic violence is defined as abuse between persons in an intimate relationship, independent of gender, age, sexuality or marital status.

7. Types of domestic violence • Inflicting or attempting to inflict physical injury • Detrimentally affecting health • Sexual – coercion or undermining of victims sexuality • Psychological - fear and isolation • Emotional • Economic • Digital/online abuse • Honour killing and forced marriage

8. Common risk factors for domestic violence • Alcohol and/or drug abuse • Fighting and then reconciliation • Pleas for forgiveness, promises to reform, lovemaking and then further cycles • Perpetrator is often very loving and repentant following a violent outburst intensifying his partner’s attachment • Socially isolated and disadvantaged including those with poor command of country’s language • Frequent house moves • Low academic achievement • Being a victim of physical or psychological abuse • Experience of poor parenting or physical discipline as a child • Unemployment • History of causing physical abuse or aggression • Borderline or antisocial personality traits

9. Victims of domestic violence • Anyone irrespective of age, sex, education, race, marital status culture, religion, or employment status • Affects all the family • Affects children • Affects the elderly

10. Signs and symptoms of domestic violence Case • Nicole aged 35 years is a nurse and mother to 2 young children • Attends for anaesthetic consultation • Refuses to take off scarf and long sleeved blouse • Female doctor persuades her to do so and sees many bruises on the arms and marks on the neck as if someone had tried to strangle her Discuss what other signs may be present

11. Signs and symptoms of domestic violence • Bruises and scratches • Bites • Broken limbs • Loosing weight • Depressed • Attempting suicide • Multiple health problems

12. Children

13. The Elderly

14. Case study: A typical case of elderly domestic violence (Finland) • 79 year old woman • Lives with her son in a 2-room apartment • Seen in day care clinic as “fell over her rollator” and bruised herself the previous evening • Difficulty breathing, widespread pain all over body, sad, shaking and making no eye contact whilst talking • Started to cry on a number of occasions during the conversation and examination • Geriatric doctor noted numerous bruises and hematomas on her body, forearms, left cheek and orbit, where a fracture was subsequently diagnosed https://mwiaviolencemanual.wordpress.com/2016/03/28/case-19/

15. Case study: elderly domestic violence Further details • Multiple old rib fractures • Previously examined due to falling – no change on lying and standing blood pressure • Denies alcohol consumption • Had malnutrition with weight of 45 kg • Plasma albumin well below normal. • Refused to eat and expressed wishes of wanting to die • Cognitive status was defined by tests as mild impairment https://mwiaviolencemanual.wordpress.com/2016/03/28/case-19/

16. How would you manage this case? • What do you think the problems are? • What screening tools could you use? • What can be done to help the patient?

17. Learning points for domestic violence of the elderly Risk factors connected with elderly abuse • Shared living • Lack of privacy (small apartment) • If weak or other illnesses more likely to be abused • Risk factors in carereg financial problems, alcohol, unemployed leading to dependence on elderly person EASI, the Elder Abuse Suspicion Index lists various signs that may indicate abuse such as • Poor eye contact • A withdrawn nature and malnutrition Most patients refuse to report the abuse • They are ashamed or are afraid of the perpetrator. • In hospitals the patient usually does not know the physicians and the lack of trust also prevents them from telling the truth • Become depressed as see no way out and may stop eating and drinking

18. Screening tool: EASI-questions • Instruction: Q.1-Q.5 asked of patient; Q.6 answered by doctor • Within the last 12 months: • Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals? • Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with? • Have you been upset because someone talked to you in a way that made you feel shamed or threatened? • Has anyone tried to force you to sign papers or to use your money against your will? • Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically? • Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months? https://www.medicine.uiowa.edu/uploadedFiles/Departments/FamilyMedicine/Content/Research/Research_Projects/easi.pdf

19. Outcome • Involvement of multidisciplinary team(doctor, nurses, social worker, physiotherapist and occupational therapist • Guardianfor the patient’s economic interests appointed • Supportive psychotherapyfor the patient to enable her to deal with the problem • Separate living facilities for mother and son organized by social worker (mother stayed in her own home) • Weekly contact with other elderly people was organized by the city council and the local church • Patient has regular (three times weekly) visits by the nurse from the local health centre to support her to function at home (regular medicine usage, buying together products from the local store, etc) • Temporary restraining order put in place as patient experienced strong fear reactions towards her son a was put https://mwiaviolencemanual.wordpress.com/2016/03/28/case-19/

20. Useful resources

21. Useful resources

22. Useful resources

23. Role of men and boys in prevention and treatment • In some cultures, boys feel entitled to abuse women. A man is always right • Women are raised with a sense of subservience, they are prepared for rape • High rate of incest. VAWG has always been seen as a woman’s problem • In many countries the focus has turned to prevention, starting in schools, working either with boys alone, or with boys and girls • Variety of initiatives eg Kenyan school project • ‘He-for-She’ campaign launched in 2014 to encourage men and boys to be advocates for gender equality • White Ribbon Alliance which is the world’s largest male-led movement to end men’s violence against women • Programmes to prevent men reoffending

24. Cultural issues

25. Permanent disfigurement

26. Death

27. Case to illustrate perpetrator programmes • Jason rang the Respect helpline following an incident of violence where he had grabbed his partner Elly by the hair and thrown her to the floor, causing bruising to her face and a sprained wrist • This was not the first time Jason had been violent but it was the first time Elly had been visibly injured • They both had good jobs and 2 children together What are the issues? – discuss in groups

28. Support put in place • Phoneline workers spent some time talking with Jason and referred him to a local DVPP • Elly initially reluctant to involve outside agencies as she felt ashamed to be a victim of domestic violence • Independent support service for Elly • Jason learnt to be non violent but struggled with being non-controlling • Group work with Jason re-enacting worst violence made him realise full impact on Elly and children • Elly felt safe for family to continue to all live together

29. Preventive measures • Screening to detect more cases • Better caregiver support and training • mandatory reporting • general awareness rising • Advocacy • Training of physicians to detect signs of abuse Use the MWIA training module on violence

30. MWIA´s training module on violence https://mwiaviolencemanual.wordpress.com/