Family Violence: Intimate Partner Violence (IPV)

1. Family Violence:Intimate Partner Violence (IPV) Ashley Owen, Ph.D. Emory University Department of Family and Preventive Medicine

2. Understanding Intimate Partner Violence

3. Understanding Intimate Partner Violence Learning Objectives: 1.) Place knowledge about the definition, epidemiology, and demography of intimate partner violence into a clinical context. 2.) Develop competence at routine inquiry about intimate partner violence using the ASSERT model. 3.) Formulate an action plan with immediate support for an abused woman returning to an unsafe environment. 4.) Facilitate an abused woman's consideration of and access to local community services and agencies.

4. Key Elements of IPV • Usually a pattern of assaultive and coercive behavior, not an isolated event; includes physical, sexual, and psychological attacks, as well as economic coercion • Perpetrator and victim are known to each other and have shared an intimate relationship.

5. Key Elements of IPV (cont.) • A combination of physical attacks and controlling tactics used by perpetrators that result in fear, as well as physical and psychological harm, to their partners and children. • A pattern of purposeful behavior, directed at achieving compliance from or control over their partner.

6. Prevalence of Intimate Partner Violence • 22% of women report lifetime prevalence • Gay and lesbian couples are at same, and possibly grater risk than heterosexuals for partner violence (30%-40% of lesbians) • More prevalent among women than diabetes, breast cancer, and cervical cancer • 30% of murdered women are killed by their intimate male partners • Findings of 45% of wives of alcoholic men have been beaten (alcohol drug most commonly associated with IPV)

7. Family Dynamics of IPV and Alcohol Abuse both substances and violence are used to resolve conflict and cope with stress; discharges tension, ends the argument, or asserts control. secrecy is maintained about both violence and substance abuse (shame, fear of unwanted intervention, and the feared career or social consequences of disclosure).

8. Family Dynamics of IPV and Alcohol Abuse Particularly due to the increased risk of harm in a family that experiences both substance abuse and family violence, after treating injuries… … the provider must FIRST focus on immediate safety planning for the victim of violence and other family members.

9. Patient Symptoms often associated with IPV • Pain in any place in the body • Vaginal discharge • Constipation • Diarrhea • Shortness of breath • Choking • Difficulty sleeping • Fatigue • Nightmares • Depression and/or anxiety • Hx of substance abuse • Suicidal Ideation

10. Progression of Violence • Phases – build-up, explosion, honeymoon

11. What keeps women in the relationship? • fear of partner’s actions (I’ll never be safe, I might as well live with him) • effects of IPV (Can’t face making decisions) • roles the culture forces on women (guilt, economic) • personal history (My father beat my mom – it just goes along with being in a relationship)

12. What keeps women in the relationship? • isolation and lack of resources The most harmful tactic an abuser can use is isolating the victim from social contacts. The world the victim lives in becomes a reality from which it is difficult to escape. (He wouldn’t let me see friends or family for so long, now I don’t have anyone to stay with anymore…) • love and hope (I don’t want to give up the good times; I keep hoping he’ll change)

13. How to think about what’s going on with your IPV patients … and how to help them.

14. STAGES OF CHANGE MODEL

15. STAGES OF CHANGE MODEL • Changing behavior is a dynamic and cyclical process and one progresses through stages in trying to modify their behavior • Stages of change – readiness to change • Processes of change – techniques or strategies to bring about change

16. STAGES OF CHANGE MODEL • Assist as your patient moves along the stages of change process (transtheoretical model of behavior change) • precontemplation • contemplation • preparation • action • maintenance

17. STAGES OF CHANGE MODEL • Precontemplation • typically referred by others • do not intend to change • relatively unaware of situation • defensive • feel helpless, and resourceless • often accept batterer’s definition of the situation-that violence is her fault • counseling: thought-oriented

18. STAGES OF CHANGE MODEL • Contemplation • intend to change but only thinking about it and not committed to changing • may use this stage to build social and emotional support and explore options for financial independence • stay in this stage for as long as weigh pros and cons of leaving the batterer • counseling: thought-oriented

19. STAGES OF CHANGE MODEL • Preparation • actively plan to change and are ready for action • develop a safety plan • discuss with a friend of family member who may provide a safe house • call an abuse hotline • set aside emergency money • contact an attorney or law enforcement • leave the abuser briefly • counseling: thought and action-oriented

20. STAGES OF CHANGE MODEL • Action • overtly make changes • implement a safety plan • leave abuser • demand and receive a reduction in, or an end to, the violence

21. STAGES OF CHANGE MODEL • Action (cont.) • tell others about the IPV and get support • obtain community support and resources • highest risk of “relapse" (recycling) during this phase • counseling: thought and action-oriented

22. STAGES OF CHANGE MODEL • Maintenance • solidify change and resist temptations to relapse • continue to work to maintain a violence-free life • counseling: thought and action-oriented

23. STAGES OF CHANGE MODEL • Once the woman is safe and has progressed to the action or maintenance phase, she may choose to engage in interventions for her trauma (ex. PTSD). “ It’s not that some people have willpower and some don’t. It’s that some people are ready to change and others are not.” - James Gordan

24. IPV ASSESSMENT: Why is it so important? • Part of any complete interview – (contribution to psychiatric/physical concerns) • Potential harm of not asking… (message to patient, help patient understand relations among abuse, health problems, and risk bx, unassessed risk) • Therapeutic value of compassionate inquiry Inquiry and support really do bring value to patients’ lives.

25. IPV ASSESSMENT: Why is it so important? "Since I can't rescue victims, I realize all I need to do is be empathetic and supportive, and this simple intervention can really help empower someone"

26. IPV ASSESSMENT: Barriers for providers • Lack of IPV education • Lack of time • Lack of effective interventions • Powerlessness • Fear of offending the patient • Privacy concerns • Personal history of abuse

27. IPV ASSESSMENT: Barriers for patients • Not asked by the clinician • Concerns about confidentiality • Perception that clinicians are not interested • Perception that clinicians have no time • Fear of involving the police • Embarrassment • Fear of retaliation

28. IPV ASSESSMENT: HOW TO… • Ask • Sympathize • Safety • Educate • Record • Treat (refer) It really is that simple!

29. ASK (sample introduction questions ) • How would you describe your relationship? • How do you and your partner work out problems? • I ask many of my patients about their family life as it affects their health and safety. May I ask you a few questions? • Sometimes when I see an injury like yours, it is because somebody got hit. How did you get this injury/bruise?

30. ASK (sample introduction questions) • What happens when there is a disagreement with your partner or others in your home? • Have you ever been hurt or threatened by your partner? • Do you ever feel afraid of (controlled or isolated by) your partner?

31. ASK (sample follow-up questions) • Has the violence gotten worse or scarier? Is it more frequent? • Has your partner ever threatened to kill you, him/herself or your children?

32. SYMPATHIZE (sample statements) • You don’t deserve this abuse and it is not your fault. • I’m afraid for your safety and that of your children. • You are not alone and help is available. • I will be here to help you. • I am here to listen. • I want to help you with this.

33. SAFETY (review with patient) - Do you have an escape route? • Doors, stairs, first floor windows, basement exits - Do you have a safe place to go to? • Home of relative/friend with unconditional support, motel, shelter - Do you have a survival kit? (hide safely or leave with trusted person) • Money, extra house and car keys and documents, ID documents (passports, birth certificates), insurance papers, checkbook and credit cards, legal documents (marriage/ separation agreements, protection orders, papers of joint ownerships), change of clothes, valuable jewelry

34. SAFETY (review with patient) • Know Domestic Violence hotline phones # and research shelter info. • Try to start individual savings account (and have statements sent to trusted person).

35. EDUCATE (sample statements) - Violence tends to continue and often becomes more frequent and severe. (cycle of violence discussion) - Domestic violence is common and happens in all kinds of relationships. - Abuse can impact your health in many ways.

36. REPORT • Document patient’s statements within chief complaint, history of present illness or social history (based on what is most pertinent). • Avoid judgmental documentation • Use “patient declines services at this time” and “patient states (or shares) that…” instead of “patient refuses help” or “patient alleges…” • Offer to report with the patient or provide documentation to help him or her report.

37. TREAT • Encourage patient to follow – up with you (open-door policy). 2) Provide referrals Hotline number Legal referral Shelter number In-house referral

38. IPV Assessment: Things to Remember • Offer nonjudgmental acceptance and validation of the battered woman and her experience • Provide immediate support and form a working alliance • Assume self-determination • View coping strategies as strengths, not pathology

39. IPV Assessment: Things to Remember • Not asking may negatively impact the physician – patient relationship. • Statements expressing sympathy, concern, and legitimacy enhance patient satisfaction with care. • Most (74%) women want their physicians to ask.

40. IPV Assessment: Things to Remember "By backing off from a rescuing role and instead respectfully appreciating someone's strengths..., my relationship with my patients becomes more important in their lives.”

41. CONCLUSION/QUESTIONS? Remember: • WE CAN MAKE A DIFFERENCE!!!