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The Common Clinical Problem of Adult Intimate Partner Violence: Learning How to Incorporate Routine Assessments Into Your Practice Kathy McCloskey University of Hartford Graduate Institute of Professional Psychology 200 Bloomfield Avenue West Hartford, CT 06177 860.768.4442 firstname.lastname@example.org http://kathymccloskey.net/ APA-Approved Pre-Conference Workshop (4 CEUs) 33rd Annual Conference of the Association for Women in Psychology (AWP) March 13, 2008 San Diego, CA The Need for Training in IPV Over a decade ago, Harway & Hansen (1993) and Hansen, Harway, & Cervantes (1991) showed that therapists were not effective in identifying intimate partner violence (IPV) issues using a clinical case vignette. The case vignette was modeled after a real-life scenario where the male partner in the couple ultimately raped and then killed his female partner (see below). In their findings, Harway and colleagues found that psychologists addressed conflict in the vignette only about half of the time, while other mental health therapists did so only about 38% of the time. Overall, 40% of all therapists in their sample failed to address conflict at all. Lethality was not once addressed by therapists in their sample. Case Vignette Carol and James have been married 10 years. They have two children: Dana, 9, and Tracy, 7. James is employed as a foreman in a concrete manufacturing plant. Carol is also employed. James is upset because on several occasions Carol did not return home from work until two or three in the morning and did not explain her whereabouts to him. He acknowledges privately to the therapist that the afternoon prior to the session, he had seen her in a bar with a man. Carol tells the therapist privately that she has made efforts to dissolve the marriage and to seek a protection order against her husband because he has repeatedly been physically violent with her and the kids and on the day prior, he grabbed her and threw her on the floor in a violent manner and then struck her. The family had made plans to go shopping, roller skating, and out to dinner after the session. Initial questions included the following: 1. What is going on in this family? 2. Using the most recent version of the DSM, what diagnosis would you make? 3. How would you intervene? 4. What outcome would you expect from your intervention? 5. What are the legal/ethical issues raised by this case? The Need for Training (cont.) Since the studies by Harway and colleagues, IPV and domestic violence issues in general have become more visible within society as well as the mental health professions. For instance, child abuse and neglect and elder abuse have become important ethical issues, especially since the advent of mandatory reporting statutes. It is expected that, over a decade later, mental health service providers would be able to identify the issues surrounding IPV in a more effective manner. Indeed, this is what Raphael, McCloskey, & Kustron (in press) found recently when they replicated Harway and colleagues’ study. The Need for Training (cont.) Even though almost 85% of today’s clinicians identified the conflict as the main focus of treatment, only one identified lethality as a possible outcome of the scenario. Only about half of today’s clinicians suggested crisis intervention (including basic safety planning) of any sort as the intervention of choice. Because of this, it is important that clinicians become more aware of the issues surrounding IPV for all clients. Indeed, as will be shown below, clinicians should expect and plan to deal with clients that are presenting with IPV issues (either from the past, or in their lives now). Background Prevalence and Severity: Gender Asymmetry IPV victimization is primarily a genderized phenomenon – that is, women are disproportionately victims of IPV and men are disproportionately the perpetrators, resulting in gender asymmetry. While there have been controversies over IPV gender asymmetry in the literature (see Malloy, McCloskey, Grigsby, & Gardner (2003) for a recent review), research overwhelmingly supports the notion that women are more negatively impacted when it comes to the consequences of IPV. Regional surveys: Washington State: 23.6% of women reported experiencing IPV compared to 16.4% of men, and 21.6% of women reported experiencing injury during IPV compared to 7.5% of men (Washington State Department of Health, 2000). Gender Asymmetry (cont.) South Carolina: 25% of women reported a lifetime prevalence of IPV at the hands of a partner compared to 13% of men (South Carolina Department of Health and Environmental Control, 2000). U.S. national surveys: National Survey of Families and Households (NSFH): of those injured as a result of IPV, 73% were women and 27% were men (Zlotnick, Kohn, Peterson, and Pearlstein, 1998). National Crime Victimization Survey (NCVS): rates of IPV victimization were 7.7 per 1,000 for women but only 1.5 per 1,000 for men, and that over 50% of female IPV victims were injured as a result of IPV (Bureau of Justice Statistics, 1999; Rennison and Welchans, 2000). within this data set the proportion of male homicide victims due to IPV dropped significantly from 1976 to 1998, while the proportion of female homicide victims increased. Gender Asymmetry (cont.) National Violence Against Women Survey (NVAWS): lifetime prevalence of physical assault and/or rape at the hands of an adult intimate was 25% for women and 7.6% for men; men reported virtually no sexual violence in this sample. 45% of women versus 20% of men reported fear of serious injury or death at the hands of an intimate partner. women sustained injury, required medical treatment, were hospitalized, sought mental health treatment, lost work time, reported IPV to the police, and obtained a protection order at greater rates than did men. women were 22.5 times more likely to be raped than men, 8.2 times more likely to be stalked, and 2.9 times more likely to be physically assaulted by an intimate partner than men. 11% of women co-habiting with women experienced IPV compared with 30.4% of women co-habiting with men, and 7.6% of men co-habiting with women experienced IPV compared with 15% of men co-habiting with men -- co-habiting with a male increased the risk of IPV for both men and women (Tjaden & Thoennes, 2000a; 2000b). Gender in the Therapy Room: Clients Are Most Likely Women and Women Are Most Likely Survivors of IPV Because most recent research suggests that about one-quarter of all women in the U.S. have been victims of IPV at some time in their lives, service providers should not only expect but prepare for women presenting with problems directly related to IPV. This is especially important because women tend to access mental health services at greater rates than men (Addis & Mahalik, 2003; Mahalik, Good, & Englar-Carlson, 2003; Rhodes, Goering, To, and Williams, 2002). Possible reasons for this gender discrepancy? impact of male gender roles (the strong, stoic, silent type) on help-seeking behavior. the inhibition of emotional awareness needed to identify and own a personal problem (e.g., Moeller-Leimkuehler, 2002). Contextualization: Psychological Effects of IPV Victimization Walker (1994) and Herman (1992) provided reviews of the literature showing that up to 60% of women seeking mental health services also had a history of physical abuse, although they tended not to be diagnosed or treated specifically for IPV. Walker (1994) suggests that the historical “invisibility” of victimization within the mental health field is because providers simply do not ask questions. If the context of IPV is absent, the psychological sequelae of IPV in women masquerade as mental health symptoms which can lead providers to misdiagnose. Thus, clinicians must put the CONTEXT back into IPV by providing a complete and thorough assessment. Contextual Factors and Possible Mental Health Sequelae Fear In couples reporting IPV, women exhibit significantly more fear of their partners than did males. Both men and women report that, overall, men are not fearful of their female partners and tend to laugh or make fun of women’s aggression. On the other hand, women report significant long-term levels of fear toward their male partners (Cantos, Neidig, & O’Leary, 1994; Dasgupta, 1999). Mental Health Symptoms Traumatic brain injury due to repeated physical assaults may present as cognitive deficits (e.g., Jackson, Philp, Nuttall, & Diller, 2002). Elevated scores on standard personality assessment tools may be found (e.g., Morrell & Rubin, 2001). The psychological sequelae of IPV in women can present as “cognitive disturbances, high avoidance or depression behaviors, and high arousal or anxiety disturbances” (Walker, 1994, pg. 70). Contextual Factors (cont.) Bloom & Reichert (1999), Herman (1992), and Walker (1994) have documented the following symptoms that may arise as a result of IPV victimization: cognitive attentional deficits that may bring about a dissociative state, a chronically pessimistic cognitive style sometimes linked to depressive presentations, neurological deficits as a result of repeated head beatings and head shaking, avoidance behaviors including seclusion/isolation, denial, minimization, and repression of traumatic memories, high arousal symptoms including anxiety, phobias, sleep disorders and nightmares, sexual dysfunctions, panic attacks, nervousness, heart palpations, hypervigilance, hypersensitive startle responses, and obsessive/compulsive behaviors, and somatic sequelae from chronic exposure to abuse that can result in a breakdown of the immunological system, stomach/intestinal disease, susceptibility to infection, chronic headaches, and other physical diseases. Contextual Factors (cont.) Common Misdiagnoses schizophrenia (particularly paranoia) clinical depression generalized anxiety disorder obsessive/compulsive disorder psychosexual disorders somatoform disorders dependent personality disorder borderline personality disorder all without regard to the context of abuse (Dienemann et al., 2000; Gleason, 1993; Rathus and Feindler, 2004; Walker, 1991; 1994). Obviously, IPV victimization can lead to psychological symptoms that may be misdiagnosed if the context of victimization is neither recognized nor understood. Summary of Background Information Victims of IPV are overwhelmingly women, and thus are likely to suffer from psychological symptoms as a result of IPV victimization. Women constitute the majority of clients presenting for mental health services. Thus, chances are QUITE HIGH that victims of IPV will be on your caseload. There are clear, predictable psychological symptoms that result from IPV victimization which may be commonly misdiagnosed by a clinician who does not understand or assess the context of IPV. It is important that mental health clinicians understand this shortcoming and educate themselves about IPV so that effective assessment, diagnosis, and initial safety-planning strategies may be used. IPV Assessment Overview Below is presented a clinical assessment approach based on conceptual and theoretical issues that heavily emphasize safety, as well as years of clinical experience within the field of IPV. It should be noted here that this approach is designed specifically for use by non- forensic practitioners in the regular course of therapy and assessment. Use in forensic arenas may require a higher level of empirical support than currently available here. This approach would likely be most effective when used for all adult clients, not just female clients presenting for treatment. While it has been shown that women are the most common victims of IPV, men can also be victims -- it is helpful to keep this in mind throughout the IPV Assessment Flowchart Initial Assessment Screening Clients presenting for services should be asked a series of basic questions related to IPV issues. As part of routine clinical practice, adults within couples or families should be separated and screened privately for the presence or absence of IPV issues. It cannot be overstated -- safety is the reason for separating adult partners during couple/family therapy for IPV assessment procedures (Rathus & Feindler, 2004). For some clients, this may be the first disclosure to any official social agent, and can represent extreme danger to the victim (Bograd & Mederos, 1999; Davies, 1994; McCloskey & Fraser, 1997). Initial Screening (cont.) It is not unusual that disclosure by the victim is followed by severe levels of violence from the perpetrator. This crucial safety issue must be kept in mind by the clinician during the initial contact, as well as throughout all future contacts with either the victim or perpetrator (Bograd & Mederos, 1999; Campbell, 2002; Davies, 1994). During the initial contact, if the individual adult denies that IPV is present in her/his life, stop the initial screening process for that session. However, since many victims (and especially perpetrators) do not initially admit to IPV when first asked due to numerous valid reasons such as fear, shame, and guilt (Campbell, 2000; 2002), revisiting the screening process whenever appropriate throughout later sessions is very helpful. Initial Screening (cont.) Relationship content brought up by the client throughout later sessions presents an ideal opportunity for the clinician to once again complete an IPV screening. Should the client disclose IPV concerns later in therapy, the full-scale assessment can be completed at that time. The IPV screening is a series of questions that asks about arguments between partners that have occurred in a client’s relationship, beginning in a general sense and becoming quite specific in terms of partner and client behavior. These questions can be converted into standardized interview questionnaires that the clinician follows during session, or can be memorized with practice by the clinician to eliminate the need for a written format. Initial Screening (cont.) To save time, some clinicians may be tempted to create a client IPV “paper-and- pencil” screening questionnaire to be filled out during standard paperwork intake procedures. However, it has been shown that clients tend to self-disclose painful and sometimes shameful IPV material at a greater rate during face-to-face interviews than on paper-and-pencil questionnaires (Campbell, 2000; Murphy & O’Leary, 1993). Thus, the recommendation remains that the screening be completed interpersonally between therapist and client, perhaps supplemented with paper-and-pencil questionnaires. The IPV screening questions given below assume that clients are presently in an intimate relationship with an adult partner. If clients are not in a current relationship, therapists should still complete the screening because past victimization can influence current psychological symptom presentation and concerns. Screening Questions Full-Scale Assessment Once the therapist has determined there is indeed the presence of IPV in a client’s life, a full-scale IPV assessment can be completed. This assessment consists of three sections: History taking Determination of the primary batterer and victim Degree of lethality These three areas help the clinician assess the frequency, duration, and intensity of IPV as well as possible avenues for effective intervention. History Taking History-Taking questions are further grouped into three content areas: (a) IPV across time in context (including injuries) (b) Intervention by others (including the criminal justice system) (c) Co-occurrence of drug-use or other mental health issues History Taking: IPV Across Time History Taking: Intervention by Others History Taking: Mental Health/Substance Abuse Issues Determination of Primary Batterer and Victim Determining the primary perpetrator and the victim is sometimes very obvious from the results of the initial screening as well as the history obtained earlier from portions of the full-scale assessment. However, there may be controversy concerning the person responsible for the continuing abuse in the relationship, especially with same-sex intimate partners, or some opposite-sex partners. Sometimes, determining the pattern of control and intimidation becomes difficult. This section of the full-scale assessment is designed to specifically address this issue. Primary Batterer/Victim (cont.) Even though the victim’s identity may be obvious from earlier clinical data, it is still recommended that the following be completed. This is so the psychological effects of IPV can be more completely described for each client, and to aid in diagnosis. This section provides: questions to elicit the way clients attribute meaning to the IPV incidents, and conceptual factors to help the clinician organize each client’s viewpoints and IPV attributions so that the primary batterer and victim can more easily be determined. Primary Batterer/Victim (cont.) These conceptual factors are primarily the work of victim advocates from the Artemis Center for Alternatives to Domestic Violence (1992) and McCloskey and Fraser (1997) that represents a liberal adaptation, integration, and expansion of their original presentations. These factors are given so that the clinician may categorize client responses in a reasonable fashion. It should be noted that for both primary batterers and victims, there are important “exceptions to the rule” for every indicator. Thus, therapists may wish to use this information in a check-list format so that the preponderance of clinical evidence drives their determination. For example, if a particular client fits a majority of indicators in the victim list, then it bolsters clinician confidence that the client indeed is the primary victim in the relationship. Meaning-Making and Victim/Perpetrator Determination (adapted from Artemis Center for Alternatives to Domestic Violence, 1992 and McCloskey and Fraser, 1997) Primary Victim Primary Victim (cont.) Primary Victim (cont.) Primary Batterer Primary Batterer (cont.) Primary Batterer (cont.) Lethality Assessment For safety reasons, the lethality assessment must be completed in every reported instance of IPV, and should be updated throughout the course of treatment (i.e., when new information comes to light due to periodic therapist inquiry and/or spontaneous client self- disclosure). Lethality is grouped into six content areas: (a) severity of violence (b) obsessive/stalking behaviors (c) psychological risk factors (d) other criminal behaviors (e) failure of past interventions (f) other Lethality Assessment (cont.) A predominance of risk factors should help the therapist determine the severity of the situation and the urgency with which she or he must act. This lethality assessment is liberally adapted from victim advocacy work (Artemis Center for Alternatives to Domestic Violence, 1992), results of community collaboration within the state of Ohio (Montgomery County Criminal Justice Council, 1996), and empirical research in the field (e.g., Campbell, 2002). Besides the standard homicidal/suicidal risk assessment items such as intent, plan, time, place, and means (Bennett, 2003; Sanchez, 2001; Shneidman, 2001), there are other lethality “red flags” unique to IPV. RED FLAGS The following batterer behaviors and beliefs should alert the clinician to the presence of extreme risk of lethal violence in order of importance (Campbell, 2002; Kropp & Hart, 1997; McFarlane, Campbell, & Watson, 2002): (a) batterer perception that relationship is threatened and/or ending (infidelity, separation, divorce, etc.) (b) past/present threats by batterer to kill self or partner (including statements such as: “I can’t live without you” and “If I can’t have you, no one will”) (c) batterer unemployment (suggests that batterer has “nothing to lose”) (d) past/present batterer violence, including attempted strangulation of victim (e) batterer stalking and monitoring behavior (a) batterer drug/alcohol use IMPORTANT! The presence of even one of these factors (especially separation or divorce) is a sign that the clinician needs to be highly wary of future lethal violence and provide safety plans to both the batterer and victim accordingly. The presence of all six of the above factors should alert the clinician that outside help for the batterer is warranted (hospitalization, contacting the police, etc). Lethality Assessment Items Lethality Assessment Items (cont.) Therapist Knowledge of Barriers in the Environment Therapists should also know about the resources available in the community and firmly imbed client experiences within the surrounding environment (Davies, 1997; Dutton, 1992; Grigsby & Hartman, 1997; McCloskey & Fraser, 1997). First, therapists should educate themselves about the local criminal justice system response to IPV, most notably regulations and assumptions of county and state laws that impact their communities. Due to reasons of safety, therapists should be able to understand their crisis intervention options in the face of high risk (e.g., criteria for hospitalization of the batterer versus police intervention), and convey accurate information concerning legal options to victims. At the very least, therapists should have referral information on hand that direct clients to the appropriate resources (IPV court advocates, etc.). Knowledge of Barriers Second, therapists should be cognizant of the effects that cultural and gender-based societal expectations can have on clients and how these expectations may present barriers to effective intervention. For example, negative interactions with socially-sanctioned officials in the past by members of minority populations may create barriers to accessing community services that could help reduce lethality. Third, therapists should examine their own psychological conceptualizations in order to recognize and honor not only the dangerousness inherent in IPV cases, but also the extreme impact that IPV can have on victims and children. This issue brings a therapist squarely into the reinterpretation of standard assessment techniques within an IPV context. In other words, clinicians must be able to embed and integrate standard psychological assessment and intervention strategies within the issues shown below. Barriers in the Environment (adapted from Grigsby and Hartman, 1997) Barriers in the Environment (cont.) Barriers in the Environment (cont.) Barriers in the Environment (cont.) Initial Safety Planning Once the IPV screening and full-scale assessment is completed, you will then have a good idea of the level of lethality inherent in the situation. Hopefully, you will also have embedded specific client information within the possible barriers to safety within the environment. For example, in the clinical vignette used by Harway and colleagues (Hansen, Harway, & Cervantes, 1991; Harway & Hansen, 1993) mentioned earlier concerning the male intimate partner who raped and then killed his female partner shortly after their family visit to a therapist, the partners would have been separated and the IPV screening would have commenced. You would then complete the full-scale assessment procedures with each partner, ending with a determination of the primary victim/batterer and completion of the lethality assessment. Safety Planning (cont.) Once barriers to safety were identified for both the victim and perpetrator, safety planning could then be tailored to the unique characteristics of both the clients and the situation. There are two major issues that we should also consider for safety reasons: First, we must have a profound understanding of the barriers in the environment that support on-going violence. If these barriers are not understood, safety planning may well be ineffective or put clients at greater risk. Second, it cannot be overstated that even when a safety plan is in place, there is no guarantee the victim will be safe. Safety Planning (cont.) Furthermore, we may be drawn to first intervene with the victim of IPV since this individual usually is the most motivated for change (McCloskey & Fraser, 1997), and may be the only presenting party in the therapy room. We should always intervene with the primary batterer when possible (such as in couple’s or family therapy), build compliance as much as possible, and be willing to bring in outside authorities if lethality is high (similar to managing homicidality/suicidality in other clinical situations; Bennett, 2003; McFarlane, Campbell, & Watson, 2002; Sanchez, 2001; Shneidman, 2001). The engagement of resources by the therapist outside the therapy room (hospitalization, contacting the police, involving other adult family members, etc.) will be a judgment call based on the level of lethality. As discussed above, presence of the most lethal, high-risk factors may tell the clinician that outside authorities should be contacted in order to keep all parties safe. Safety Planning (cont.) If the victim is the only individual presenting for services, safety plans can still be devised. By discussing with victims the safety plan shown below, we underscore the level of danger the batterer represents and sending the message that the therapist takes this risk very seriously. It is possible that we could copy this safety plan as a handout and give to victims after explanation in session has occurred and any possible barriers to implementing the plan are explored. However, the victim is usually not the family member who is in most danger of using lethal violence, although it is possible victims may use violence as a self-defense measure (Malloy et al., 2003). While an in-depth discussion of long-term intervention strategies is outside the scope of this presentation, the reader is referred to Campbell (2002), McCloskey and Fraser (1997), and Walker (1994) for further discussions of IPV safety planning, initial treatment plans, and long-term interventions, respectively. Safety Planning With Clients Who Are IPV Victims Safety Planning With Clients Who Are IPV Victims (cont.) SUMMARY Concrete intervention strategies were presented, beginning with initial screening procedures and ending with in-depth assessment approaches. The recommended assessment began with very specific, direct questions concerning IPV as part of screening and history taking which included examination of specific violent behaviors, the occurrence of IPV across time, intervention by others, and the co- morbid presence of substance abuse or other mental health issues. The assessment then moved to questions assessing the meaning that clients attribute to IPV as well as the effects of IPV, followed by a conceptual model with which the therapist can organize all the preceding information in order to determine the primary victim and batterer in the IPV situation. Summary (cont.) Finally, all the information gleaned from the above was integrated into a lethality assessment as an aid for determining the seriousness of the violence and the urgency with which the therapist should intervene, all within the context of possible barriers to safety found in the environment. The assessment moved from the concrete to the abstract. Thus, this approach was designed specifically to incorporate both clinical data collection and conceptualization. It is hoped that this approach will help us all become more mindful of the ubiquitous presence of IPV in clients’ lives. It is also hoped that the presentation of concrete strategies for assessing dangerousness will increase the chances that therapists will assist clients in remaining safe WRAP-UP Questions? Answers? Comments? Suggestions for Improvement?