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- 3. Definition of Domestic ViolenceDefinition of Domestic Violence The use of physical, sexual, economic, and/or emotional abuse by one person in an intimate relationship in order to establish and maintain power and control over the other person
- 4. Who areWho are thethe VICTIMS ?VICTIMS ?
- 5. THE VICTIMSTHE VICTIMS • Domestic violence happens between people who are dating, married, separated, and divorced. • It occurs in heterosexual as well as in gay and lesbian relationships and in adolescent dating relationships.
- 6. Who are theWho are the VICTIMS?VICTIMS? Victims cross all socio-economic, religious, racial, ethnic, age groups
- 7. THE VICTIMSTHE VICTIMS Stacy Allison First American woman to summit Mount Everest “When people meet me, and find out that I’ve been in an abusive relationship… they just can’t believe it.” “Looking at me, with all the things I’ve done in my life.. They think, how could I have been in a relationship like that?”
- 8. THE VICTIMSTHE VICTIMS • Women represent 95% of adult victims * • Between 1 and 4 million women abused per year • Lifetime risk for women is about 20 – 30% • *Why might this figure be inaccurate?
- 9. THE VICTIMSTHE VICTIMS Domestic violence is the leading cause of injury to women ages 15-44 in the United States
- 10. THE VICTIMSTHE VICTIMS Research suggests DV results in more injuries to women requiring medical treatment than rape, auto accidents and muggings. (US Senate Judiciary Committee, 1992; Stark & Flitcraft, 1988)
- 11. •Why don’t they just leave?
- 12. Why don’t they just leave?Why don’t they just leave? FEAR LOW SELF ESTEEM ISOLATION LACK OF RESOURCES PROMISES TO CHANGE
- 13. “Everyone seems to think that what you need to do is to just leave the relationship and then everything will be fine.” That’s the myth. The reality is that the violence escalates if you try to get away. “I knew that not only did I have to leave, I had to DISAPPEAR.” FEARFEAR
- 14. FEAR SEPARATION VIOLENCEFEAR SEPARATION VIOLENCE • 73% of battered women seek emergency medical services after separation (Stark, 1981) • Up to 75% of domestic assaults reported to police are made after separation (US Dept. of Justice, 1995) • Women are most likely to be killed when attempting to report abuse or leave the abuser (Sonkin, 1985) • Approximately one-half of males who kill their wives, do so after separation (Hart, 1992)
- 15. “I thought that I was worthless, that I couldn’t do anything right.” I thought I was ugly, just a horrible individual … no one would ever love me and I myself was incapable of love.” LOW SELF ESTEEM:LOW SELF ESTEEM: Cause orCause or Consequence?Consequence? Stacy First American Woman to summit Mount Everest
- 16. LEAVING IS A PROCESSLEAVING IS A PROCESS “I think I left 12 times before I finally stayed gone. When I look back on it now, I realize I was practicing. It was a process… it took time, I had to learn how to leave and I had to learn how to stay gone.”
- 17. Promises to ChangePromises to Change “I don’t really know why I kept going back... He begged me to, swore he’d never do it again.” “And, I wanted to hear it. I was overweight, I felt unloved…”
- 18. “After years of violence, I was completely bewildered. I didn’t know how to get away!” There has to be a place to go to, its not just a matter of leaving from someone. And, for many victims of domestic violence that place either doesn’t exist or they don’t know that it exists. LACK OF RESOURCESLACK OF RESOURCES
- 19. Leaving is a ProcessLeaving is a Process • Safety Issues • Threats of Retaliation • Fear of Talking about Abuse to Others • Breaking Isolation • Access to Resources • Survival Strategies • Batterer Accountability
- 20. Leaving Is a ProcessLeaving Is a Process • SURVIVORS OF DOMESTIC VIOLENCE DO LEAVE! – They leave when they are ready – They leave when it is safe to do so – We can support their process by providing an institutional response affirming battered women and their decision making ability
- 21. DYNAMICS OFDYNAMICS OF DOMESTIC VIOLENCEDOMESTIC VIOLENCE POWER AND CONTROL
- 22. THE DYNAMICS OFTHE DYNAMICS OF DOMESTIC VIOLENCEDOMESTIC VIOLENCE • A pattern of assaultive and coercive behavior • Physical • Sexual • Psychological threats intimidation emotional abuse isolation • Economic
- 23. DYNAMICS OFDYNAMICS OF DOMESTIC VIOLENCEDOMESTIC VIOLENCE “Either dinner wasn’t exactly what he wanted, the house wasn’t immaculate, I didn’t look presentable enough… any excuse at all, really… and it was always my fault.” “ It was very debilitating, I ended up walking on eggshells. I began questioning my own competence to do anything.”
- 24. THE DYNAMICS OFTHE DYNAMICS OF DOMESTIC VIOLENCEDOMESTIC VIOLENCE • “It started out slowly. At first he just wanted to know where I was going all the time. Then he wanted to tell me where I was going all the time. By the end, I wasn’t allowed to go anywhere.” • “If I went out with my girlfriends, I knew I would come back to find the house trashed… he would always break something he knew I really cared about.”
- 27. Who are theWho are the BATTERERS?BATTERERS? Batterers cross all socio-economic,Batterers cross all socio-economic, religious, racial, ethnic, age groupsreligious, racial, ethnic, age groups
- 28. Characteristics of Batterers Sense of Entitlement Controlling Manipulative Frequently Charming Uninvolved parent Show contempt for others Extreme Jealousy
- 29. THE BATTERERSTHE BATTERERS • DV Is Learned Behavior by Batterers • DV Is NOT Caused By: – Illness – Genetics or gender – Alcohol or other drugs – Anger – Stress – Victim’s behavior – Relationship problems
- 30. The BatterersThe Batterers • One study done with men who wanted to avoid prison did find 2 types of batterers: • Pit bulls • Snakes
- 31. What Makes Batterers So Powerful?What Makes Batterers So Powerful? • Isolation of victim • Societal Denial • Use of Religious Issues • Use of Cultural Issues • Threats of Retaliation
- 32. THE CHILDRENTHE CHILDREN Perpetrators of domestic violence traumatize children (1) Physical injuries - intentional - unintentional (2) Psychological injuries - witnessing violence
- 33. THE CHILDRENTHE CHILDREN Effect on Children: • In 85% of police calls for domestic violence, children had witnessed the violence • Witnessing parental violence is a risk factor for: Males- to physically abuse Females- to become victims of abuse
- 35. DOMESTIC VIOLENCEDOMESTIC VIOLENCE and the Emergency Departmentand the Emergency Department • 30% of all female trauma patients • 22-35% of all females presenting to the Emergency Department • most are repeat ER patients 20% 11 or more abuse related visits 23% 6-10 abuse related visits
- 36. DOMESTIC VIOLENCEDOMESTIC VIOLENCE SEQUELAESEQUELAE In the 12 month period following violence: – Victims use health care services twice as often as non-victims – Healthcare costs were 2.5 times higher for victims Victimization was the single best predictor of total yearly physician visits and of outpatient health care costs
- 37. FAILURE TO DIAGNOSEFAILURE TO DIAGNOSE DOMESTIC VIOLENCEDOMESTIC VIOLENCE • Inappropriate treatment • Increase victim’s sense of helplessness and entrapment • Lost opportunity to refer to appropriate community resources • Increase danger to the patient
- 38. REFER - Intervention With aREFER - Intervention With a VictimVictim • Be aware, materials and referrals you provide a victim may place her in danger • Make a follow-up appointment
- 39. LawsLaws Rule of thumb Family vs. criminal court (1962, NY) Suffolk County has a mandatory arrest law: pros and cons? VAWA (1994)
- 41. ResourceResource • VIBES: 631-360-3606 • National Domestic Violence Hotline: 1−800−799−SAFE(7233)
- 42. • http://www.youtube.com/watch?v=uelHwf8o7_U • How is the video accurate? How is it not accurate? Why would Rhianna and Eminem sing this song? Does it make the song more powerful or weaken it?
Editor's Notes
- Slides and Notes Pages were developed by: Patricia J. Bland, M.A. CCDC, Trainer, Providence Health System Family Violence Program at Medalia HealthCare Leigh Nachman Hofheimer, M.A., Education Coordinator, Washington State Coalition Against Domestic Violence Ramoncita Maestas, M.D., Faculty Family Physician at the Providence Family Practice Residency Program and Clinical Associate Professor, U.W. School of Medicine, Department of Family Medicine Roy G. Farrell, M.D., Chair, Violence Prevention Committee, Washington State Medical Association; Immediate Past President, Washington Physicians for Social Responsibility. Kristine Stewart, MSW, ACSW, Perinatal Social Worker, Swedish Medical Center Division of Perinatal Medicine Note: This program may be freely used, copied and distributed as long as this cover page is included. Significant portions of slides & notes originally adapted from the publication entitled, “Improving the Health Care System’s Response to Domestic Violence: A resource Manual for Health Care Providers,” produced by the Family Violence Prevention Fund in collaboration with the Pennsylvania Coalition Against Domestic Violence. Written by Carole Warshaw, M.D. and Anne L. Ganley, Ph.D, with contributions by Patricia R. Salber M.D. Other sources cited also. Special thanks to the following for technical assistance: Mary Pontarolo, Executive Director, Washington State Coalition Against Domestic Violence; Lois Loontjens, Executive Director, New Beginnings for Battered Women and their Children; Ann Forbes, Director, Alcohol Drug Help Line; Margaret Hobart, Program Manager, Domestic Violence Fatality Review; Marian Hilfrink, Program Coordinator; Pamela Rhoads, Program Assistant; Kara Laverde, former Coordinator; Providence Health System Family Violence Program - Linda Klein, Washington State Hospital Association and Linda Chamberlain, Ph.D., Director, Alaska Family Violence Prevention Project, DHSS, Public Health, Section of Maternal, Child &Family Health.
- Domestic violence is about power and control. It is about one person in an intimate relationship, exerting power and control over a partner. Domestic violence perpetrators are clearly definable primary aggressors who intentionally use any tactic necessary to exert power and control in their intimate relationships. Domestic violence is not a single incident of abuse. Rather, it is a repeated pattern of unpredictable abusive behavior. Attempts by a victim to resist this pattern of abuse generally result in retaliation by the batterer. Without intervention, the violence may increase in intensity (it gets more severe), and in frequency (it happens more often). Some Key Elements of Domestic Violence (Ganley, 1995): a pattern of assaultive and coercive behaviors that includes psychological attacks as well as economic coercion. a pattern of behaviors including a variety of tactics, some physically injurious and some not, some criminal and some not, carried out in multiple, sometimes daily episodes. a pattern of purposeful behavior, directed at achieving compliance from or control over the victim. a combination of physical attacks, terrorizing acts and controlling tactics used by perpetrators that result in fear as well as physical and psychological harm to victims and their children.1(pp. 16). Reference 1. Ganley, A. (1995). Understanding Domestic Violence. In Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers, produced by The Family Violence Prevention Fund in collaboration with the PCADV.
- Adolescent dating violence is frequently over-looked; however, girls as young as 12 are often found in violent relationships. By the age of 20, one-third of all young women will experience dating violence (Metropolitan King County Council, 1996). 1 Domestic violence occurs in a relationship where the perpetrator and victim are known to each other. The relationship may be of short or long duration. The partners or former partners may or may not have children together. The intimate context of the violence is important to understanding the nature of the problem and in developing effective interventions. DV victims experience trauma similar to that of victims of stranger violence. Unfortunately, the intimate context often leads others to negate the seriousness of the violence. DV occurs in an unpredictable pattern that is recognizable when power and control dynamics are understood. Abusive partners have on-going access to victims, know daily routines, vulnerabilities, etc. and can continue to have considerable control over their partners’ lives. Family ties, social sanctions and other social barriers complicate the situation and create additional barriers to strategies for self-protection. (Ganley,1995). 2 References 1. Metropolitan King County Council (1996). Domestic and dating violence: An information handbook (pp.12). Seattle, WA. 2. See Ganley, A. Understanding DV (pp. 17-18) on earlier notes page for full citation.
- Though not meant to detract from those cases where the victim is male, the majority of domestic violence victims are female. “The U.S. Dept. of Justice estimates that 95% of reported assaults on spouses or ex-spouses are committed by men against women (Douglas, 1991) There are no prevalence figures for domestic violence in gay and lesbian relationships, but experts (Lobel, 1986; Renzetti, 1992; Letelier, 1994) indicate that DV is a significant problem in same-sex relationships as well,” (Family Violence Prevention Fund, 1995). 1 The invisibility of violent behaviors directed towards intimate partners tends to be greatest for victims on either end of the economic continuum. Both very poor and very wealthy women are victims of domestic violence. Women on public assistance responding to Washington State PRAMS survey questions were 5 times more likely to report injury from a husband or partner. 2 All women, regardless of their socio-economic status must be routinely screened for domestic violence in the health care setting. References - ( Slide) 1. This figure comes from FBI Statistics, which are probably conservative estimates. 2. Schulman, M.A., A Survey of Spousal Violence Against Women in Kentucky. Washington, DC: US. Government Printing Office, 1979. References - (Notes page) 1. Ganley, A. Understanding Domestic Violence, pp. 17. ( See earlier notes page for full citation). 2. PRAMS (Pregnancy Risk Monitoring System) = population based surveillance system using birth certificates to help survey new moms representative of all registered births to WA State residents collected by WA State DOH since 1993.
- It is important to realize that we are not talking about ‘us’ and ‘them.’ Domestic violence touches us all. Whenever training on DV in a health care setting it is important to acknowledge the many staff and providers present who may have experienced DV themselves, or have known a friend, family member or co-worker who has. Domestic Violence training can be difficult or upsetting for some individuals. Old memories can be triggered as well as current concerns about one’s own (or a friend’s co-worker’s, neighbor’s or relative’s) relationship. Be sure to include Employee Assistance Program (EAP) participation when training, either on-site or as a resource, whenever possible. Handouts should always include local DV program resources for staff as well as for the patients they serve. Like many other public health problems, domestic violence is frequently chronic, often progressive and can be lethal. Staff we are training may currently be involved in an abusive relationship and have not known where to turn. Establishing a relationship with your local DV victims service providers empowers both patients and providers. Reference 1. Stark, E. & Flitcraft, A., Violence Among Intimates: An Epidemiological Review, in Haslett et al. [eds.}, Handbook of Family Violence, 1987.
- The greatest consequence battered women face when leaving an abusive relationship is death. Again, health care providers are not responsible for ‘curing’ DV. Leaving an abusive relationship is a process and on any given day, a provider may meet a victim at the beginning, middle or end of the process. It is important to define success not as, ‘Getting her to leave,’ or making decisions for a battered woman; but as breaking the isolation and giving the message, ‘You are not alone.’ Battered women understand the complex constraints their abuser forces upon them. They recognize the unique features of their abusive relationships as well as the dangers that exist. Women experiencing DV benefit most from supportive statements such as: “This must be very hard for you. Anyone could find themselves in this situation. I’m sure when you met your partner neither you nor anyone else could have guessed this would happen. It must be painful when someone you love can be frightening. It’s not your fault. What can I do to support you today?” Providing a referral to local DV shelter or community advocacy programs is the single best step you can take in addition to providing any needed medical treatment. Advocates are your allies and experts at safety planning which is a complicated and lengthy process. Remember, most battered women do not routinely self-identify as victims. Many will never consider shelter as an option. However, they may be comfortable talking to someone. Many battered women say they want the violence to stop rather than their relationships to end. When making a referral, don’t stress ending the relationship -- stress getting safe. Advise patients to call their local DV advocate to talk about their relationships and to safety plan. References - Statistics on Separation Violence provided by WSCADV; (compiled from sources cited on slide).
- Leaving is a process and is often dangerous for a victim. As a society we need to begin reframing our questions, asking ,“Why are batterers allowed to harm their partners?” rather than, “Why don’t victims leave?” Batterers must be held accountable for their actions and the choices they make. When we as a society say NO to intimate partner abuse and MEAN it, our need for battered women’s advocates may decrease sharply. Separation violence clearly is a safety issue. A victim can say, ‘Goodbye,’ but the perpetrator’s response may be to stalk, harass at work, threaten retaliation such as harm to children, pets or property. The list of tactics used by batterers is daunting. DV victims are often isolated from friends and family by their abusers. Yet, DV victims actively develop survival strategies to keep themselves and their children safe. Many factors shape a woman’s repeated attempts to live violence free. These factors may include (but are not limited to): a lack of housing; limited (or no) access to economic resources; threats of retaliation and hopes that a batterer will change or stop the violence. Many battered women make repeated efforts to achieve safety; often, struggling alone rather than revealing their situation to others. It is not unusual for a battered woman to fear telling anyone about her situation until it is safe for her to do so. Believing the victim and letting her know, “You are not alone,” is an intervention in and of itself. You may be the first person who believes her story and offers support without question. This may be the first of many conversations creating a ‘climate of safety,’ and respect for this woman. Your local DV advocates are always available to offer education, resources and safety planning assistance. Health care providers must always remember, there is no quick fix for domestic violence.
- Leaving is a process. Remember, batterers are extremely controlling, manipulative and directive. Interventions perceived by the battered woman as authoritarian or overly directive are not as successful as those designed to acknowledge her unique survival strategies. Survivors of domestic violence do leave. They leave when they are ready. They leave when they believe it is safe to do so. Success can be defined very simply. Did you break her isolation, provide a referral, ask about safety? Offer options and avoid ‘pushing’ your own opinion or time-frame agenda. Victims leave when they are ready. Think of yourself as one who ‘sows seeds’. An medical response that affirms a battered woman’s story and decision-making process is essential because there are so many societal sanctions that perpetuate violence. To illustrate this point during training, ask the group to quickly brainstorm songs that glorify or endorse violence against women. TV shows, movies and newspaper articles also provide examples of cultural messages about domestic violence. Ask group members to examine their own beliefs about violence and challenge them to move away from asking ‘why,’ someone stays to ‘why’ batterers are allowed to continue abusing. We all need to acknowledge victims of violence don’t like abuse, don’t cause abuse, and may need time to realize they can’t change an abuser’s behavior. Providers, Social Workers, Nurses, Medical Assistants, Nutritionists, Security, Patient Service Reps…all who come in contact with victims of violence, play a part within our state’s coordinated community response to end domestic violence.
- Though not meant to detract from those cases where the victim is male, the majority of domestic violence victims are female. “The U.S. Dept. of Justice estimates that 95% of reported assaults on spouses or ex-spouses are committed by men against women (Douglas, 1991) There are no prevalence figures for domestic violence in gay and lesbian relationships, but experts (Lobel, 1986; Renzetti, 1992; Letelier, 1994) indicate that DV is a significant problem in same-sex relationships as well,” (Family Violence Prevention Fund, 1995). 1 The invisibility of violent behaviors directed towards intimate partners tends to be greatest for victims on either end of the economic continuum. Both very poor and very wealthy women are victims of domestic violence. Women on public assistance responding to Washington State PRAMS survey questions were 5 times more likely to report injury from a husband or partner. 2 All women, regardless of their socio-economic status must be routinely screened for domestic violence in the health care setting. References - ( Slide) 1. This figure comes from FBI Statistics, which are probably conservative estimates. 2. Schulman, M.A., A Survey of Spousal Violence Against Women in Kentucky. Washington, DC: US. Government Printing Office, 1979. References - (Notes page) 1. Ganley, A. Understanding Domestic Violence, pp. 17. ( See earlier notes page for full citation). 2. PRAMS (Pregnancy Risk Monitoring System) = population based surveillance system using birth certificates to help survey new moms representative of all registered births to WA State residents collected by WA State DOH since 1993.
- Domestic Violence is learned behavior. It is learned through observation, experience and reinforcement. Batterer’s learn the benefits of exerting power within the family, (and also from societal institutions where power and control dynamics are emphasized). Rarely is abuse caused by perpetrator illness or disease. Alcohol and other drugs: Use by victims may be a consequence of violence and not the cause. Perpetrators may use alcohol or other drugs as an excuse for the battering. Batterers who are misusing alcohol or other drugs must get treatment for both problems. Treatment for substance abuse alone does not mean battering behavior will cease. And, treatment by a WA state certified batterers program cannot ensure safety; especially, if substance misuse goes undetected. Substance abuse by a batterer, victim or both, while not the cause, is often associated with greater severity of injuries and increased lethality rates. Chemically affected victims of violence often believe their use of a substance means violence against them is warranted. Always affirm no one has the right to hurt them and that violence directed against them is never their fault under any circumstance. Stress: Violence is a choice; it is one of many behavioral options when stress occurs. While stress may be experienced in varying degrees of intensity, each individual can choose an alternative to violence in response to stress. “People choose ways to reduce stress according to what they have learned about strategies that have worked for them in the past. It is important to hold individuals accountable for the choices they make to reduce stress especially when those choices involve violence or other illegal behaviors,” (Ganley, 1995). Reference (Causes of DV continued next page) (See Ganley, A., Understanding Domestic Violence (pp. 29) on earlier notes page for full citation).
- Batterers use isolation to prevent victims from using support systems among friends or family. Frequently, batterers do not allow their partners to have friends or contact with anyone they perceive as a threat or supportive to their victims. Jealousy is often used as an excuse by batterers for this as well as for other tactics of abuse they use when choosing to get their own way. Isolation limits a victim to one point of view: the batterer’s. This tactic makes a batterer seem omnipotent. Tactics such as isolation, humiliation, enforcement of trivial demands and intermittent re-enforcement may be perceived not solely as tactics of violence, but also as tools designed to maintain control and prevent escape. Batterers issue threats of retaliation to cultivate fear and despair. They induce debility by denying sleep, medications and food. Batterers also monitor and monopolize all a victim’s time (NiCarthy, 1984). They make the rules in a relationship. They enforce the rules in a relationship. They change the rules in a relationship. DV is often perceived as a private matter. ‘Don’t get involved in family business,’ is a cultural norm for many, as are religious beliefs such as, ‘Marriage is for life,’ or, ‘Children need two parents.’ Many professionals don’t understand the dynamics of DV or are frightened of intruding. Potential helpers may worry they too could be targeted by an abuser. Clergy have told victims to pray for change or to be a better wife. Historically battered women have been prescribed psychotropic meds (e.g., sedatives) making victims vulnerable to addiction and less capable of protecting themselves. Therapists have told couples to work on communication and have failed to note couples counseling is dangerous and contra-indicated when domestic violence exists. These attitudes and beliefs foster societal denial about the severity of DV and the need for a coordinated community response to combat it. Reference NiCarthy, G., Merriam, K . and Coffman, S., ( 1984). Talking it out: A guide to groups for abused women (pp.99-100). Seattle: Seal Press.
- Remember to be discrete and to ask whether it is safe for your patient to take information about DV home with her. The wallet cards in the WSMA domestic violence packet may be a helpful resource to provide your patient. Offer to let your patient use the phone at the health care facility to make calls. Check to see if she is aware that the Washington State DV Hotline can patch through long distance calls for her when a batterer is monitoring her phone bills or she is in an emergency situation. Offer options. Respect your patients’ decisions even if you don’t agree with them. Remember dealing with DV is a process. Be sure your door is always open!