Intimate Partner Violence: Prevalence, impact, treatment, prevention

1. Intimate partner violence: Prevalence, impact, treatment, prevention
ALIYA R. WEBERMANN, B.A.
M.A. CANDIDATE, CLINICAL PSYCHOLOGY
TOWSON UNIVERSITY

2. Overview
 This presentation will discuss the following topics:
Definition of intimate partner violence (IPV) and typologies
U.S. national IPV prevalence
Impact and outcomes of victimization, including psychiatric comorbidities
Risk factors for IPV
IPV and identity
Assessment and treatment of IPV
Preventative and protective factors
Trigger warning: this presentation will provide examples of IPV perpetration and consequences of IPV victimization, which may cause emotional distress.

3. Definition
 Physical, sexual, psychological, or emotional harm from a current or former partner or spouse
 A pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another partner
(CDC, 2013)

4. Typologies
 Physical: Intentional use of physical force- kicking, using a weapon, grabbing
 Sexual: Force, coercion, assault/rape, involvement with incapacitated person
 Psychological: Threats, intimidation, isolation, controlling behavior
 Emotional: Insults, put-downs, humiliation
 Financial (not in CDC definition): Limiting access to money and resources, identity theft, sabotaging career opportunities, incurring debt
(CDC, 2013; NNEDV, 2014a)

5. Typologies, continued
 Based on physiological differences in heart rate reactivity that may indicate differences in intent and motivation:
Characterological violence (Type 1): heart rate lowers during interactions, behavior stems from desire for power and control
Increased verbal and facial expressions of anger
Situational violence (Type 2): heart rate increases during interactions, behavior stems from emotion dysregulation and physical loss of control
Situational aggression increases more over time
Equally violent within romantic partnerships as Type 1
(Babcock et al., 2004; Gottman et al., 1995; Meehan et al., 2001)

6. Prevalence: Victimization
 Lifetime prevalence:
Severe physical IPV: 1 in 4 women and 1 in 7 men
Rape: 1 in 5 women and 1 in 71 men
Emotional IPV: 1 in 2 women and men
 One day of victim services:
66,581 victims served
36,348 in emergency shelter
30,233 receiving non-residential services such as counseling and court advocacy
20,267 hotline calls answered
9,641 unmet requests for services
(CDC, 2011; NNEDV, 2014b)

7. Prevalence: Perpetration
 Lack of similar epidemiological U.S. national statistics on IPV perpetration
 Physical IPV: 19.2% of males are perpetrators
 Gender of perpetrators:
Toward male victims:
Physical and emotional IPV: Female
Stalking: Mix of male and female
Sexual violence: Male
Toward female victims:
Physical and emotional IPV: Male
Stalking: Male
Sexual violence: Male
(CDC, 2011; Singh et al., 2014)

8. Impact: Adult victims
 Mental health
PTSD: Greater than 60%
Depression and anxiety disorders
 Physical health
Chronic health conditions: asthma, diabetes, gastrointestinal issues
 Substance use
Alcoholism
Illicit and intravenous drug use
 81% of women and 35% of men report 1 or more adverse health or safety outcomes (emergency medical treatment, shelter stays, fear for one’s life)
2003: $8.3 billion spent on physical and mental health services and lost productivity
(CDC, 2011; Dube et al., 2002; Goodman & Epstein, 2007; Max et al., 2004)

9. Impact: Child victims
 Mental health
PTSD
Personality disorders: Borderline personality disorder , antisocial personality disorder
Dissociative disorders
 Physical health
Chronic health issues: Heart disease, cancer, gastrointestinal issues
Sexually transmitted diseases
Obesity
 Linked to other forms of childhood maltreatment
Physical, sexual, emotional, psychological abuse
(American Psychiatric Association, 2013; Dube et al., 2002; Putnam et al., 2013)

10. Risk factors: Perpetration
 Childhood maltreatment and witnessing of domestic violence
 Multiple types of IPV (engaging in an IPV type increases likelihood of other types)
 Marital dissatisfaction
 Illicit drug use and alcoholism
 Traditional gender and sex role ideology
 Implicit attitudes condoning violence
 Physical health issues: Insomnia, gastrointestinal issues
 Mental health issues: Personality disorders, depression
 Insecure/disorganized attachment style
(Alexander & Warner, 2003; Eckhardt & Crane, 2014; Heise & Garcia-Moreno, 2002; Singh et al., 2014; Stith et al., 2004; Tjaden & Thoennes, 2000; Whitfield et al., 2003;)

11. Risk factors: Victimization
 Childhood maltreatment and witnessing of domestic violence
 Mental health issues: Personality disorders, depression, dissociative disorders
 Economic disempowerment
 Youth: 80% of female sexual assault victims are under 25
 Insecure/disorganized attachment style
 Predictors of escalation in abusive relationships:
Female victims perpetrating violence toward male perpetrators
Partner threats to harm and/or kill
(Alexander, 2009; CDC, 2011; Goodman & Epstein, 2007; Stith et al., 2004; ; Tjaden & Thoennes, 2000; Whitfield et al., 2003)

12. IPV and identity
 Race
Institutionalized racism (criminal justice system)
“Traitor” to community
 Gender identity
Male and transgender victims
 Religion
Taboo of divorce
 Sexual orientation
“Outness” of victim v. perpetrator
Female perpetrators

13. IPV and identity
Income level
Financially dependent on perpetrator
Difficult to access resources
Immigration status
Fear of deportation
Need to report perpetrator/assist in prosecution to receive visa
Language abilities
Disability
Dependent on perpetrator for survival
Lack of resources

14. Assessments
 Revised Conflict Tactics Scale (CTS2)
Assesses perpetration and victimization typology/severity/frequency, and negotiation
More often used in research, but appropriate for clinical practice
 Timeline Followback Spousal Violence Interview (TLFB-SV)
Daily calendar method documenting typology and frequency of violence
 Proximal Antecedents to Violent Episodes (PAVE) Scale
Context and functions of IPV incidents
 Guidelines
Screen IPV separately with each partner
Complete a lethality assessment to determine appropriate services
Screen IPV again later, as it may initially be denied due to shame, fear, and guilt
If IPV is identified, creating a safety plan is crucial
(Fals-Stewart et al., 2003; McCloskey & Grigsby, 2005; Babcock et al., 2004; Straus et al., 1996)

16. Treatment: Perpetration
 Treatment as usual: Duluth Model/Derivative
Grounded in theory of patriarchal dominance
Goal = behavior change via psychoeducation and in-group processing and modeling of healthy relationships and conflict resolution
Limited effectiveness, likely due to lack of addressing comorbid psychiatric and substance abuse issues and trauma history
(Babcock et al., 2000; Easton, 2013)

17. Power and Control Wheel- Duluth Model/Derivative

18. Treatment: Perpetration, continued
 Couples therapy
Only recommended with situational common-couple violence, rather then characterological violence perpetrated by one partner
Behavioral couples therapy shown to be effective with substance using couples
Multi-couple group therapy
Demonstrated success with mild to moderate situational common-couple violence
 Group therapy
Batterer/abuser intervention programs
Most effective if comorbid psychiatric and substance use issues are addressed
Demonstrated success utilizing CBT and MI modalities and in conjunction with individual therapy
(Connors, Mills, & Gray, 2013; Easton, 2013; Fals-Stewart & Clinton-Sherrod, 2009; Gottman et al., 1995; Stare & Fernando, 2014; Stith et al., 2004)

19. Preventative and protective factors
 Preventing child maltreatment, including witnessing of domestic violence
 Promoting flexible gender roles, egalitarian relationships, non-violence, and feminist identity
 Treating comorbid substance use and psychiatric disorders
 Training physical and mental health care providers to a) identify the effects of IPV on patients presenting to treatment and b) accurately and appropriately assess IPV
 Targeted education about intimate partner violence, sexual assault, and healthy relationships
 Economic independence, vocational opportunities, affordable housing
 Social supports
(Backus & Mahalik, 2011; Easton, 2013; Goodman & Epstein, 2007; McCloskey & Grigsby, 2005)

20. References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Alexander, P. C. (2009). Childhood trauma, attachment, and abuse by multiple partners. Psychological Trauma: Theory, Research, Practice, And Policy, 1(1), 78-88. Alexander, P. C., & Warner, S. (2003). Attachment theory and family systems theory as frameworks for understanding the intergenerational transmission of family violence. In P. Erdman, T. Caffery (Eds.) , Attachment and family systems: Conceptual, empirical, and therapeutic relatedness (pp. 241-257). New York, NY, US: Brunner-Routledge. Babcock, J. C., Green, C. E., & Robie, C. (2004). Does batterers' treatment work? A meta-analytic review of domestic violence treatment. Clinical Psychology Review, 23(8), 1023-1053. Backus, F. R., & Mahalik, J. R. (2011). The masculinity of Mr. Right: Feminist identity and heterosexual women’s ideal romantic partners. Psychology of Women Quarterly, 35(2), 318-326. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention (2013). Intimate Partner Violence. Retrieved from http://www.cdc.gov/violenceprevention/intimatepartnerviolence/.

21. References, continued
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention (2011). National Intimate Partner and Sexual Violence Survey 2010. Retrieved from http://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_overview_insert_final-a.pdf.
Conners, A. D., Mills, J. F., & Gray, A. L. (2013). Intimate partner violence intervention for high-risk offenders. Psychological Services, 10, 12-23.
Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Williamson, D. F. (2002). Exposure to abuse, neglect and household dysfunction among adults who witnessed intimate partner violence as children: Implications for health and social services. Violence And Victims, 17(1), 3-18.
Easton, C. J. (2013). Treatments for offenders of intimate partner violence. In M. McMurran (Ed.) , Alcohol-related violence: Prevention and treatment (pp. 171-185). Wiley-Blackwell.
Eckhardt, C. I., & Crane, C. A. (2014). Male perpetrators of intimate partner violence and implicit attitudes toward violence: Associations with treatment outcomes. Cognitive Therapy And Research, 38(3), 291-301.
Fals-Stewart, W., Birchler, G. R., & Kelley, M. L. (2003). The Timeline Followback Spousal Violence Interview to Assess Physical Aggression Between Intimate Partners: Reliability and Validity. Journal Of Family Violence, 18(3), 131-142.
Fals-Stewart, W., & Clinton-Sherrod, M. (2009). Treating intimate partner violence among substance-abusing dyads: The effect of couples therapy. Professional Psychology: Research And Practice, 40(3), 257-263.

22. References, continued
Goodman, L. A., & Epstein, D. (2007). Listening to battered women: A survivor-centered approach to advocacy, mental health, and justice. Washington, D.C.: American Psychological Association.
Heise, L., & Garcia-Moreno, C. (2002). Violence by intimate partners. In E. Krug, L. L. Dahlberg, J.A. Mercy, et al. (Eds.), World report on violence and health (pp. 87-121). Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/violence_injury_prevention/violence/ global_campaign/en/chap4.pdf.
Max, W., Rice, D. P., Finkelstein, E., Bardwell, R. A., & Leadbetter, S. (2004). The Economic Toll of Intimate Partner Violence Against Women in the United States. Violence And Victims, 19(3), 259-272.
McCloskey, K., & Grigsby, N. (2005). The Ubiquitous Clinical Problem of Adult Intimate Partner Violence: The Need for Routine Assessment. Professional Psychology: Research And Practice, 36(3), 264-275.
Meehan, J. C., Holtzworth-Munroe, A., & Herron, K. (2001). Maritally violent men's heart rate reactivity to marital interactions: A failure to replicate the Gottman et al. (1995) typology. Journal Of Family Psychology, 15(3), 394-408.
National Network to End Domestic Violence (2014a). About Financial Abuse. Retrieved from http://nnedv.org/resources/ejresources/about-financial-abuse.html.
National Network to End Domestic Violence (2014b). Domestic Violence Counts National Summary 2013. Retrieved from http://nnedv.org/downloads/Census/DVCounts2013/DVCounts13_NatlSummary.pdf.

23. References, continued
Putnam, K. T., Harris, W. W., & Putnam, F. W. (2013). Synergistic childhood adversities and complex adult psychopathology. Journal of Traumatic Stress, 26(4), 435-442.
Singh, V., Tolman, R., Walton, M., Chermack, S., & Cunningham, R. (2014). Characteristics of men who perpetrate intimate partner violence. Journal of Behavioral Family Medicine, 27(5), 661-668.
Stare, B. G., & Fernando, D. M. (2014). Intimate partner violence typology and treatment: A brief literature review. The Family Journal, 22(3), 298-303.
Stith, S. M., Smith, D. B., Penn, C. E., Ward, D. B., & Tritt, D. (2004). Intimate partner physical abuse perpetration and victimization risk factors: A meta-analytic review. Aggression And Violent Behavior, 10(1), 65-98.
Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283-316.
Tjaden, P., & Thoennes, N. (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey. Washington (DC): Department of Justice. Retrieved from: http://www.ojp.usdoj.gov/nij/pubs-sum/181867.htm.
Whitfield, C. L., Anda, R. F., Dube, S. R., & Felitti, V. J. (2003). Violent childhood experiences and the risk of intimate partner violence in adults: Assessment in a large health maintenance organization. Journal Of Interpersonal Violence, 18(2), 166-185.