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Domestic Violence for Health Professionals 101


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Overview of domestic violence, screening tools, and resources for health care professionals.

Domestic Violence for Health Professionals 101

  1. 1. Domestic Violence 101 Building Knowledge to Empower Patients
  2. 2. What is domestic violence? <ul><li>Domestic violence is a pattern of behaviors used by one individual to maintain power and control over a partner in the context of an intimate relationship. Domestic violence can not only be physical violence, but can also include emotional abuse and/or sexual assault. </li></ul>
  3. 3. Types of Violence
  4. 4. <ul><li>Physical abuse . Physical abuse is usually recurrent and usually escalates both in frequency and severity. It may include the following: </li></ul><ul><li>Pushing, shoving, slapping, hitting, punching, kicking the victim. </li></ul><ul><li>Holding, tying down, or restraining the victim. </li></ul><ul><li>Inflicting bruises, welts, lacerations, punctures, fractures, burns, scratches. </li></ul><ul><li>Strangling the victim. </li></ul><ul><li>Pulling the victim's hair or dragging the victim by the victim's hair or body parts. </li></ul><ul><li>Assaulting the victim with a weapon. </li></ul><ul><li>Inflicting injury upon pets or animals. </li></ul>
  5. 5. <ul><li>Sexual abuse . Sexual abuse in violent relationships is often the most difficult aspect of abuse for individuals to discuss. It may include any form of forced sex or sexual degradation: </li></ul><ul><li>Trying to make or making the victim perform sexual acts against their will. </li></ul><ul><li>Pursuing sexual activity when the victim is not fully conscious, or is not asked, or is afraid to say no. </li></ul><ul><li>Physically hurting the victim during sex or assaulting her genitals, including the use of objects or weapons intravaginally, orally, or anally. </li></ul><ul><li>Coercing the victim to have sex without protection against pregnancy or sexually transmittable diseases. </li></ul><ul><li>Criticizing the victim and calling her sexually degrading names </li></ul>
  6. 6. <ul><li>Emotional or psychological abuse . Emotional or psychological abuse may precede or accompany physical violence as a means of controlling through fear and degradation. It may include the following: </li></ul><ul><li>Threats of harm. </li></ul><ul><li>Physical and social isolation. </li></ul><ul><li>Extreme jealousy and possessiveness. </li></ul><ul><li>Deprivation of resources to meet basic needs. </li></ul><ul><li>Intimidation, degradation, and humiliation. Name calling and constant criticizing, insulting, and belittling the victim. </li></ul><ul><li>False accusations, blaming the victim for everything. </li></ul><ul><li>Ignoring, dismissing, or ridiculing the victim's needs. </li></ul><ul><li>Lying, breaking promises, and destroying the victim's trust. </li></ul><ul><li>Driving fast and recklessly to frighten and intimidate the victim. </li></ul><ul><li>Leaving the victim in a dangerous place. </li></ul><ul><li>Refusing to help when the victim is sick or injured. </li></ul><ul><li>Threats or acts of violence/injury upon pets or animals. </li></ul>
  7. 7. Similarities of the three forms <ul><ul><li>Done without concern for the mental or physical well-being of the victim. The victim is de-humanized. </li></ul></ul><ul><ul><li>Done to punish, induce fear, and show domination. The victim is controlled. </li></ul></ul><ul><ul><li>Recurring; often escalates in severity and frequency. The danger to the victim increases. </li></ul></ul>
  8. 8. Who is affected?
  9. 9. Domestic violence is a problem that affects every community across the country. Victims and Abusers come from all ethnic groups and cultures, all backgrounds, among all ages, all income levels, all faiths, all relationship types, and all education levels.
  10. 10. Special Populations Recognizing Domestic and Sexual Violence Cross Culturally
  11. 11. LGBTQ Domestic Violence <ul><li>Same sex domestic violence </li></ul><ul><ul><li>Same sex domestic violence is perpetrated by partners or ex-partners of LGBT people. Partners and ex-partners may be lesbian, gay, bisexual or heterosexual. </li></ul></ul><ul><li>Homophobic, Biphobic, Transphobic domestic violence </li></ul><ul><ul><li>Domestic Violence perpetrated by family member, care giver, or partner based on real or perceived sexual orientation </li></ul></ul><ul><li>Child abuse: homophobic, biphobic and transphobic </li></ul><ul><ul><li>Young people under the age of 18 years may experience homophobic, biphobic or transphobic child abuse from family members. Any young person reporting such abuse will be referred to an appropriate agency, such as Social Services. </li></ul></ul>
  12. 12. Mentally Ill <ul><li>TRAUMA AND MENTAL HEALTH </li></ul><ul><li>Lifetime experiences of abuse and violence are common among women seen in mental health settings. </li></ul><ul><li>Of 140 women attending an outpatient psychiatric clinic, 64% had a lifetime history of physical and/or sexual abuse (Surrey et al, 1990). </li></ul><ul><li>Among 153 women seen in a range of psychiatric settings, half had been sexually abused and 16% had been physically assaulted as children (Mueser et al, 1998). As adults, 64% had been sexually assaulted, 36% had been physically attacked, and 24% had witnessed severe violence. </li></ul><ul><li>Out of 303 depressed women culled from a large random sample, 63% had experienced abuse at some point in their life (Scholle et al, 1998). 55% reported having been abused in adulthood by “a family member or someone they knew well, such as a boyfriend.” </li></ul>
  13. 13. CMI Statistics <ul><li>Experiences of abuse and violence are especially high for women diagnosed with serious mental illness (SMI). </li></ul><ul><ul><li>• Out of 39 adult female clients in an intensive psychiatric case management program , 59% had been sexually abused and 62% had been physically abused as children and/or adults (Rose, Peabody, & Stratigeas, 1991). </li></ul></ul><ul><ul><li>• In a sample of 123 female patients on a psychiatric inpatient unit, 53% had a lifetime history of abuse (Carmen et al 1984). </li></ul></ul><ul><ul><li>• Although not explicitly identifying the perpetrator, another study found that of the 64% of female inpatients who had been physically assaulted as adults, 56% shared a home with the perpetrator (Jacobson and Richardson 1987). </li></ul></ul><ul><ul><li>• In one study with 66 female psychiatric inpatients, 44% had experienced physical assault as an adult (Bryer et al 1987). Of those, 59% had been assaulted by an intimate partner. </li></ul></ul><ul><ul><li>• Out of 93 women seen in a psychiatric emergency room , approximately half had been physically and/or sexually abused as children, 42% had been abused by a partner in adulthood, and 37% had experienced an attempted or completed rape (Briere et al, 1997). </li></ul></ul><ul><ul><li>• In a study of 69 inpatients (male and female) who had ongoing relationships with partners or family members, 63% reported a history of physical victimization by a partner and 46% reported physical abuse by a family member (Cascardi et al., 1996). Twenty-nine percent had experienced domestic abuse within the past year. </li></ul></ul>
  14. 14. Homeless/Mentally Ill <ul><li>Abuse rates are even higher among homeless women with serious mental illness. In a study with 99 episodically homeless women with SMI, Goodman et al (1995) found that significant numbers had been physically </li></ul><ul><li>(70%) or sexually (30.4%) abused by a partner. Rates of physical or sexual abuse in adulthood by any perpetrator were 87% and 76%, respectively. </li></ul>
  15. 15. Poverty and Domestic Violence <ul><li>In the 1990s, as poor families lost their guarantee of income supports, studies began to look at domestic violence among low-income women. Unsurprisingly, it was pervasive. Examining one low-income neighborhood in Chicago, researchers found that 33% of welfare recipients and 25% of low-income non-recipients had experienced &quot;severe aggression&quot; in adulthood by a partner. Further, 19% of recipients and 8% of non-recipients had experienced serious aggression within the past 12 months ( Lloyd &Taluc, 1999 ). </li></ul><ul><li>Looking at low-income housed and homeless mothers in Worcester, Massachusetts, researchers reported that 32% of the women experienced severe physical violence during the previous two years ( Browne &Bassuk, 1997 ). And the National Family Violence Survey suggested that rates of &quot;abusive violence&quot; to women with annual incomes below $10,000 are more than 3.5 times those found in households with incomes over $40,000. </li></ul>
  16. 16. Causes of Domestic Violence
  17. 17. Why does battering happen? MYTHS <ul><li>Out of Control </li></ul><ul><li>Poor Anger Control </li></ul><ul><li>Stress </li></ul><ul><li>Low Self-Esteem </li></ul><ul><li>Substance Abuse </li></ul><ul><li>History of abuse from childhood </li></ul><ul><li>Poor communication skills </li></ul><ul><li>Victim provoked battering </li></ul><ul><li>Batterers need to learn non-violence </li></ul>
  18. 18. So, Why do batterers abuse? <ul><li>A. Abusers batter because IT WORKS. Violence and the threat of violence are effective means of control. </li></ul><ul><ul><ul><li>Victims will expend a great deal of energy trying to avoid abuse and violence, including attempts to satisfy every need, wish, and whim of their abusers. </li></ul></ul></ul><ul><ul><ul><li>Abusers have an over inflated sense of entitlement. An abuser may believe he has the right to control “his woman”. </li></ul></ul></ul><ul><ul><ul><li>People who batter often report their partners will not do what they say, therefore they must be disciplined. (Example: Making a partner stand in the yard in her underwear) </li></ul></ul></ul><ul><li>B. Abusers Batter because THEY CAN. </li></ul><ul><ul><ul><li>Society has not sent a clear message to batterers that their behavior is unacceptable. </li></ul></ul></ul><ul><ul><ul><li>Batterers are not held accountable for their violent behavior. Penalties for assaults on spouses and other family members are usually less than assaults on strangers or acquaintances. </li></ul></ul></ul>
  19. 19. Common Characteristics of Batterers <ul><li>Behavioral Traits </li></ul><ul><li>Extremely jealous and possessive of his/her spouse or partner. </li></ul><ul><li>Hypersensitive, often overreacting to perceived slights/ridicule. </li></ul><ul><li>Controlling, often attributing these behaviors to concern or love. </li></ul><ul><li>Displaced anger (usually at authority figures) directed at partner. </li></ul><ul><li>Public behavior different from private behavior. </li></ul><ul><li>Quick involvement in intimate relationships. </li></ul><ul><li>Offenders typically see themselves as the victims of those they are abusing. </li></ul><ul><li>People who resort to violence do not lack self-control. </li></ul>
  20. 20. <ul><li>Family background </li></ul><ul><li>Witnessed abuse as a child. </li></ul><ul><li>Learn violent behavior from family of origin. </li></ul><ul><li>Psychological Traits. </li></ul><ul><li>Low self-esteem </li></ul><ul><li>Low assertiveness </li></ul><ul><li>Feels masculinity is inadequate </li></ul><ul><li>Projects blame onto victim (externalizes) </li></ul><ul><li>External centers of control. Believes in luck, fate. Sees self as victim. Feels misunderstood. </li></ul><ul><li>Inappropriate expectations and distorted perceptions of victim. </li></ul><ul><li>Denial and minimization of abusive behaviors. </li></ul>
  21. 21. Cycle of Violence Theory
  22. 22. This theory suggests that battering is cyclical in nature and the phases are identifiable. <ul><li>Tension Building Phase </li></ul><ul><li>Financial, emotional, and/or physical stress is present. </li></ul><ul><li>Conflicts arise between the partners and are not resolved. </li></ul><ul><li>The abuser uses verbal and emotional abuse. </li></ul><ul><li>The victim is compliant and accommodating to pacify the abuser and avoid abuse (Walking on eggshells). </li></ul><ul><li>Children in the household are aware of the rise in tension. </li></ul><ul><li>This phase may last for weeks or months. </li></ul><ul><li>Law enforcement is occasionally called in during this phase. </li></ul>
  23. 23. Violent Incident Phase <ul><li>The abuser assaults the victim. Earlier stage beatings are typically less severe. Later stage assaults may involve serious injuries or death. </li></ul><ul><li>The abuser blames the victims for the assault, he “teaches her a lesson”. </li></ul><ul><li>The victim does not know when the assault will stop and adapts to survive. </li></ul><ul><li>Some victims disassociate. Some escape and return when the crisis is over. </li></ul><ul><li>Children know when violence has occurred. They sometimes try to intervene to protect their mother and are at risk for injury as well. </li></ul><ul><li>This phase typically lasts 2-24 hours or intermittently for a few days. </li></ul><ul><li>Law Enforcement is often called in during this phase. </li></ul>
  24. 24. Honeymoon or calm phase <ul><li>In early stages, the abuser rationalizes the violence and promises to change. Some may ask for forgiveness. In later stages, the abuser may never explain the violence, but the abuse will temporarily stop. </li></ul><ul><li>In early stages the victim will believe that the violence will not recur. In later stages, she is worn down physically and emotionally and will accept promises, if offered. </li></ul><ul><li>Children take on the role of caretaker and try to “keep the peace.” </li></ul><ul><li>This phase may last for days or weeks. In later stages, this phase may disappear altogether. </li></ul><ul><li>If an assault and battery charge has been filed, it is likely to be heard in court during this phase. (This is one reason why many victims are reluctant to testify in court. He has apologized and promised it will never happen again). </li></ul>
  25. 26. Power and Control Theory
  26. 27. This theory states that battering is NOT a “lack of control” but rather an attempt to “over control” the victim. <ul><li>Violent behavior is only one tactic in an array of abusive strategies used by the abuser to maintain power and control in the relationship. Physical and sexual violence are the most extreme of these strategies. The threat of these violent acts and their occasional use gives power to the abuser’s verbal and emotional threats. </li></ul><ul><li>Many victims report that the most difficult abuse they suffered was not physical, but emotional and verbal abuse. </li></ul>
  27. 29. <ul><li>The most consistent predictor of abusive behavior is PRIOR violent or abusive behavior. </li></ul>
  28. 30. Barriers to Leaving an Abusive Relationship
  29. 31. Why doesn’t the victim just leave? <ul><li>&quot;Why doesn't the abused person just leave?&quot; This question shows a misunderstanding of the dynamics of domestic violence, puts responsibility on the victim and reveals a tendency to blame the victim. A more appropriate question would be: &quot;Why does he abuse her?&quot; or &quot;Why can't he be stopped from hurting his family?“ </li></ul>
  30. 32. <ul><li>Reflect on your own life. Have you ever maintained a relationship with a difficult relative or friend? Or stayed too long in a job with an difficult manager? People in an abusive relationship face even more difficult choices when leaving. </li></ul>There are many barriers to leaving a relationship
  31. 33. Fear… <ul><li>Of being killed, of the abuser committing suicide, of not being believed about the abuse, of being stalked by the abuser, of placing their kids at risk via unsupervised visitation with the abuser - note that 75% of domestic violence homicides occur during or after the victim has left the abuser </li></ul>
  32. 34. Isolation… <ul><li>By the abuser often results in a lack of a support system for the victim including helpful friends or family members, a job or money, transportation, childcare, housing, and social services </li></ul>
  33. 35. Economic Reality… <ul><li>May be that a victim is not able to support her/himself and the children without the abuser's income, may not possess marketable skills, may have limited access to government assistance, may dread welfare, and due to an abuser's control of money may have no access to cash, checks, or important documents </li></ul>
  34. 36. Childhood Experiences… <ul><li>Of living in a home where abuse was perpetrated by one parent against the other may leave a victim feeling that abuse is unavoidable in relationships, or that it is okay to abuse people you love when they have done something wrong </li></ul>
  35. 37. Beliefs About the Abuser… <ul><li>Often include strong feelings of love and emotional connection, as well as the belief that the abuser is all-powerful and will be able to find the victim anywhere, or due to compassion or pity a victim may feel that s/he is the only one who can help the abuser overcome problems </li></ul>
  36. 38. Beliefs About Themselves… <ul><li>Over time include an acceptance of responsibility for the problems in a relationship, due to repeated blame placed on a victim by the abuser, as well as low self-esteem due to repeated acts of abuse and a feeling that abusive behavior is all the victim deserves. </li></ul>
  37. 39. <ul><li>Leaving is better understood as a process rather than an event. </li></ul>
  38. 40. Community and Hospital Advocacy Understanding Your Resources
  39. 41. What is an advocate? <ul><li>An Advocate is a social worker specifically trained to work with survivors of sexual, physical, and emotional violence. The Forensic Advocate at VCUMC has specialized training in forensic evidence collection and legal processes. </li></ul>
  40. 42. What does an Advocate do? <ul><li>Provides crisis intervention and support for victims during hospitalization </li></ul><ul><li>Accompanies victims throughout evidence collection, examination, evidence collection, and discharge processes </li></ul><ul><li>Provides case management services post-discharge to ensure patient has been linked with community agencies for counseling support, medical care, housing, emergency shelter, legal assistance, and financial support </li></ul>
  41. 43. <ul><li>Provides assistance filing for Orders of Protection and navigating court system </li></ul><ul><li>Assistance filing for and navigating Crime Victim’s Compensation Claims </li></ul><ul><li>Provides follow-up case management for 6-8 weeks post-discharge </li></ul><ul><li>Provides continued secondary victim support for 6-8 weeks post-discharge for family members, friends, and partners of victims </li></ul>
  42. 44. Screening for Abuse What you can do
  43. 45. Screening <ul><li>Management of Patient Care </li></ul><ul><li>RADAR </li></ul><ul><li>R R outinely inquire about violence </li></ul><ul><li>A A sk direct questions </li></ul><ul><li>D D ocument findings </li></ul><ul><li>A A ssess safety </li></ul><ul><li>R R eview options and referrals </li></ul>
  44. 46. Homicide Risk Assessment <ul><li>Screening tool to predict a patient’s level of risk for becoming the victim of domestic homicide. </li></ul><ul><li>Community and online training provided in scoring system used for tool </li></ul><ul><li>Tool is free to use without scoring/certification system </li></ul><ul><li> </li></ul>
  45. 47. <ul><li>Validate the patient’s feelings </li></ul><ul><li>Be non-judgmental (Don’t make assumptions) </li></ul><ul><li>REFER to hospital social worker immediately </li></ul><ul><li>CALL an ADVOCATE if you have one available in your community </li></ul>If a patient discloses abuse:
  46. 48. If you need more help… <ul><li>Call. If you feel like a patient’s needs are greater than the services that you can provide or if you have specific questions about a patient’s case, please call your hospital social worker or domestic violence agency. They can help guide you through planning to assist your patient. </li></ul>
  47. 49. Remembering Denora Hill December 5, 2007
  48. 50. <ul><li>Denora Hill was evaluated in the ED just 12 hours before she was fatally shot by her partner. She was not screened for domestic violence and was not offered services to assist in ensuring her safety. </li></ul><ul><li>“ I am living in fear and I want it to end.” </li></ul>Denora Hill
  49. 51. <ul><li>Taking the time to screen your patients may save a life. </li></ul>