Spousal Abuse Material

Spousal or Partner Abuse, 1
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Chapter 1: Introduction and Theories
Introduction
Take a moment to think about the words domestic violence. What images come
to mind? Do you think about a submissive, middle aged-woman being beaten by
her alcoholic husband? Do you think why doesnt she just leave? or Not in my
practice, hospital or agency. The reality of domestic violence is that while these
stereotypes fit some situations, they do not even begin to touch upon the scope
of the problem. Many mental health practitioners are working with clients
experiencing current domestic violence, and are unaware that it is occurring
because of the shame that is often associated with it.
The National Coalition Against Domestic Violence defines domestic violence as

the willful intimidation, physical assault, battery, sexual assault, and/or other
abusive behavior perpetrated by an intimate partner against another. While
there have been studies of domestic violence from a cultural perspective,
domestic violence affects individuals in every community, regardless of age,
economic status, race, religion, nationality or educational background. Domestic
violence is often accompanied by emotionally abusive or controlling behavior,
and thus is part of a systematic pattern of dominance and control. There are
many consequences associated with domestic violence including physical injury,
psychological trauma, and sometimes death.
There are factors that often occur co-morbidly with domestic violence, including
family dysfunction, inadequate communication skills, stress and economic
hardship. Alcohol abuse is present in about 50 percent of battering relationships.
Personality disorders and mental illness may also compound domestic violence.
While these issues are associated with the domestic abuse, they are not the
cause, nor will the removal of these factors mitigate or stop it.
This course will provide an introduction to domestic violence, including

prevalence and impact, laws, and the cycle of violence. The terms domestic
violence, domestic abuse, and intimate partner violence will be used
interchangeably throughout the text. The author has chosen to limit use of the
word battering, which although still prevalent in the popular lexicon may
suggest that domestic violence is confined to physical violence only.
Upon completion of this chapter you will be able to:
1. Define domestic violence and the term intimate partner.

2. Discuss prevalence of domestic violence.
3. Describe some factors associated with domestic violence.
4. Compare and contrast the various approaches to, and theories of,
domestic violence.
5. List the warning signs of domestic violence.
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Defining Domestic Violence
Case Vignette
Sarah Ann is consulting with Dr. Jenkins. During the intake Dr. Jenkins is aware
of a number of behaviors which draw his attention to the idea that Sarah Ann
may be experiencing domestic abuse. When asked about her marital status, she
fearfully replies that she is married, and asks whether Dr. Jenkins will be talking
to her husband. Similar concerns arise when Dr. Jenkins describes
confidentiality. When Dr. Jenkins gently reflects that Sarah Ann seems scared
and asks for the source of her fears, Sarah Ann breaks down and reveals that
her husband had become increasingly angry and frustrated, that he had pushed
her roughly, and that she was fearful that he could become violent.
Domestic violence is often called battering or wife beating, however, domestic

violence is not limited to physical abuse, but most often includes other types of
violence. The Introduction provided a more comprehensive definition of domestic
violence (also called intimate partner violence): the willful intimidation, physical
assault, battery, sexual assault, and/or other abusive behavior perpetrated by an
intimate partner against another.
There is some variability in the use of the term intimate partner. This also
relates to the varying perspectives of domestic violence (e.g., psychological,
legal). The varying perspectives on domestic violence will be detailed in a
subsequent section of this material. With regard to the legal definition, states
differ on the type of relationship that qualifies under domestic violence laws. Most
states require the perpetrator and victim to be current or former spouses, living
together, or have a child in common. A significant number of states include
current or former dating relationships in domestic violence laws. Delaware,
Montana and South Carolina specifically exclude same-sex relationships in their
domestic violence laws.
This training material will take a broader view of the definition of intimate partner,
defining the term as a particularly close interpersonal relationship that involves
physical or emotional intimacy. With this broad definition, intimate partners may
be married unmarried; heterosexual, gay, or lesbian; living together, separated or
dating, spouses or ex-spouses, nonmarried co-habitating partners or partners in
a romantic relationship. Intimate partners can also be any age, including teens
and the elderly.
While the majority of reported domestic violence occurs against women, men are
also victims of domestic violence. According to a study by Tjaden and Thoennes
(2000) 835,000 men in a national survey reported being victims of domestic
violence. Domestic violence against men can take many forms, including
emotional, sexual and physical abuse and threats of abuse. It can happen in
heterosexual or same sex relationships. As with many forms of abuse, these
numbers are likely underreported due to misunderstanding of the definition of

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domestic violence and the shame that men may feel in identifying themselves as
abuse survivors.
Examples of domestic violence include (Berry, 2000):
Intimidation or emotional abuse. Emotional abuse (also called

psychological abuse or mental abuse) includes behaviors that make the
person feel diminished or embarrassed. Emotional abuse can include
verbal abuse and is defined as any behavior that threatens, intimidates,
undermines the victims self-worth or self-esteem, or controls the victims
freedom (Follingstad, & DeHart, 2000) This can include threatening the
victim with injury or harm, telling the victim that they will be killed if they
ever leave the relationship, and public humiliation. Abusers will often
employ criticism and fault-finding, which may be a precursor to physical
violence, but may also accompany it. This may also include withholding
money or affection as a means of controlling the other person, threatening
abandonment, hurting or threatening children or pets, or isolating the
person from friends and family.
Economic or financial abuse. Abusive partners may use access to

money as a means of control. Economic or financial abuse includes:
withholding money or credit cards, withholding basic necessities (food,
clothes, medications, shelter), sabotaging the persons job (such as
making them miss work or calling constantly), stealing from you or taking
money.
Physical violence comprises any behaviors that injure the other person
or to cause physical pain. Physical abuse can also include behaviors such
as denying the person needed medical care, depriving the person of sleep
or other functions necessary to live, or forcing the victim to engage in
drug/alcohol use against his/her will.
Sexual abuse is any situation in which force or threat is used to obtain

participation in unwanted sexual activity. Sexual abuse may involve a wide
range of behaviors. The important component here is that the behavior is
non-consensual or makes the other person feel demeaned or violated. It
may include rape, forcing someone to perform sexual acts that he/she
finds unpleasant, forcing someone to have sex with others or watch
others, forcing someone into reproductive decisions.
Stalking can be defined as the willful and repeated following, watching

and/or harassing of another person. While stalking does not always occur
within an intimate partner relationship, it has become an area of increasing
concern in the domestic violence literature.
Case Vignette

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Jennifer has recently separated from her husband Jon and plans to file for
divorce. She has been subjected to repeated phone calls, text messages,
and emails telling her that Jon will never let her go. The content infers
that he has intimate knowledge of her movements. Jennifer has been told
by police that there is nothing they can do since the messages are not
threatening. Most recently, Jennifers has begun to receive gifts, of
flowers and chocolates, which appear on her apartment doorstep and car
windshield. She is certain they are from Jon. Jennifer describes feeling as
if she is in a constant state of panic.
Nearly 60 percent of women and 30 percent of men are stalked by a

current partner (Tjaden & Thoennes,1998.) The majority of stalking victims
are women (78 percent), and the majority of offenders (87 percent) are
men. (Tjaden & Thoennes, 1998).
As in the case vignette, stalking can be seen as "a course of conduct

directed at a specific person that involves repeated (two or more
occasions) visual or physical proximity, nonconsensual communication, or
verbal, written, or implied threats, or a combination thereof, that would
cause a reasonable person fear" (Tjaden & Thoennes,1998). While there
is a range of stalking behaviors, they may include leaving or sending the
victim unwanted items or presents, damaging the victims home, car or
other property, following or waiting for the victim, or leaving unwanted
messages or other actions intended to control the victim.
With increasing use of technology, cyberstalking has become more

prevalent. Some examples of cyberstalking are: researching the victim
using public records or on-line search services, monitoring phone calls or
computer use, and using technology, like hidden cameras or global
positioning systems (GPS), to track the victims movements.
Like other forms of domestic violence, stalking usually escalates. It is a

behavior that should be taken seriously and mental health clinicians may
benefit from being aware of specific laws in their states of practice.

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Prevalence of Domestic Violence
How widespread is domestic violence? Domestic violence is one of the most

chronically underreported crimes (U.S. Department of Justice, Bureau of Justice
Statistics, 2003). There is a great deal of stigma associated with intimate partner
violence. While there are many reasons for stigma, Mitchell and Anglin (2009)
believe that victims of domestic violence feel that the abuse is a result of a
personal flaw and do not disclose the abuse due to shame. There are other
reasons as well including family loyalty, fears of breaking up a family, and distrust
of authority and the efficacy of authority figures.
It is believed that only one-quarter of all physical assaults, one-fifth of all rapes,
and one-half of all stalkings perpetuated against females by intimate partners are
reported to the police (Tjaden, & Thoennes, 2000).
Research on intimate partner violence against women has exploded in the past
20 years, but despite this increase in research, many gaps exist in our
understanding of domestic violence. To further understanding of domestic
violence against women, the National Institute of Justice and the Centers for
Disease Control and Prevention conducted a national survey entitled The
National Violence Against Women (NVAW) Survey (Tjaden, & Thoennes, 2000).
The researchers sampled both women and men.
Some of the key findings are:
Physical assault is widespread among adults: An estimated 1.9 million

women and 3.2 million men are physically assaulted annually in the United
States.
Approximately 1.3 million women and 835,000 men are physically

assaulted by an intimate partner annually in the United States.
Violence against women is primarily intimate partner violence: 64.0

percent of the women who reported being raped, physically assaulted,
and/or stalked since age 18 were victimized by a current or former
husband, cohabiting partner, boyfriend, or date. 16.2 percent of the men
who reported being raped and/or physically assaulted since age 18 were
victimized by such a perpetrator.
Stalking is more prevalent than previously thought: 8.1 percent of

surveyed women and 2.2 percent of surveyed men reported being stalked
at some time in their life; 1.0 percent of women surveyed and 0.4 percent
of men surveyed reported being stalked in the 12 months preceding the
survey. Approximately 1 million women and 371,000 men are stalked
annually in the United States.

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Almost one-third of female homicide victims that are reported in police

records are killed by an intimate partner.14 In 70-80% of intimate partner
homicides, no matter which partner was killed, the man physically abused
the woman before the murder (Campbell et. al., 2003).
For both men and women, divorced or separated persons were subjected
to highest rates of intimate partner victimization, followed by never-
married persons (Rennison, & Welchans, 2000).
While these numbers are eye-opening, domestic violence impacts other areas as
well. Intimate partner violence results in more than 18.5 million mental health
care visits each year; the cost of intimate partner violence exceeds $5.8 billion
each year, $4.1 billion of which is for direct medical and mental health services
(CDC, 2003).
With prevalence ratings this significant, it is likely that most mental health
professionals will work with a current or past victim of intimate partner violence.
Theories on Domestic Violence
While have been many efforts to explain why domestic violence occurs, there is
no one explanation. While a common understanding of the causes of domestic
violence can help practitioners develop more effective responses to domestic
violence, this is not an easy task with the many perspectives regarding intimate
partner violence. Mitchell and Anglin (2009) summarize this in the chart below.
Several of these perspectives will be detailed further.
Group Population studied Conceptualization

Psychological/Medical Patients seeking care Violence as a result of
frustration; as a cause of
presenting symptoms;
trauma response
Family Violence College students, general Violence as a response
Researchers population to intermittent conflict
Domestic Violence Women seeking services; Violence is part of a
Movement, Feminist men in batterer coercive pattern of
Researchers programs behavior meant to
establish power and
control
Legal System Crime victims and Violence as a criminal act
perpetrators

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Although many of these systems may seem to offer contradictory views of

domestic abuse, another perspective is that they can all provide information that
increases understanding of domestic violence.
Psychological Framework
Frustration-Aggression Theory
Dollard (1939) was one of the first writers to identify a theory that was applied to
intimate partner violence: the frustration-aggression theory. Simply put the theory
states that when people perceive that they are being prevented from achieving a
goal, their frustration is likely to turn to aggression. Aggression, then, is seen as
an instinctual response to frustration. When applied to intimate partner violence,
marital/dating relationships can trigger anger (justified frustration) or aggression
(unjustified frustration).
Social Learning Theory
The Social Learning Theory is a popular way to explain violent behavior. Social
learning theorists reject the idea of instinct, and instead believe that human
aggression is learned conduct that, like other forms of social behavior, is under
stimulus, reinforcement, and cognitive control.
According to social learning theory, family violence arises due to many contextual
and situational factors. Examples of contextual factors include individual/couple
characteristics, stress, or an aggressive personality. Situational factors include
substance abuse and financial difficulties. Social learning theory also extends
these factors onto the influence of children growing up in families in which these
external forces exist (Domestic Violence Group Action Project).
Although the relationship is not entirely straightforward, there does seem to be

some support for the learned behavior theory of violence. The strongest risk
factor for males who become perpetrators of domestic violence is witnessing
violence between ones parents or caretakers (Break the Cycle, 2006). Boys who
witness domestic violence are twice as likely to abuse their own partners and
children when they become adults (Strauss, Gelles & Smith, 1990) 30% to 60%
of perpetrators of intimate partner violence also abuse children in the household
(Edelson, 1999). Witnessing violence in the home seems to provide these young
men with lessons that validate that its appropriate to control women and that
physically acting out is one way to do so.
The relationship between witnessing domestic violence and acting out or entering
an abusive relationship is not as clear-cut for women. There have been virtually
no studies of women who become domestic abusers. Research does show that
women who witness domestic violence are not any more likely to be battered as

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adults. Women who were physically or sexually abused as children, however,

may be more likely to be abused as adults (Family Violence Prevention Fund).
Cognitive-Behavioral Theories
Cognitive-Behavioral theorists look at how a person perceives, interprets, and

processes the events in any given situation (Todd & Bohart, 1994). Aggressive
behaviors are influenced by what a person perceives and interprets prior to the
aggression. Changing these thought patterns, then, will contribute to a change in
behavior.
CBT also emphasizes that violence and aggression are choices. People cannot
be forced to act abusively, a cognitive-behavioral approach encourages the
individual to acknowledge that they chose to behave in the way that they do.
A common CBT intervention is an anger log. This log encourages individuals to

monitor and record the thoughts and behaviors which immediately preceded
violent outbursts (Koonin, Cabarcas, & Geffner, 2002). This anger log is like
other cognitive-behavioral thought logs but also includes awareness of the
persons physiology prior to aggression.
Feminist/Domestic Violence Movement Framework
Emphasis on the importance of addressing domestic violence dates to the 1970s,

which also coincides with a boom in feminist approaches to psychology. The
feminist/domestic violence movement explains domestic violence as a result of
historically created gender hierarchy and sexual division of labor in the home, in
which men dominate and control women (Messerschmidt, 1986). In addition to
looking at power/gender inequalities, an important part of the feminist approach
is in educating society about the problem of intimate partner violence.
Many authors have written about the link between domestic violence and power
and control dynamics in the relationship. One commonly used paradigm is The
Power and Control Wheel (Domestic Intervention Programs, Duluth, Minnesota).
It was developed based on focus groups of women who had been victims of
domestic abuse.
The Power and Control Wheel describes the different tactics that are used by
abusive individuals to maintain power and control over a partner. The Wheel is
depicted below.

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What is significant about this depiction is that it looks at domestic violence as part
of a larger pattern of behavior rather than a single (although repeated) loss of
control.
As an outgrowth of other research, domestic violence professionals have

attempted to look at individual and familial variables in domestic violence.
Crowell (1996) was one of the first researchers to conduct a study of family
violence in the United States. She correlated domestic violence with households
below the poverty line, racial minority households, and heads of household being
18-30 years old. These characteristic produced high degrees of stress. Straus et
al. (1990) found that in middle or upper class households, family violence was
much more sheltered.
There is also a body of research and antidotal information on individual factors
that may heighten the risk of potential abuse (Alabama Coalition of Domestic
Violence). Males who abuse may display the following:
Jealousy History of past battering

Controlling behavior Threats of violence
Quick involvement Breaking or striking objects
Unrealistic expectations Any force during an argument
Isolation of victim Objectification of women
Blames others for his problems Tight control over finances
Blames others for his feelings Minimization of the violence
Hypersensitivity Manipulation through guilt

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Cruelty to animals or children Extreme highs and lows

"Playful" use of force during sex Expects her to follow his orders
Verbal abuse Frightening rage
Rigid sex roles Use of physical force
Jekyll and Hyde personality Closed mindedness
In addition to identifying the characteristics of abusive men, domestic violence

researchers have also developed a schema for what they term the cycle of
abuse. This classic conceptualization was developed by Lenore Walker in the
1970s (Walker, 1979).
Tension Building Phase

Characterized by poor communication, tension, fear of causing outbursts.
During this stage the victims try to calm the abuser down, to avoid any
major violent confrontations.
Violent Episode
Characterized by outbursts of violent, abusive incidents. During this stage
the abuser attempts to dominate his/her partner(victim), with the use of
domestic violence.
Honeymoon Phase
Characterized by affection, apology, and apparent end of violence. During
this stage the abuser feels overwhelming feelings of remorse and
sadness. Some abusers walk away from the situation, while others shower
their victims with love and affection.
Calm phase
During this phase (which is often considered an element of the
honeymoon/reconciliation phase), the relationship is relatively calm and
peaceable. However, interpersonal difficulties will inevitably arise, leading
again to the tension building phase.
Case Vignette
Anna has been attending therapy sessions, a bold move considering how fearful
she is that her physically abusive husband will discover it. Following a particularly
brutal encounter, she tells her therapist that she feels that her husband has
finally made a change. He appears attentive, and has even brought her flowers,
something that has not occurred since their earliest years together. Although her
therapist cautions that abusive situations are very difficult to change without
therapy and support, Anna is shocked when he again hurts her after an
argument.

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Integrative Models
The Socio-Ecological Model
The Socio-Ecological Model (Heise, 1998) attempts to integrate many of these

approaches as a means of creating change. As depicted in the graphic below,
this model places individual characteristics within the family/relationship, the
individual and family within the community, and the individual, family and
community within society.
When applied to domestic violence prevention, this framework allows for

development of specific interventions. For example, an individual factor may
include use of power and control, and an appropriate strategy may be coaching.
This must be viewed, however, within the larger societal context. For example,
domestic violence may be associated with historical patterns that glorify violence
against women and a strategy may include public education campaigns.
Warning Signs of Abuse
The following warning signs may alert practitioners to the possibility of abuse.
Psychological warning signs of abuse

Depression, anxiety, or suicidality or post traumatic stress symptoms.
Clients that display outbursts of anger or poor impulse control.
Clients that display extreme hypervigilance
Clients that have very low self-esteem, or report that they used to be
confident.
Clients that demonstrate major personality changes (e.g. an outgoing
person becomes withdrawn).

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General warning signs of domestic abuse

Secrecy about entering therapy, in particular keeping the decision from a
partner or spouse.
Clients that seem overly afraid or anxious to please their partner, or who
go along with everything their partner says and does.
Clients that check in often with their partner to report where they are and
what theyre doing.
Clients that receive frequent, harassing phone calls from their partner or
who are constantly checking the cell phones for messages from a partner
Client who talk about their partners temper, jealousy, or possessiveness.
Warning signs of physical abuse

Clients that have frequent injuries, with the excuse of accidents.
Frequently missing appointments without explanation.
Clients that dress in clothing designed to hide bruises or scars (e.g.
wearing long sleeves in the summer or sunglasses indoors).
Warning signs of isolation

Clients who report being restricted from seeing family and friends.
Clients that rarely go out in public without their partner.
Clients that have limited access to money, credit cards, or the car.

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References
Alabama Coalition Against Domestic Violence. Why do abusers batter?

Retrieved February 2, 2012 from http://www.acadv.org/abusers.html
Berry, D.B. (2000). The domestic violence sourcebook. Los Angeles, CA: Lowell
House.
Break the Cycle. (2006). Startling Statistics. Retrieved February 2, 2012 from
http://www.breakthecycle.org/html%20files/I_4a_startstatis.htm.
Campbell, et al. (2003). Assessing Risk Factors for Intimate Partner Homicide.
Intimate Partner Homicide, NIJ Journal, 250, 14-19. Washington, D.C.: National
Institute of Justice, U.S. Department of Justice.
Centers for Disease Control and Prevention, National Centers for Injury
Prevention and Control (2003).Costs of Intimate Partner Violence Against
Women in the United States. Atlanta, GA.
Crowell, N.A. (1996). Understanding violence against women. Washington, D.C.:

National Academy Press.
Dollard, J. et. al., (1939). Frustration and aggression. New Haven: Yale
University Press.
Domestic Violence Group Action Project. Domestic violence: Theories of

causation. Retrieved February 9, 2012 from
http://wost201h_domviol.tripod.com/groupactionproject/id4.html
Duluth Model (1984). The Violence Wheel. Retrieved February 6, 2012 from
http://www.theduluthmodel.org/training/wheels.html
Edelson, J.L. (1999). The Overlap Between Child Maltreatment and Woman
Battering. Violence Against Women. 5:134-154.
Follingstad, D & DeHart, J. (2000). "Defining psychological abuse of husbands

towards wives: Contexts, behaviors, and typologies". Journal of Interpersonal
Violence 15: 720745.
Gelles, R.J. & Straus, M.A. (1988). Intimate violence. New York: Simon and
Schuster.

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Koonin, M., Cabarcas, A., & Geffner, R. (2002). Treatment of women arrested for
domestic violence: Women ending abusive/violent episodes respectfully
(WEAVER) manual. San Diego: Family Violence & Sexual Assault Institute.
Mitchell, C. & Anglin, D. (2009). Intimate partner violence: A health-based

perspective. London: Oxford.
Messerschmidt, J.W. (1986). Capitalism, patriarchy, and crime. Totowa, NJ:

Rowman and Littlefield.
Rennison, M. & W. Welchans (2000). Intimate Partner Violence. U.S. Department

of Justice, Office of Justice Programs, Bureau of Justice Statistics.
Strauss, M.A., Gelles, R.J. & Smith (1990). Physical Violence in American
Families: Risk Factors and Adaptations to Violence in 8,145 Families.
Transaction Publishers.
Tjaden, P. & Thoennes, N. (2000). National Institute of Justice and the Centers of
Disease Control and Prevention, Extent, Nature and Consequences of Intimate
Partner Violence: Findings from the National Violence Against Women Survey.
Tjaden, P. & Thoennes, N. (1998). National Institute of Justice, Stalking in

America: Findings From the National Violence Against Women Survey.
Walker, L.E. (1979) The Battered Woman. New York: Harper and Row.

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Chapter 2: The Effects
Introduction
Case Vignette
Dr. Katz has been working with Kelly, a 46-year-old client for a month. The
primary focus of counseling to this point in time has been Kellys anxiety. As a
nurse at a local hospital, she has talked about the stresses that job entails. Dr.
Katz is surprised, however, to learn that Kelly has been fired from her position.
As she breaks down in Dr. Katzs office, Kelly reveals that the termination
resulted from the numerous and relentless phone calls her husband had been
making to her while she was at work. Her supervisor was concerned that she
was unable to focus on her patients and when she did make a relatively minor
mistake with some medication, Kelly was terminated. As Dr. Katz probes, he
realizes that Kelly has been dealing with domestic violence.
As the case vignette illustrates, domestic violence has many potential effects on
its victims. Like Kelly, many men and women who are subjected to intimate
partner violence do not disclose it, due to shame or fear. The reach of domestic
violence is far: stress, economic hardship, psychological illness, and addiction.
Like other forms of trauma, intimate partner violence has a number of effects on
its victims. However, the impact of domestic violence varies enormously between
individuals. Clinicians working with victims of domestic violence should not
assume that they are one homogeneous group. In addition to individual
differences, it is also important to consider whether the person who has
experienced domestic violence has any prior history of trauma. There are also
differences in terms of the type and severity of abuse.
While these differences are important, research indicates that there are a number
of long-term effects of domestic violence. These may include (Newton, 2001):
anxiety
chronic depression
chronic pain
drug and alcohol dependence
eating disorders
hyper vigilance
emotional numbing
chronic health problems
panic attacks
post traumatic stress symptoms
self-injury and self-neglect
inconsistent parenting

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While domestic violence adversely affects its victims, it is important to recognize

that domestic violence is a family matter in that it also affects the children in the
family. These reactions can vary depending on the child's gender and age.
Children exposed to family violence are more likely to develop social, emotional,
psychological and or behavioral problems than those who are not. Recent
studies indicates that children who witness domestic violence show more anxiety,
low self esteem, depression, anger and temperament problems than children
who grow up in homes where there is no trauma. The effects of family violence
can continue into adulthood.
The National Coalition Against Domestic Violence defines domestic violence as

the willful intimidation, physical assault, battery, sexual assault, and/or other
abusive behavior perpetrated by an intimate partner against another. Domestic
violence is displayed across a broad spectrum of cultural, economic, religious
and racial groups. While this is not an exhaustive list, Kurst-Swanger and
Petocsky (2003), have identified some behaviors indicative of intimate partner
violence which include:
Denying a person autonomy

Isolating victims from family and friends
Instilling fear through intimidation, threats and violence
Manipulating behavior
Punishing victims for challenging an abusers authority
Unjustified jealousy
Controlling financial resources
Using children as a way to hurt, control or manipulate
This course will discuss the effects of domestic violence. The terms domestic
violence, domestic abuse, and intimate partner violence will be used
interchangeably throughout the text.
1. Define domestic violence and the term intimate partner

2. Discuss common patterns of abusive behavior
3. Discuss chronic physical symptoms in survivors of domestic violence
4. Discuss mental health effects of domestic violence, including depression
and posttraumatic stress disorder
5. Describe the effects of domestic violence on children
Common Patterns of Intimate Partner Violence
Prior to discussing the effects of domestic partner abuse, it is helpful to

understand common patterns of abuse. There is also variability in the degree of
chronicity with which abusive behaviors occur. Johnson and Ferraro (2000)
describe these patterns of violence:

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Common Couple Violence - within the context of a single issue, there

is one or at most two incidents of violence, and it is not used as part of
a pattern of behavior to control the partner. This is similar to the "family-
only" batterer, or someone who is not violent outside the home and is
the least likely to be sexually and emotionally abusive. Johnson and
Ferraro report this kind of batterer is about evenly split between males
(56%) and females (44%), and some studies showing that in younger
samples women may use more aggression than men. However, women
still tend to suffer more serious injuries compared to men.
Intimate Terrorism this pattern of relationship violence is centered on

the abusers need to control his/her victim. This form of violence is likely
to increase over time, to involve a higher frequency of incidents, and
more serious injuries.
Violent Resistance - This kind of violence occurs in response to a

perceived threat, and is not part of a pattern of control and
manipulation.
Mutual Violent Control - this kind of violence occurs when two parties
use violence to control each other. Johnson and Ferraro note that even
in these cases some gender differences remain. In 31% of these
couples, the male initiated more violence, as opposed to 8% for the
female.
Effects on Victims
Unexplained Physical Symptoms/Somatization
Emotional pain is often expressed through physical pain. Studies confirm an

association between domestic violence and poor physical health (Hagion-Rzepka
(2000; Mitchell & Anglin, 2009). While it may seem to follow that these symptoms
are a result of the person having been physically assaulted, this does not appear
to be the case. Often the problems appear unrelated to physical injury.
Those who have been victims of domestic violence may exhibit a wide range of
physical symptoms, a greater number of symptoms, and more severe symptoms.
According to Hagion-Rzepka (2000) The stress of being in an abusive
relationship often has a physiological impact, as well as the obvious physical and
psychological impact: it often increases ones vulnerability to illness. The
following case study provides an example.
Case Vignette

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Natalie, a 48-year-old woman, who has been in an emotionally abusive and

controlling relationship is presenting for therapy. She states that she is there
reluctantly, and knows that the doctor just hasnt found what is wrong.
Symptoms include diffuse pain, periods in which her fatigue is so great that she
cannot get out of bed, shortness of breath, and blinding headaches. Natalie has
consulted with several doctors, including her PCP, a neurologist and a
cardiologist. Natalie believes that she must have a rare physical problem, but
that it has not yet been found. She is upset that the doctor has referred her for
therapy.
Patients with unexplained physical ailments generally first seek treatment in

primary care settings, but may be even more common in neurologic settings. In
addition to unexplained physical problems, such a chronic pain or migraine
headaches, a number of symptom-based syndromes are also related to domestic
violence. These include fibromyalgia, chronic fatigue syndrome, multiple
chemical sensitivity, temporomandibular disorder, irritable bowel syndrome, and
tinnutis (Richardson & Engel, 2004). These disorders share some important
features, such as fatigue or pain, disability that is out of proportion to physical
findings and stress or psychosocial factors. They also tend to effect women more
than men.
The impact of abuse seems to be in large part biological. Abuse appears to

activate the bodys stress responses, and the release of cortisol. While small
increases in cortisol are not problematic, chronic stress has negative effects.
In addition to biology, chronic stress has psychological effects. Somatization is

the idea that emotional pain and stress are expressed through bodily symptoms.
While some victims of intimate partner violence may meet DSM criteria for
Somatization Disorder, many do not meet the full criteria. It is helpful to recognize
that trauma may underlie unexplained physical symptoms.

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DSM Criteria: Somatization Disorder
A history of many physical complaints beginning before age 30

years that occur over a period of several years and result in
treatment being sought or significant impairment of functioning.
Each of the following criteria must have been met, with individual
symptoms occurring at any time during the course of the
disturbance.
4 pain symptoms: a history of pain related to at least 4 different

sites or functions
2 gastrointestinal symptoms: a history of at least 2 gastrointestinal
symptoms other than pain
1 sexual symptom: a history of at least 1 sexual or reproductive
symptom other than pain
1 pseudoneurological symptom: a history of at least 1 symptom or
deficit suggesting a neurological condition not limited to pain
Either:
After appropriate investigation, each of the symptoms cannot be
fully explained by a known general medical condition or the direct
effects of a substance OR
When there is a related general medical condition, the physical
complaints or resulting social or occupational impairment are in
excess of what would be expected from the history, physical
examination, or laboratory findings
The symptoms are not intentionally produced or feigned.
It is important for clinicians to be aware of the possibility that clients with chronic
pain or unexplained physical symptoms (but especially with multiple symptoms)
may have a history of abuse, and explore this sensitively. It is important that
clinicians not express doubt as to the symptoms or imply that they are
imagined, but rather to state that traumatic experiences can worsen the
experience of pain or make physical symptoms more severe or difficult to handle.
Other Mental Health Consequences of Domestic Violence
Domestic abuse and other forms of violence are associated with increased risk
for developing a range of psychiatric conditions including depression, anxiety
and posttraumatic stress disorder or of exacerbating existing mental health
concerns. Substance abuse, somatoform disorders, eating disorders, sexual
difficulties and psychotic episodes have also been linked to adult and childhood

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abuse (Briere et al, 1997; McCauley et al, 1995; Poirier, 2000). Partner abuse is
also a significant risk factor for suicidality (Plichta & Weisman, 1995). What is
also concerning is that living with a serious mental illness may increase a
womans vulnerability to abuse.
Some of these prevalence statistics are as follows:
Of 140 women attending an outpatient psychiatric clinic, 64% had a

lifetime history of physical and/or sexual abuse (Surrey et al, 1990). On
average, half of all women seen in a range of mental health settings have
been abused by an intimate partner (Friedman & Lou, 2007).
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.
Out of 303 depressed women culled from a large random sample, 63%
had experienced abuse at some point in their life (Scholle et al, 2008).
55% reported having been abused in adulthood by a family member or
someone they knew well, such as a boyfriend.
Experiences of abuse and violence are especially high for women diagnosed with
serious mental illness.
64% of female inpatients that had been physically assaulted as adults,

56% shared a home with the perpetrator (Jacobson and Richardson
2007).
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.
Out of 93 women seen in a psychiatric emergency room 42% had

been abused by a partner (Briere et al, 1997).
Case Vignette
Anna has been married to Mark, and has been a victim of intimate partner
violence. She has been able to seek help from Dr. Frank, an outpatient
psychologist. Dr. Frank has diagnosed Anna with depression, and she has begun
taking medication. Anna was tearful in the last session, stating that Mark now
had more ammunition against me. Whenever he becomes upset with her, he
asks if she has taken her medication and frequently calls he crazy. He has also
shared the fact that she is in therapy with members of her church, and is seen as
a saint for sticking by her.

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While the statistics verify the scope of mental health consequences and domestic
violence, what is not reflected in the statistics is that mental illness and intimate
partner violence have a circular effect. Mental illness is often cited as the impetus
for incidents of family violence, particularly among those with severe mental
illnesses. Additionally abuse results in more acute symptoms of these disorders,
or can be a stressor underlying the mental health concern.
Depressive Disorders
Chief among the mental health effects of domestic violence is depression.

Prevalence rates of women who have been abused by a partner range from
37.7% to 63% (Bonomi et al., 2006). One factor that increases a victims risk for
depression is perpetrator behavior. Perpetrators often exert control, manipulate
and degrade their victims, and isolate them from friends and family. When sexual
abuse or assault is added to the mix, the result is even higher levels of
depression.
Several studies of depression and intimate partner violence suggest that the
strongest predictors of depression among abuse victims are the frequency and
severity of family violence, emotional or psychological abuse, sexual violence,
and lack of social support (Koopman, Ismailji & Palesh, 2007, Pico-Alfonso,
2005, Pico-Alfonso, Garcia-Linares & Celda-Navaro, 2006). These appear to be
stronger predictors than cultural/demographic factors or preexisting mental
illness.
The research also confirms that the incidence of depression is higher among
women who reported more frequent sexual abuse by partners. Among those
surveyed in the National Violence Against Women Study, twenty-five percent of
women and 8 percent of men, said they were raped and/or physically assaulted
by a current or former spouse, cohabiting partner, or date at some time in their
life; 1.5 percent of women and 0.9 percent of all men said they were raped by a
partner (Thaden & Thonnes, 1998). Although symptoms of anxiety more often
predominate immediately following a sexual assault, depression quickly develops
and can persist over time. Survivors of childhood abuse who are then assaulted
by adult partners are at significant risk of depression (Dickinson et al., 1999).
Depression appears to be significantly associated with domestic violence.

Clinicians should be aware that this may a consequence of intimate partner
violence and screen for such symptoms when working with survivors.
Case Vignette
Anna Louise, a 28-year-old married woman has a history of psychiatric illness. In
her most recent hospitalization for a failed suicide attempt, Anna Louise
disclosed that she was a victim of sexual abuse in childhood. When she initially
met her husband Ken, she thought that he was different, but that has not

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proven to be the case. She states that he is verbally abusive and controlling. Her
hospitalization was precipitated by an incident in which she felt that Ken forced
her to have sexual intercourse despite her indications that she did not wish to.
Anna Louise is despondent and hopeless that her situation will change.
Posttraumatic Stress Disorder
Like depression, posttraumatic stress disorder (at clinical or subclinical levels) is

frequently a consequence of intimate partner violence. Rates of PTSD among
survivors of domestic violence are estimated to be between 33% and 84%
(Kemp, Rawlings & Green, 1994; Woods & Wineman, 2004). In the National
Violence Against Women Study (Thaden & Thonnes, 1998), 24% of those who
had experienced partner violence in the past year met full clinical criteria for
PTSD.
Diagnostic criteria for PTSD include exposure to a severe stressor (such as

threats to the physical integrity of oneself), a response that involved intense fear,
helplessness, or horror. For a diagnosis of PTSD, the person must also have
experienced symptoms of intrusive recollection, such as recurrent and intrusive
distressing recollections of the event, dreams, or flashbacks; avoidant/numbing
reactions, such as efforts to avoid things that arouse recollections of the trauma,
diminished interest or participation in significant activities or restricted range of
affect; hyperarousal, such as irritability or exaggerated startle response.
Responses of men and women who have been victims of domestic violence are
similar to those of other types of traumatic exposure.
Using a PTSD framework is helpful as it places symptoms squarely within the

context of it being a consequence of the abuse.
As with depression, PTSD in domestic violence victims has been associated with
severity of the abuse, history of repeated abuse, sexual abuse and/or assault,
and psychological abuse. Stalking is also associated with the development of
PTSD. The more kinds of abuse someone experiences (physical, emotional,
sexual) the greater his or her risk becomes for developing PTSD (Coker, Davis &
Arias, 2002).
Case Vignette
Marybeth is a 29-year-old woman presenting for an initial consultation with Dr.
Arian. She states that she has been feeling overwhelmed and exhausted. She
has been more irritable than normal, is having sleep problems and nightmares,
and has a feeling of dread. Due to her current symptoms, Marybeth is
increasingly isolating herself and has missed several days of work. She reports
that she is separated from her husband Charlie, who is an alcoholic and often
violent and unpredictable.

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Domestic Violence and Children
While many past research efforts have focused on direct victims of intimate
partner violence, increased attention is now being focused on the children who
witness domestic violence. Between 10 to 20 percent of children nationwide are
exposed to domestic violence (Carlson, 2000). That means that approximately
3.3 to 10 million children who witness the abuse of a parent or adult caregiver
each year (Carlson, 1984; Straus and Gelles, 1990).
Children are affected by domestic violence in a variety of ways. Domestic

violence in the household is often accompanied by other major developmental
risk factors for children such as poverty, female-headed household, and low
education level of primary care giver (Fantuzzo, et al, 1997).
Children who live in violent households also are at risk for physical injury both
prenatally and post-natally (Peedicayil et al., 2004). Prevalence rates for
domestic violence during pregnancy range from 0.9% to 20.1% depending on the
definition for violence in the study (Peedicayil et al., 2004). Domestic violence is
the major cause of trauma-related visits to health care providers during
pregnancy (Harner, 2004).
While many children who live in homes in which there is intimate partner violence
also are recipients of the violent acts, children who live in homes in which there Is
domestic violence are victims, whether or not they are the direct target of the
violent behaviors. "Families under stress produce children under stress. If a
spouse is being abused and there are children in the home, the children are
affected by the abuse." (Ackerman & Pickering, 1989).
Research does indicate that children exposed to domestic violence are at an

increased risk of being abused or neglected. In 30 to 60 percent of families in
which there is past or present domestic violence, children are also abused
(Edleson, 1999; Jaffe and Wolfe, 1990). Kaufman and Henrich (2000) estimate
that approximately 40% of children who witness domestic violence are also
physically abused. The severity of the domestic violence appears predictive of
the severity of the child abuse (DiLauro, 2004). Mothers in domestic violence
relationships are more likely to physically and/or emotionally abuse their children
than are mothers in nonviolent relationships (Lutenbacher, Cohen, & Conner,
2004)
Children who grow up in families in which there is domestic violence are also four
to six times more likely to be victims of sexual abuse (as cited in Wilson, 2006).
This may be because abusers have a history of requiring others to meet their
needs, and this may extend to sexual needs.
Just as the Domestic Abuse Prevention Project developed a Domestic Violence

Wheel, they have also developed a Child Abuse Wheel. It is significant that many

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of the descriptors on the wheel mirror the Domestic Violence Wheel (see
Introduction to Domestic Violence).
Domestic Abuse Prevention Project, Duluth, MN
Although the abused parent frequently tries to shield children from exposure to
the domestic violence, 80 to 90 percent of children from households in which
there is domestic violence can recount in detail the violent episodes (Doyne,
Bowermaster & Meloy, 1999). They may hear the parents screams or crying, or
the abusers threats. They may also see the aftermath of the abuse, such as
broken furniture or windows. This results in emotional trauma, fears and guilt
(Wilson, 2006).
Dynamics of domestic violence which are unhealthy for children include

(Alabama Coalition Against Domestic Violence):
control of family by one dominant member.

abuse of a parent.
isolation.
protecting the "family secret".
The results of domestic violence vary, depending on the childs age, individual
personality variables, and the type and frequency of violence that they are
exposed to. In general, children are more likely to develop negative psychological

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effects from witnessing domestic violence if they witness severe or chronic

violence, if they are younger, if the violence is frequent, and if it is perpetrated in
close proximity to them (Knapp, 1998).
Overall, the trauma children experience can show up in emotional, behavioral,

social and physical disturbances that effect their development and can continue
into adulthood (Alabama Coalition Against Domestic Violence).
Effects of Domestic Violence on Children
Emotional
Depression, helplessness, powerlessness.

Shame, guilt, and self-blame.
Confusion about conflicting feelings toward parents.
Fear of abandonment
Anger.
Shame
Behavioral
Acting out or withdrawing.

Aggressive or passive.
Refusing to go to school.
Care taking; acting as a parent substitute.
Lying to avoid confrontation.
Rigid defenses.
Excessive attention seeking.
Bedwetting and nightmares.
Out of control behavior.
Reduced intellectual competency.
Manipulation, dependency, mood swings.
Social
Isolation from friends and relatives.

Stormy relationships.
Difficulty in trusting, especially adults.
Poor anger management and problem solving skills.
Excessive social involvement to avoid home.
Passivity with peers or bullying
Engaged in exploitative relationships as perpetrator or victim

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Physical
Somatic complaints, headaches and stomachaches

Nervous, anxious, short attention span
Tired and lethargic
Frequently illnesses
Poor personal hygiene
Regression in development
High risk play
Self abuse
While the list above documents a number of behavioral effects of domestic

violence, just as with adult victims, children are at risk for depression, anxiety
disorders, and posttraumatic stress disorder. The severity, duration, and
proximity of an individuals exposure to the traumatic event are the most
important factors affecting the likelihood of developing PTSD (Groves, 1999).
The criteria includes exposure to a traumatic event in which the person
witnessed or experienced an event that involved actual or threatened death or
serious injury to self or others and the individuals response involved intense fear,
helplessness, horror, or, in children, disorganized or agitated behavior. For
children with PTSD re-experiencing symptoms may include repetitive play
expressing a theme of the trauma.
In addition to the childhood effects of domestic violence and children, it is also

important to understand the long-term effects. There is much evidence that
domestic violence begets domestic violence. According to the American
Psychological Association, Violence and the Family: Report of the APA
Presidential Task Force on Violence and the Family (1996), A child's exposure to
the father abusing the mother is the strongest risk fact for transmitting violent
behavior from one generation to the next. Witnessing domestic violence as a
child increases the risk for the child to be in a violent relationship as an adult
(Ornduff, Kelsey, & OLeary, 2001).
Summary
Domestic violence is an important mental health issue that affects the entire
family. There are a number of long-term effects of domestic violence, including
chronic anxiety and depression, inconsistent parenting and posttraumatic stress
symptoms. Children that witness domestic violence are also at risk not only for
mental health concerns, but also for carrying the violence forward to the next
generation. It is important, then, to intervene with the whole family system.

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Chapter 3: Intimate partner sexual abuse
Introduction
Case Vignettes
Cami, a 38-year-old woman is married to Carl. The relationship is frequently

physically abusive, and the abuse often extends to violent, forced, sexual
intercourse. Cami is fearful of staying, and fearful of leaving.
Elaine, a 35-year-old married woman is seeking counseling due to severe

depression. She states that her primary stressor is her marriage to Bill. The
couple has one child, and Elaine is a stay-at-home mother. She feels distant from
Bill, but stuck in the marriage. Elaine shares that one of the hardest parts of the
relationship is that she often feels coerced into having sexual relations with Bill.
She has clearly said no, but Bills guilt inducing tactics and threats to leave her
and take their child leave her with no choice but to submit.
The case vignettes above illustrate the range of intimate partner sexual abuse.
When most people think about sexual abuse or violence, they often think of it as
an assault by a stranger on an unsuspecting victim. As clinical knowledge of
sexual abuse advances, so does our understanding that sexual abuse can occur
between two people who know one another, or even two people who have an
intimate relationship. The term Intimate partner sexual abuse (IPSA) refers to
sexual abuse or assault that occurs between two people who have or have had a
consensual sexual relationship. The term Intimate Partner Sexual Violence
(IPSV) is more often used in relationships where there are other forms of
physical abuse, or when the sexual abuse is accompanied by violence. Partner
rape is more of a legal term and is defined as sexual acts committed without a
person's consent and/or against a person's will when the perpetrator is the
individual's current partner (married or not), previous partner, or co-habitator.
Regardless of terminology, intimate partner sexual abuse constitutes a form of
power and control seen in other types of domestic violence.
While many people would look at the first case vignette and agree that it
constitutes sexual abuse, some would question the second case vignette. Does
coercion constitute abuse? It is helpful to look at the definition of sexual assault.
Sexual assault refers to any sexual contact of a person by another without
appropriate legal consent. While physical force may be present, this is not always
the case. Lack of voluntary consent for sexual contact, such as through the use
of intimidation or threats are equivalent to no consent (Sachs & Gomberg, 2009).
Intimate partner sexual abuse can occur in dating relationships, marriages or
long-term gay or lesbian relationships.

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Marital rape, also known as spousal rape, is non-consensual sex in which the
perpetrator is the victim's spouse. While marital rape is a recognized problem in
the United States as well as internationally, a major issue is whether it has been
criminalized. Marital rape is considered a criminal offense in many countries,
however, cultural norms and the perceived stigma discourage women from
reporting marital rape. Until 1976, marital rape was legal in every state in the
United States. Marital rape is now a crime in all 50 states in the U.S., however,
some states still don't consider it as serious as other forms of rape. Clinicians
may want to check whether their home state is one that makes a distinction
between marital rape and other forms of rape. State laws also vary with regard to
the nature of acts that are considered abusive sexual contact.
While societal views sometimes minimize the consequences of intimate partner

sexual abuse, research finds that it is as problematic, if not more problematic,
than abuse by a stranger. In one of the first discussions of intimate partner
sexual abuse, early researchers Finkelhor and Yllo (1985), write about the
special traumas of this type of domestic violence and state, It is these special
traumas that we need to understand in their full and terrible reality.
This course will examine the issue of intimate partner sexual abuse. Upon
completion of this chapter you will be able to:
1. Define the terms sexual assault and rape

2. Describe the incidence and prevalence of intimate partner sexual abuse
3. Compare and contrast intimate partner sexual abuse with abuse by a non-
intimate partner
4. Compare intimate partner sexual abuse with general domestic violence
5. Describe the physical and mental health effects of intimate partner sexual
abuse
6. Discuss intervening in intimate partner sexual abuse, and providing
trauma-informed care
Definitions, Prevalence and Incidence of Intimate Partner Sexual Abuse
Obtaining prevalence data about sexual assault in the US is problematic due to

different survey methodology and definitions of what constitutes assault
and/rape. Most studies are thought to grossly underestimate the incidence due to
low disclosure rates. While this is true for many types of domestic violence,
intimate partner sexual abuse seems to carry a particular stigma. Victims of
intimate partner sexual abuse seem to also express many fears of
revictimization.
Prior to looking at incidence data, it is important to look at some definitions of

what constitutes sexual assault, and to expand upon those offered in the
introduction. These definitions are important because they determine the scope

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of inquiry and the questions included in research, affect the wording of questions
and guide sample selection.
According to the American Psychological Association, sexual assault can be

viewed on a continuum that ranges from forcible rape to nonphysical forms of
pressure that compel people to engage in sexual acts against their wishes.
Sexual assault takes many forms. It includes acts such as sexual degradation,
intentionally hurting someone during sexual intercourse, the use of objects
intravaginally, orally, or anally, pursuing sex when someone is not fully conscious
or afraid to say no, and coercing an individual to have sex without protection
against pregnancy or sexually transmitted diseases.
In contrast, rape is a legal term. Three elements characterize legal definitions of

rape: lack of consent; penetration, no matter how slight or independent of
whether ejaculation occurred; and compelling participation by force, threat of
bodily harm, or with a person incapable of giving consent due to intoxication or
mental incapacitation.
A key, population-based survey is the National Crime Victimization Survey

(NCVS), which looks at the incidence of sexual assault. Data are obtained from a
nationally representative sample of about 40,000 households comprising nearly
75,000 persons on the frequency, characteristics and consequences of criminal
victimization in the United States. According to the 2006 NCVS survey, there
were an estimated 272,350 sexual assaults against victims age 12 and older.
This is a decline from previous years; sexual assault has decreased by two-thirds
since 1993. The 2006 NCVS survey did not include statistics for victim and
offender relationships, but past studies did. In fact, past data has revealed that
an estimated 73% of all sexual assaults were committed by someone known to
the victim: 38% of perpetrators were a friend or acquaintance of the victim; 28%
were an intimate partner; and 7% were another relative.
Another important source of data is the CDCs 2010 National Intimate Partner
and Sexual Violence Survey (NIPSVS). This survey presents interview data
obtained from 16,507 adults (9,086 women and 7,421 men). The survey found
that nearly 1 in 5 women (18.3%) and 1 in 71 men (1.4%) have been raped at
some time in their lives, including completed forced penetration, attempted forced
penetration, or alcohol/drug facilitated completed penetration. More than half
(51.1%) of female victims of rape reported being raped by an intimate partner
and 40.8% by an acquaintance; for male victims, more than half (52.4%) reported
being raped by an acquaintance and 15.1% by a stranger. Among victims of
intimate partner violence, more than 1 in 3 women experienced multiple forms of
rape, stalking, or physical violence; 92.1% of male victims experienced physical
violence alone, and 6.3% experienced physical violence and stalking.
A final study that looked at intimate partner sexual abuse is the National Violence
Against Women Survey (NVAWS) published in 2000. This survey looked at both

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sexual assault and rape. According to the NVAWS, each year women experience
about 4.8 million intimate partner related physical assaults and rapes. Men are
the victims of about 2.9 million intimate partner related physical assaults. Nearly
two-thirds of women who reported being raped, physically assaulted, or stalked
since age 18 were victimized by a current or former husband, cohabiting partner,
boyfriend, or date.
Given the statistics in these studies, it is important to address sexual assault and
rape by intimate partners.
Comparing Intimate Partner Sexual Abuse to Abuse by a Non-intimate

Partner
Case Vignette
Rowanna, a 42-year-old African American woman is seeking treatment. She has
just left an abusive relationship with her husband Mac. Rowanna describes a
long history of intimate partner physical and sexual abuse, including multiple
rapes. Although she is close to her sisters, she was not able to share what was
occurring in the marriage. When her 10-year-old daughter inadvertently
witnessed one of the rapes, Rowanna finally had the courage to ask for her older
sisters help, and was able to leave. Rowanna reports nightmares, depression,
and fears of Mac coming to get me.
Sexual abuse is always traumatic. The literature has shown that people who are
sexually abused display a range of problems. While some may display what is
considered a trauma reaction, and symptoms of posttraumatic stress disorder
(PTSD), others will develop a wider range of difficulties including substance
abuse, eating disorders, deliberate self-abuse, social phobias, depression, and
anxiety. The aftereffects of chronic trauma may intrude on many life spheres:
social and vocational; psychological or emotional; physical; sexual; family; sense
of self; and relations with others. Chronic sexual abuse, whether by an intimate
partner or another often results in a sense of stigmatization and powerlessness.
Logic would dictate that sexual abuse perpetrated by an intimate partner would
be different from sexual abuse by a non-intimate partner, and this is the case.
While some people believe that intimate partner sexual abuse doesnt have as
traumatic an impact as sexual assault by a stranger, this is not the case. In fact,
intimate partner sexual abuse is in many ways more problematic than other types
of sexual abuse or assault. There are a number of significant differences:
Longer-lasting trauma: In their study of marital rape, Finkelhor &Yllo (1987)

found that rape by an intimate partner often results in more chronic trauma.
The researchers found that the significant reasons for this are lack of
recognition that intimate partner sexual abuse is problematic and survivors
ability to share their experiences with others.

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Higher levels of physical injury: Intimate partner sexual abuse more often
involves higher levels of physical injury than other types of rape or sexual
abuse. This may be because those people who are sexually abused by a
partner are also physically abused (Myhill & Allen, 2002).
Repeated traumas: Survivors of intimate partner sexual abuse suffer the

highest frequency of multiple sexual assaults and repeated abuse. This
results in more severe overall symptoms (Myhill & Allen, 2002).
Different types of sexual abuse. Partner perpetrators of intimate partner

sexual abuse often select abuse that is designed to humiliate and denigrate
the victim. Intimate partner sexual abuse more often includes oral and anal
rape when compared with other forms of sexual abuse or rape (Bergen,
1996; Arledge, 2008).
The unclear status of intimate partner sexual abuse. While it is clear cut that
rape or sexual abuse by a non-intimate partner is wrong, this is not always
the case for intimate partner sexual abuse. Many survivors of intimate
partner sexual abuse report being advised by church, family or friends that
they should be grateful that the rapist is a good father or that its their
duty to submit to the abuse. Women are also often socialized to see rape
as involving non-consensual sex between two strangers. It may be difficult
to see an intimate partner as a rapist. (Arledge, 2008).
Financial dependency on the abuser. Many women who are in relationships

in which there is intimate partner sexual abuse or other forms of domestic
violence cannot leave the relationship due to financial issues. In many
situations, domestic violence victims have been cut off from their own jobs
or other means of financial support. This becomes even more difficult when
there are children involved in the relationship.
Complexity of ensuring safety. It is often difficult to work within the system

of restraining orders, custody issues, etc. Even mental health professionals
are not always aware of the resources available for survivors of domestic
violence. Additionally, many states do not have laws that include protections
for survivors of intimate partner sexual abuse. Those states that do have
protections may mire them in red tape, making them difficult to access.
Intimate Partner Sexual Abuse Compared with General Domestic Violence
Case Vignette
Janine is a 27-year-old women married to Michael. Janine has been the victim of
numerous incidents of physical violence during their years together. She has also
been a victim of forced sexual intercourse. While she has difficulty calling these

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episodes rape, she is quite clear that the sexual abuse is much more devastating
to her than the physical violence.
Intimate partner sexual abuse often seen in relationships in which there are other
forms of domestic violence. In Campbells (2002) study of domestic violence
survivors, 46% reported sexual abuse by a physically abusive partner. Women
who were also sexually abused by partners reported more negative health
symptoms, gynecological problems, and increased risk of being murdered by a
partner. There was also a greater likelihood that these women would experience
depression, and the risk increased with the number of sexually abusive events
that the women identified. Campbell theorizes that a possible mechanism of
increased risk for health problems include the shame and stress reported with
forced sex manifesting as especially high levels of stress and depression known
to depress the immune system. Coker et. al.s (2000) study of family practice
patients found that in relationships in which there was domestic violence coupled
with sexual abuse, there was a greater degree of overall violence.
Another dynamic to consider is the reason that abusers use sexual violence.
More than other forms of domestic violence, sexual abuse, such as rape, has the
power to violate or humiliate victims. Abusers may also rape partners to
impregnate them in order to force them to remain in or return to the relationship
(Easteal & McOrmond-Plummer, 2006). They may also force their partners into
unprotected sex to infect them with STDs (Wilson, 2005).
These studies confirm the likelihood that perpetrators that use sexual violence
are a more dangerous subgroup of abusers.

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Health Impact of Intimate Partner Sexual Abuse
Intimate partner sexual abuse puts women at risk for a number of physical and
mental health problems.
Physical Health
Women who are abused are frequently treated within health-care systems
(Campbell, 2002). Intimate partner sexual abuse has long-term negative health
consequences for survivors, even after the abuse has ended. According to
several authors (El-Bassell et. al., 1998 Wingood, and Declemente, 1997),
women who were victims of intimate partner sexual abuse were more likely to
present with sexually transmitted illnesses. They were also less likely to use
condoms and more likely to engage in other high-risk sexual behaviors.
A number of other studies also looked at physical/health consequences of

intimate partner sexual violence. These studies found that some common
sequalae of intimate partner violence included (McCauley et. al, 1995: Campbell,
2002, Coker et. al, 2000):
General health problems; lowered immunity to illnesses

Digestive
Eating disorder symptoms Abdominal and stomach pain
Higher incidence of urinary tract infections
Vaginal infection discharge, and itching
Sexually transmitted disease AIDS or HIV-1
Vaginal bleeding, severe menstrual problems, dysmenorrhea
Pelvic pain, genital area pain
Fibroids or hysterectomy
Painful intercourse and sexual dysfunction
Headaches, migraines
Fainting, passing out
Seizures, convulsions
Back pain, chronic neck pain
Sleep disturbance, nightmares
Temporomandibular joint disorder (TMJ)
Hypertension
The physical effects of intimate partner sexual abuse are related to the chronic
nature of this abuse and the body being under constant stress. It is similar to the
effects seen in childhood survivors of sexual abuse. For both adult and childhood
sexual abuse, constant stress causes the bodys natural alarm system to be on
overdrive. This is often referred to as the fight or flight response. The body
reacts by releasing adrenaline and cortisol. Long-term activation of the stress-
response system, and the subsequent overexposure to cortisol and other stress
hormones, can disrupt almost all the body's processes.

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Mental Health
Case Vignette
Caroline was taken by a friend to a rape crisis center following a particularly
brutal sexual assault by her boyfriend. Her friend told the counselor that it was
not the first time that this had occurred. Caroline appeared numb and
disconnected, telling the counselor that she was not sure why her friend was
concerned and that everything was fine and everyone is making such a big
deal about this.
Victims of intimate partner sexual assault have been violated both physically and
emotionally. Due to the close nature of the relationship between victim and
abuser, the mental health effects of intimate partner sexual violence are
especially great. Finkelhor and Yllo (1987) state In addition to the violation of
their bodies, victims are faced with a betrayal of trust and intimacy. They also
point out the tendency for victims to blame themselves, as well as the complex
dynamics that involve many victims loving the offender but hating the offense.
As a result, intimate partner sexual assault victims often suffer long-lasting
physical and psychological injuries.
In addition to Finkelhor and Yllo (1987), the psychological sequalae of intimate

partner sexual abuse have been documented by a number of researchers
(Campbell, 2002; Sachs & Gromberg, 2009; Silva et. al., 1997; Winfield et. al.,
1990;). According to Sachs and Gromberg (2009) victims of intimate partner
sexual abuse/rape often develop symptomatology that consists of disruptions to
normal physical, emotional, cognitive, behavioral, and interpersonal
characteristics. Some of these disturbances include memory impairment, dulled
sensory, affective and memory functions, sleep disturbance (insomnia,
wakefulness, night terrors), self-blame and guilt, and activity avoidance. Together
these are termed rape trauma syndrome (RTS). This term was first used by
Burgess and Holmstrom in 1974 and is similar to posttraumatic stress disorder.
Additionally victims of intimate partner sexual abuse may struggle with chronic
depression and suicidality, marked anxiety and panic. There may also be mood
swings, obsessive qualities and somatoform disorders (physical symptoms with
no identifiable cause). In terms of PTSD diagnosis, rape survivors represent the
largest non-combat group of individuals with posttraumatic stress disorder.
(Campbell and Wasco, 2005)
Another mental health consequence of intimate partner sexual abuse concerns

lifestyle changes. Victims often experience a sense that their personal security or
safety is damaged. They may have difficulty trusting others (often a challenge for
clinicians) or feel hesitant to enter new relationships. They may also isolate
themselves from families, friends and others.

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Common coping mechanisms seen in survivors may make it difficult to initially

comprehend the impact of the abuse. An example of this can be seen in the case
vignette. Some common coping mechanisms/defense mechanisms include
minimization (pretending that everything is fine), suppression (refusal to discuss
the abuse) or intellectualization (detached analysis what happened, often with
focus on the victims role in the abuse.) Victims of intimate partner sexual abuse
may also rely on maladaptive coping mechanisms, such as deliberate self-harm,
drug, or alcohol abuse or use of eating disorder symptoms.
Finally another dynamic seen in intimate partner sexual abuse is the Stockholm
Syndrome (see de Fabrique et al., 2007). Described as a victims emotional
bonding with their abuser, Stockholm Syndrome develops subconsciously and
on an involuntary basis.
Understanding the Dynamics of Intimate Partner Sexual Abuse
While this document highlighted many of the differences between intimate

partner sexual abuse and other forms of domestic violence, the dynamics of
intimate partner sexual abuse is similar to other forms of domestic abuse. The
National Center For the Prosecution of Violence Against Women (2005) in its
publication on understanding the dynamics of intimate partner sexual abuse,
does highlight an important similarity between intimate partner sexual abuse and
other forms of domestic violence, namely the need for authority/power seen in
perpetrators.
Sexual assault is about power, and, therefore, sex is a weapon and a means of
expressing the rapists aggression or power. Sexual abusers do not rape out of
sexual desire. While some intimate partner abusers limit their violence to sexual
assault, the majority of intimate partner sexual assaults occur within a physically
abusive relationship. Many intimate partner sexual assaults also involve domestic
violence dynamics. One useful tool to understand this dynamic is the Power and
Control Wheel created by the Domestic Abuse Intervention Project in Duluth (see
Introduction to Domestic Violence).
Some relationships in which there is intimate partner sexual abuse may also
include a cycle of violence. This term cycle of violence was developed by
Lenore Walker to describe three phases in an abusive relationship: tension
building, physical abuse, and the honeymoon phase.
The behaviors of victims of intimate partner sexual abuse may conflict with many
sexual assault victims. They may not resist during a rape or assault; frequently
delay reporting their rape; and they may continue to have contact with their
assailant.
Interventions for Victims of Intimate Partner Sexual Abuse

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Although the clinical picture for survivors in intimate partner sexual abuse clearly
highlights the seriousness of the abuse, victims of intimate partner sexual abuse
rarely seek treatment. When they do, it is important to provide services in an
informed way.
Intimate partner sexual abuse is a complex problem. Victims issues are

multidimensional (e.g., physical, mental, economic, legal, spiritual, emotional),
and clinicians will often need to interact as part of a treatment team. This team
may include psychologists, social workers, advocates and people in the legal
realm.
Trauma Informed Care
Trauma-informed services (Laskey, 2009) refers to the idea that providers

offering mental health and other services to victims of intimate partner sexual
abuse should be informed about, and sensitive to, trauma-related issues present
in survivors.
A trauma-informed system is one that includes an understanding of the role that

violence plays in the lives of adults, children and adolescents and families or
caregivers seeking mental health and addictions services (Harris & Fallot, 2001).
One of the primary goals of a trauma informed system is to deliver service in a
way that will avoid inadvertent re-traumatization and will facilitate treatment
compliance.

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Elements of Trauma Informed Care
Trauma informed treatment focuses on understanding the context of a persons

experience. It emphasizes safety, choice, empowerment, and cultural
competence. Elements of trauma informed strategies include (Laskey, 2009):
Focus on trust and safety

Trauma knowledge, awareness/sensitivity
Prevention-oriented
Strengths-based, focused on empowerment and resilience
Collaborative
Culturally-competent/sensitive services
An additional requirement of a trauma informed approach is safety. Providers

must be aware of safety issues. Victims of intimate partner sexual abuse may
need to develop a plan for physical safety. Emotional safety is also important and
can be fostered through non-judgmental treatment, informed consent practices
and holistic care. This helps to build trust. Additionally it is important to attend to
boundary issues, such as consistency, accessibility and clear role delineation.
Vicarious Traumatization
Clinicians who work with sexual assault victims may experience vicarious
trauma. Symptoms of vicarious trauma are similar to those experienced by
individuals with Post Traumatic Stress Disorder and include numbing,
hypervigilance, sleep difficulties and intrusive thoughts of traumas described by
victims (Lassey, 2005). Trauma informed care lessen the likelihood of vicarious
trauma among mental health professionals.

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REFERENCES
Arledge, K. (2008). Considering the Differences: Intimate Partner Sexual

Violence in Sexual Assault and Domestic Violence Discourse. A Biannual
Publication of Washington Coalition of Sexual Assault Programs.
Bergen, R. (1996). Wife Rape: Understanding the response of survivors and

service providers. California: Sage Publications.
Burgess, A.W. & Holmstrom, L. (1974). Rape Trauma Syndrome. American

Journal of Psychiatry, 131(9), 981986.
Campbell, J.C. (2002). Health consequences of intimate partner violence, The

Lancet, 359. www.thelancet.com
Campbell, R. & Wasco, S. (2005). Understanding Rape and Sexual Assault: 20

Years of Progress and Future Directions, Journal of Interpersonal Violence,
20(1), 127-131.
Coker, A., Smith, P., & King, M. (2000). Physical, sexual and psychological
battering. American Journal of Public Health, 90, 533-539.
de Fabrique, N., Romano, S.J., Vecchi, G.M., van Hasselt, V.B. (2007).
Understanding Stockholm Syndrome. FBI Law Enforcement Bulletin (Law
Enforcement Communication Unit) 76 (7): 1015.
Easteal, P. & L McOrmond-Plummer (2006). Real Rape, Real Pain: Help for
Women Sexually Assaulted by Male Partners, Melbourne: Hybrid.
Finkelhor,D. & Yllo, K. (1987). License to Rape: Sexual Abuse of Wives. New
York: The Free Press.
Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems.
New Directions for Mental Health Services, 89. NY: Jossey Bass.
Laskey, S.J. (2009). Trauma Informed Care for Victims of Intimate Partner
Sexual Assault. Retrieved May 31, 2012 from
http://www.trainingforums.org/forums/viewtopic.php?f=11&p=39
McCauley J, Kern DE, Kolodner K, et al. (1995). The battering syndrome:

prevalence and clinical characteristics of domestic violence in primary care
internal medicine practices. Annuals of Internal Medicine, 123, 73746.

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Myhill, A. & Allen, J. (2002). Rape and Sexual Assault of Women. Retrieved May
16, 2012 from http:homeoffice.gov.uk/rds/pdfs2/r159.pdf
National Center For the Prosecution of Violence Against Women (2005).

Understanding the rape victim. www.ncpvaw.org
National Violence Against Women Survey (1996). Downloaded May 3, 2012 from
http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/datasources.html
Russell, D. (1990) Rape in Marriage. New York: MacMillan.
Sachs, C., & Gomberg, L.J. (2009). Intimate partner sexual abuse. In C. Mitchell,
& F. D. Anglin (Eds.), Intimate Partner Violence: A Health-Based Perspective
(265-287). New York: Oxford.
Silva C, McFarlane J, Soeken K, Parker B, Reel S. (1997). Symptoms of post-

traumatic stress disorder in abused women in a primary care setting. Journal of
Womens Health, 6, 54352.
Wilson, K.J. (2005) When Violence Begins at Home: A comprehensive guide to

understanding and ending domestic violence, CA: Hunter House Inc.

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Chapter 4: Special Populations
Introduction
Case Vignettes
Andrew is a 45-year-old man, who has been in a 5-year relationship with David,
an emergency room physician. Andrews work as an artist allows him to stay
home and raise Chloe, the couples 5-year-old daughter. David routinely holds
back funds that Andrew needs to run the household, and on several occasions
David has punched Andrew, the most recent time in front of Chloe.
Robert and Beatrice are 70 and 68. They have been married for 45 years. They
have recently been experiencing some financial stress, and Robert has been
drinking. When he drinks, he becomes very angry, and often screams at Beatrice
and calls her names.
Lauren and Brent, juniors in high school, have been dating since freshman year.
Brent is very jealous of Lauren, and expects her to see him every day. He keeps
close tabs on her. She has lost friendships as a result of defending Brents
actions. When Lauren and Brent fight, it often becomes physical.
While on the surface there are differences between Andrew, Beatrice and Laura,
they share that they are victims of domestic or intimate partner violence.
Domestic violence is the willful intimidation, physical assault, battery, sexual
assault, and/or other abusive behavior perpetrated by an intimate partner against
another (The National Coalition Against Domestic Violence). Domestic violence
affects individuals from every walk of life, whether gay or straight, young or old,
married or unmarried. As these cases illustrate, domestic violence is often
accompanied by emotionally abusive or controlling behavior, and thus is part of a
systematic pattern of dominance and control. The terms domestic violence, and
intimate partner violence, are synonymous, although the later is more inclusive.
While this is not an exhaustive list, Kurst-Swanger and Petocsky (2003), have
identified some behaviors indicative of intimate partner violence. These include:
Denying a person autonomy

Isolating victims from family and friends
Instilling fear through intimidation, threats and violence
Manipulating behavior
Unjustified jealousy
Controlling financial resources
While domestic violence researchers have focused primarily on traditional

marriages in which there is abuse, this does a disservice to many victims. It is

________________________________________________________________
important to recognize that intimate partner violence occurs in all types of

partnerships.
This course will discuss the domestic violence in special populations including
among gay and lesbian couples, among the elderly, and among teen dating
relationships. The terms domestic violence and intimate partner violence will be
used interchangeably throughout the text.
1. Discuss prevalence and types of abuse among Gay, Lesbian, Bisexual and
Transgendered (GBLT) Relationships
2. Discuss barriers to treatment and treatment recommendations for GBLT

relationships
3. Discuss domestic violence in later life, including factors that may play a role
4. Describe why older men and women stay in abusive relationships
5. Discuss teen dating violence, including contributing factors and prevention
Domestic Violence in Gay, Lesbian, Bisexual and Transgendered (GBLT)

Relationships
Prevalence
Intimate partner violence is a serious issue in the GLBT community. How

serious? Island and Letellier (1990, 1991) suggest that intimate partner violence
occurs in about 15-20% of gay male relationships. They describe intimate partner
violence as the third most severe health problem facing gay men today, behind
HIV/AIDS and substance abuse.
While study of violence in GBLT relationships is not widespread, an important

source of compiling data is the National Coalition of Antiviolence Programs. Their
reported prevalence data for 2010 underscores the need for clinicians to be
aware of and responsive to intimate partner violence in GBLT couples. The
following are some key findings:
In 2010, NCAVP programs received 5,052 reports of intimate partner

violence. While this represents an increase of 38.1% from 2009 (3,658
reports this was mainly due increased funding at the Los Angeles Gay &
Lesbian Center (LAGLC) for their intimate partner violence programming.

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NCAVP documented six IPV murders/homicides in 2010 equal to the six

documented murders/homicides in 2009. The majority ofvictims were
women.
The average age of murder/homicide victims increased. In 2009 the
average age of the victims was 30, while in 2010 theaverage age was 39.
Females accounted for nearly half (45.7%) of victims who reported to
NCAVP member programs in 2010, while males accounted for more than
a third (37%).
50.6% of survivors indicated they experienced intimate partner violence
with a boyfriend/girlfriend or long-term partner, a decrease from 2009
(61.3%).
More victims in 2010 (44.6%) were turned away from shelter than in 2009
(34.8%)
More than half of victims (55.4%) experienced physical violence from their
abusive partners, a substantial increase from 2009 (36.5%). Less victims
called the police. In 2010 7.1% of victims called thepolice for support, a
decrease from 2009 where 21.7% of victims called the police.
What makes these figures even more alarming is that LGBT domestic violence is
vastly underreported, unacknowledged, and often reported as something other
than domestic violence (National Coalition of Anti-Violence Programs, 2006). Gay
men and women who are abused by a partner frequently report being afraid
ofrevealing their sexual orientation or the nature of their relationship. Delaware,
Montana and South Carolina explicitly exclude same-sex survivors of domestic
violence from protection under criminal laws. Eighteen states have
domesticviolence laws that are gender neutral but apply to household members
only. There are a number of additional barriers to reporting such abuse, and
these will be discussed later in this material.
Nature of Abuse
In many ways, domestic violence in lesbian, bisexual and gay relationships is the
same as in heterosexually-paired relationships. Some of these behaviors that are
similar in heterosexual and GLBT relationships include (National Coalition of
Antiviolence Programs, 2000):
Verbal abuse, such as calling a partner names or belittling them in some

way.
Isolating a partner from their family or friends.
Withholding money, shelter, food, clothing and/or medication from a
partner as a means of controlling them.
Interfering with a partners ability to obtain or keep employment, housing
or any other benefit or service.
Harming or attempting to harm a partner physically, or threatening to do
so. Threats of harm may also extend to a partners family, friends, children
and/or pets.

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Sexually assaulting or raping a partner.

Threatening a partner with suicide or harm to self, if a partner tries to end
a relationship or does not comply with an abusers demands.
Stalking or otherwise harassing a partner.
While these types of abuse may be found in gay or straight relationships, there
are some very specific forms of abuse that may be found in GBLT relationships.
Some examples include (National Coalition of Antiviolence Programs, 2000):
Outing or threatening to out a partner to friends, family, or employers.

Reinforcing fears that no one will help a partner because he or she is
lesbian, gay, bisexual or transgender, or that for this reason, the partner
deserves the abuse.
Justifying abuse with the notion that a partner is not really lesbian, gay,
bisexual or transgender.
Telling the partner that abusive behavior is a normal part of GBLT
relationships, or that it cannot be domestic violence because it is occurring
between same gender individuals.
Portraying the violence as mutual or consensual.
According to the National Coalition of Anti-Violence Programs (2006), specific

forms of abuse occur in relationships where one partner is transgendered,
including:
Using offensive pronouns such as it to refer to the transgender partner

Ridiculing the transgender partners body and/or appearance
Telling the transgender partner that he or she is not a real man or woman
Denying the transgender partners access to medical treatment or
hormones
Case Vignette
Keliana and Jeanette have been in an exclusive relationship for the past two
years. In the past three months, Jeanettes behaviors have become increasingly
erratic. Keliana would like to leave the relationship, but is fearful to do so
because Jeanette has threatened to kill herself if Keliana leaves. She also says
that if Keliana leaves her she will call members of Kelianas very religious family
and let them know that the two have been lovers.
There is a domestic abuse power wheel specific to GBLT couples experiencing

intimate partner violence:

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Barriers to Seeking Services
While it is undeniable that there is a need for GBLT men and women to seek
services, there are barriers to doing so. Some of these barriers include:
The belief that domestic violence does not occur in GBLT relationships
Societal anti-GBLT bias (homophobia, biphobia and transphobia)
Lack of funding for research into GBLT relationship abuse
Fear that airing of the problems among the GLBT population will detract
from progress toward equality or fuel bias.
Lack of appropriate training regarding GBLT domestic violence for service
providers
Domestic violence shelters are typically female only, thus transgender
people may not be allowed entrance into shelters or emergency facilities.
Factors that Increase Vulnerability in GBLT Relationships

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Some of the factors that increase vulnerability to domestic violence in GBLT

Relationships:
Isolation of some GBLT individuals from families of origin

Acceptance of violence in LGBT relationships from general population
The double closet, need to hide sexual orientation status and need to hide
the relationship abuse
Co-Existent situations, such as low self-esteem and substance abuse
Dismissal by police and some social service providers
Impact of HIV in keeping couples together
Lack of support from peers who would rather keep quiet
Recommendations for Providers
While there are a number of important issues in working with GBLT individuals
who have been affected by domestic violence, the following recommendations
are a few helpful ones (many excerpted from American Psychological
Association recommendations):
Increase their knowledge and understanding of homosexuality and

bisexuality through continuing education, training, supervision, and
consultation.
Recognize the scope of the problem, and know that domestic violence is a
real issue among same gender partners.
Understand the effects of stigma (i.e., prejudice, discrimination, and
violence) and its various contextual manifestations in the lives of lesbian,
gay, and bisexual people.
Understand that same-sex attractions, feelings, and behavior are normal
variants of human sexuality.
Be knowledgeable about and respect the importance of lesbian, gay, and
bisexual relationships. Recognize that domestic violence should not be an
acceptable part of these relationships.
Domestic Violence and Older Adults
Case Vignette
Frank and Emma have been married 50 years. While the marriage has been
somewhat rocky for a number of years, it has worsened in the last several
months. Recently Emma has started to develop memory problems, which have
frustrated Frank. He often angrily tells her to quit it and calls her stupid. Their
son David became concerned when he heard Frank asking Emma if shed like
him to knock some sense into her.

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It is often overlooked that intimate partner violence occurs throughout the

lifespan. Domestic abuse in later life is a problem that has not received the
attention it deserves. It is, however, a significant problem in older men and
women. The dynamics in this type of abuse are unique and require a specialized
response from clinicians (Harris, 1996; US Department of Justice, 2005).
There are a number of factors that make it difficult to get an accurate picture of
the scope of domestic violence in older adults. Probably the biggest factor is that
intimate partner violence is often studied in conjunction with other types of elder
abuse. While intimate partner violence and domestic violence share many
similarities, there are differences as well. There is often not a universally agreed
upon definition of what constitutes either intimate partner abuse or elder abuse.
Due to these factors, and the general lack of research in this area, it is
impossible to estimate prevalence.
Age versus vulnerability: Some definitions of intimate partner/elder abuse are

based solely on the age of the victim. These vary from state to state, with a range
of 60 to 70 as the age threshold for individuals who are victims. Many abuse in
later life programs for older victims, however, identify individuals who are age 50
and older as those who are eligible to receive their support and services.
Another type of definition of elder abuse includes the vulnerability of the older
adult as a factor in determining whether the individual is a victim of elder abuse.
In the example in the case vignette, for example, Emmas dementia would be
indicative of one such vulnerability.
Forms of abuse: The forms of elder abuse identified and defined by most states
laws include physical, sexual and emotional abuse, neglect, and financial
exploitation. Some definitions also include abandonment.
.
Abuse in later life may include physical, sexual, or psychological abuse, neglect,
financial exploitation, or stalking of an older adult. The phrase Abuse in Later
Life is often used by domestic violence and sexual assault advocates who work
with older victims.
Older victims come from a variety of racial and ethnic groups and all economic
levels. Many older victims are active members of the community. Some older
victims are frail and live with significant health issues, physical disabilities, and/or
cognitive limitations.
Gender. Abuse in later life affects older women more often than older men,
although some men may be victims. Although older women often experience
more significant violence and are more apt to change their lives to stay safe or
accommodate the abuser, some older men are also victims of abuse, neglect,
and exploitation.
Dynamics. In later life, another dynamic that is important to note is the length of

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the relationship. Spousal or partner relationships may sometimes be new,

following the death of a previous partner. In these relationships there is not a
history, and perpetrators will rarely disclose that violence had also been present
in a prior relationship.
Another type of intimate partner abuse is late-onset abuse. In this situation long-
term relationship that had not been abusive previously becomes so in later life.
What is significant about late-onset abuse is that a medical or mental health
condition may have led to aggressive or violent behavior (more later). In other
there where there has been ongoing abuse, medical or mental health conditions
are likely not present (US Department of Justice, 2005).
What causes abuse in later life?
Like other forms of domestic violence, many cases of abuse in later life involve
dynamics of power and control. Even if physical abuse is not present, the threat
of harm is often enough to persuade the older person to capitulate to the
abusers demands. The types of abuse seen in later life include physical abuse,
emotional and psychological abuse, threats of physical violence or abandonment,
isolating the individual from family and friends, limiting the victims use of the
telephone, denying the person finances to manage their needs, breaking
assistive devices, and denying health care. The abusing partner can be very
persuasive, and often try to convince family, friends, and professionals that they
are only trying to help.
Many issues co-occur with abuse in later life including anger, stress, caregiver
issues, medical conditions, mental health issues, substance abuse, or prior poor
relationships. While these do not cause the abusive behavior, they can present
the catalyst that may result in the violence. It is important that clinicians intervene
to support resolution of these underlying problems and do not focus only on the
abuse.
Because of the strong connection between caregiving and domestic violence, it is

important to look at this in terms of domestic abuse. Many theories of domestic
abuse in later life center on the stress of caring for a physically or mentally
impaired partner. Certainly providing care for an ill or frail older person can be
stressful, but there are many instances in which caregivers do not become
abusive. Research has borne out the idea that caregiver stress is not a primary
cause of elder abuse (www.ncall.us.)
In older adults it is important to consider that violent behavior may occur as a

symptom of some medical or mental conditions or as a side effect of
combinations of medications. These conditions include various dementias
(Alzheimers, Vascular Dementia, Lewy body disease, and other degenerative
dementias.) Alzheimer's disease and related disorders account for more than
90% of dementia cases in the elderly. Delirium is another medical condition that

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can account for violent behavior. Medication side effects should also be
considered.
As in other populations, use of drugs and alcohol may intensify situations and
cause escalation into abuse. Alcohol abuse and alcoholism are common but
under recognized problems among older adults. One third of older alcoholic
persons develop a problem with alcohol in later life, while the other two thirds
grow older with the medical and psychosocial sequalae of early-onset
alcoholism. Physiologic changes related to aging can alter the presentation of
medical complications of alcoholism (Rigler, 2000). Substance abuse among
those 60 years and older (including misuse of prescription drugs) currently
affects about 17 percent of this population. By 2020, the number of older adults
with substance abuse problems is expected to double (Hazeldon, 2012). Mental
health clinicians should include a screening for these disorders when working
with older adult perpetrators.
Case Vignette
Mary and John, both in their 70s, have been married for 51 years. Mary is
seeking counseling due to depression. In assessing Mary, Dr. Cox asked about
relationships and supports. Mary tearfully reports that her husband John had
always been her biggest supporter, but lately it seemed like he was a different
person. He has seemed distracted, and has been short-tempered, often raising
his voice when he becomes frustrated with something, and these outbursts often
seem to be directed at Mary. When Dr. Cox asks if Mary and John have seen
their physician recently, Mary says that they have not, and agrees to schedule
appointments for them both.
Domestic Violence Wheel Older Adults

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Why do victims stay?
As with domestic violence in people younger than 60, many older victims choose
to remain in the relationship. Some of the reasons for this are similar to younger
victims, but some are age-related. Victims sometimes stay in violent relationships
because: (National Center on Elder Abuse, 2005; US Department of Justice,
2005).
Fear of the unknown of fears of being alone

Economic dependence
Fear of institutionalization
Values and culture that frown upon separation
Shame and guilt
Not wanting to leave behind cherished possessions or pets
Medical conditions and disabilities
Fear of loss of autonomy
Mandated reporting

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Please be aware of your states mandated reporting laws, and whether elder
abuse is a mandated reporting issue.
Teen Dating Violence
When we think of intimate partner violence, teens are another population that
often are overlooked. Unhealthy relationships often start as an early pattern, and
can last a lifetime. Consider the following scenario:
Case Vignette
Anna, a 23-year-old college student is seeking counseling at the student-
counseling center. She presents as anxious and tells the intake counselor that
she has been a mess since the end of her last relationship. Anna reports that
when she first met Brent, she thought he was different, but that he just likes all
the others. She describes a pattern of abuse that began early in the relationship.
When asked about prior relationships, Anna described a 5-year relationship that
began in high school and lasted until her sophomore year of college. She
described her former boyfriend Connor as controlling and jealous, and shared
that he would often follow her to know her whereabouts. Connor would also hack
into her social networking site. She feels that much of her anxiety began during
those years and as a result of those experiences.
Teen dating violence is defined as the physical, sexual, or psychological or

emotional violence within a dating relationship, as well as stalking. It can occur in
person or electronically and may occur between a current or former dating
partner (CDC).
Just how prevalent is teen dating violence? A comparison of Intimate Partner

Violence rates between teens and adults reveals that teens are at higher risk of
intimate partner abuse (Silverman et. al, 2001). Females ages 16-24 are more
vulnerable to intimate partner violence than any other age group at a rate
almost triple the national average (U.S. Department of Justice, 2001).
In 2009 the CDC conducted a nationwide survey in order to look at teen dating
violence. 9.8 percent of high school students reported being hit, slapped, or
physically hurt on purpose by their boyfriend or girlfriend in the 12 months prior to
the survey. (Centers for Disease Control and Prevention, 2009 Youth Risk
Behavior Survey). About 1 in 5 women and nearly 1 in 7 men who ever
experienced rape, physical violence, and/or stalking by an intimate partner, first
experienced some form of partner violence between 11 and 17 years of age
(Centers for Disease Control and Prevention, 2010 National Intimate Partner and
Sexual Violence Survey).
Despite the prevalence of teen dating violence, it is rarely reported to authorities,

rather teens confide in peers, who are not equipped to help them handle the

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situation. Zwicker (2002) conducted a survey of female high school students.

When asked who they would talk to if someone they dates was attempting to
control them, insulted them, or physically harmed them, 86% percent said they
would confide in a friend, while only 7% said they would talk to police. In another
survey conducted on behalf of the Claiborne Foundation (2005), only 33% of
teens who were in an abusive relationship ever told anyone about the abuse. The
prevalence of dating violence in teen relationships is similar to that of opposite
gender relationships (Halpern et al., 2004).
Consequences of dating violence
One of the biggest overall influences for teens are relationships, dating and
otherwise. Teens that are exposed to healthy relationship behaviors experience
positive emotional affects. Conversely, unhealthy, abusive or violent relationships
can cause negative effects.
Violent relationships in adolescence can have serious ramifications for victims.

Teens who are victims are more likely to be depressed and do poorly in school.
Many teens that are abused will continue to be abused in their adult
relationships. Teens experiencing teen dating violence are also at higher risk for
substance abuse, eating disorders, risky sexual behavior, and suicide (Silverman
et. al, 2001). The severity of violence among intimate partners has been shown
to increase if the pattern has been established in adolescence (Field & Strauss,
2001).
Why does teen dating violence happen?
Violence is related to certain risk factors. According to the CDC, the risks of
having an unhealthy relationship increase for teens who:
Believe it's okay to use threats or violence to get their way or to express
frustration or anger.
Use alcohol or drugs.
Can't manage anger or frustration.
Hang out with violent peers.
Have multiple sexual partners.
Have a friend involved in dating violence.
Are depressed or anxious.
Have learning difficulties and other problems at school.
Don't have parental supervision and support.
Witness violence at home or in the community.
Have a history of aggressive behavior or bullying.
Attitudes about violence/contributing factors

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Teen dating violence does not happen in a vacuum. It can be traced to attitudinal
factors and beliefs that many adolescents and adults alike have about
relationships. First, many adults do not recognize the teen relationships can be
violent, or believe that physical or emotional violence can be attributed to a lack
of maturity. There is also the societal tendency to blame the victim. Lavoie
(2003) conducted a qualitative study of teens. She found that the teens'
explanatory models still attribute part of the responsibility to victims and is
caused by: provocation by the girl; the victims personality type; the girls need for
affection; communication problems; and peer group influence. The teens also
pointed out the influence of pornography. Jackson et. al. (2000) also found that
many high school students (77% of female and 67% of males) endorse some
form of sexual coercion, including unwanted kissing, hugging, genital contact,
and sexual intercourse. Clearly educational efforts are needed.
Prevention
Working with teens who have experienced abuse is similar to other populations.
It is helpful, however, to implement prevention strategies that will enable us to
stop teen violence before it begins. Prevention programs focus on strategies that
promote healthy relationships. The teen years are ones in which learning the
skills of relationships, whether friendships or romantic, are crucial. The ultimate
goal of prevention programs is to avert patterns of dating violence that can last
into adulthood. Prevention programs change the attitudes and behaviors linked
with dating violence.
One example is Safe Dates, a school-based program. The goals of this program
are to:
Raise students awareness of what constitutes healthy and abusive dating
relationships.
Raise students awareness of dating abuse and its causes and
consequences.
Equip students with the skills and resources to help themselves or friends in
abusive dating relationships.
Equip students with the skills to develop healthy dating relationships,
including positive communication, anger management, and conflict
resolution.

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REFERENCES
Halpern, C.T., Young, M.L., Waller, M.W., Martin, S.L., & Kupper, L.L. (2004).
Prevalence of Partner Violence in Same-Sex Romantic and Sexual Relationships
in a National Sample of Adolescents, Journal of Adolescent Health, 35(2), 124-
131.
Harris, S. (1996). For Better or Worse: Spouse Abuse Grown Old. Journal of
Elder Abuse & Neglect, 8(1), 1-33.
Island, I. & P. Letellier (1990). The Scourge of Domestic Violence, Gay Book #
9, San Francisco, CA, RainbowVenturesInc.,14.
Island, D. & P Letellier (1991). Men who beat the men who love them: Battered
gay men and domestic violence. New York: Harrington Park Press.
M. Jackson, F. Cram & F.W. Seymour (2001) . High school students' responses
to dating aggression. Violence and Victims, 16(3), 339-348
Lavoie, F. (2002). Teen Dating Relationships and Aggression, Universit Laval.

Lie, G.W. & Gentlewarrier, S. (1991). Intimate Violence in Lesbian Relationships:
Discussion of Survey Findings and Practice Implications, Journal of Social
Service Research, 15(46).
Liz Claiborne Incorporated (2005). Survey on Teen Violence. Conducted by

Teenage Research Unlimited, (February 2005).
National Coalition of Anti-Violence Programs (2000). Lesbian, Gay, Bisexual And
Transgender Domestic Violence In 2000.
National Center on Elder Abuse (2005). Domestic violence: Older women can be
victims too.
National Coalition of Anti-Violence Programs. (2006). Anti-Lesbian, Gay,

Bisexual and Transgender Violence in 2006. Retrieved April 7, 2012 from
www.ncavp.org
Rigler, S. (2000). Alcoholism and the elderly. American Academy of Family
Physicians.
Ristock, J. (1994). And Justice for All? The Social Context of Legal Responses to
Abuse in Lesbian Relationships, Canadian Journal of Women and the Law, (7),
420.

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Silverman, J.G. et al. (2001). Dating Violence Against Adolescent Girls and
Associated Substance Use, Unhealthy Weight Control, Sexual Risk Behavior,
Pregnancy, and Suicidality. Journal of the American Medical Association,
286(572), 576-577.
U.S. Department of Justice (1995). In their own words: Domestic abuse in later
life. Retrieved April 8, 2012 from www.ojp.usdoj.gov
U.S. Department of Justice, Bureau of Justice Statistics, Special Report: Intimate

Partner Violence and Age of Victim, 1993-99 (2001, rev. 11/28/01)
Zwicker, T.J. (2002). Education Policy Brief, The Imperative of Developing Teen
Dating Violence Prevention and Intervention Programs in Secondary Schools.
Southern California Review of Law and Womens Studies, 131.
National Coalition of Anti-Violence Programs (2010) GBTQ Intimate Partner

Violence in 2010 in the United States, retrieved April 24, 2012 from
http://avp.org/documents/IPVReportfull-web.pdf.

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Chapter 5: Motivational Interviewing and Stages of Change
Introduction
Case Vignette
Kelly Sykes, LSW, is working with Lauren, an adolescent client. Lauren has been
dating Nick for 6 months, and thinks that he is the one. Laurens mother is
concerned about Nicks severe verbal abuse towards her daughter, and Kelly has
been working hard to educate Lauren about healthy relationships. They have
worked together on assertiveness skills, and Kelly has enlisted Laurens mom as
a positive, supportive influence.
Kelly is relieved when Lauren tearfully tells her that she and Nick are over. In
their next session, Lauren joyfully tells Kelly that she and Nick are together again,
and that Nick has promised not to yell at her or call her names. Two weeks later,
Nick shoves Lauren against a wall. Kelly is extremely disappointed, feeling that
she has somehow failed Lauren.
This case vignette may sound familiar to many working with intimate partner
violence. While there are numerous therapeutic issues in working with men and
women who are in abusive partnerships, many of the challenges in domestic
violence counseling can be summed up by a single word: change.
As evidenced in Kellys interventions, traditional behavior change interventions

have focused on increasing skills and reducing barriers. While both of these
things are important, they are not always enough. Telling people what to do, or
how to do it, is rarely effective in supporting change. This is especially true in
working with domestic violence, where change may be synonymous with
endings.
In partnerships touched by domestic violence, what does genuine change look

like? Is it even possible? How can clinicians motivate someone to make
changes? How can you determine if someone is embarking on this process?

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One of the main contributions of the Transtheoretical Model (Prochaska &

DeClemente, 1984) is its utility in helping clients to make changes. Motivational
Interviewing is an empathic, gentle, and skillful style of counseling that allows
clinicians to have productive conversations with clients. While widely used with
clients with addictive and co-occurring disorders, this approach is applicable to a
wide range of behaviors and is well-suited to working with domestic violence
issues (Prochaska & DeClemente, 1984; Prochaska, DeClemente & Norcross,
1992).
Much of the evidence base for the transtheoretical model comes from addictions
treatment and practice. Alcohol and drug-dependent clients are often resistant to
making changes, and traditional methods of treatment that were appropriate for
self-motivated clients did not always work. In the mid 1990s, researchers first
began looking at the potential applicability of the TTM in understanding the
change process for both perpetrators (Daniels & Murphy, 1997) and victims
(Brown, 1997) of domestic abuse. With regard to perpetrators, resistance to
change is often apparent. There may be a tendency to deny or minimize
problems or to blame others for their actions. They also often fail to attend even
court-mandated treatment and are noncompliant with interventions intended to
change behavior (Murphy & Maiuro, 2009). Victims often need to change existing
values, thinking processes, and relationship skills and may not be ready to do so.
It is important to review the definition of domestic violence. The National Coalition

Against Domestic Violence defines domestic violence as the willful intimidation,
physical assault, battery, sexual assault, and/or other abusive behavior
perpetrated by an intimate partner against another. Domestic violence is
displayed across a broad spectrum of cultural, economic, religious and racial
groups. The terms domestic violence and intimate partner violence will be
used interchangeably in this training material.
This course will provide an overview of the transtheoretical model of behavior

change. It will also include motivational interviewing skills and techniques and
their applicability to working with domestic violence.

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1. Discuss the overall goals of the transtheoretical model of behavior

change, including the stages of change
2. Discuss the research base regarding the applicability of the
transtheoretical model to domestic violence
3. List the components and strategies of motivational interviewing and
describe how these are used to promote change
4. Discuss the applicability of motivational interviewing in work with
perpetrators and victims of domestic violence
Goals of the Transtheoretical Model
Case Vignette 1
Tom and Mary are presenting for couples counseling. The two describe periods
of intense conflict that often escalates to physical violence. Tom is clearly angry
to be attending the session, and states if she wouldnt provoke me all the time,
things would be fine. Mary becomes enraged, stating, I provoke him? Let me
tell you what he says to me. Tom angrily stalks out of the room, slamming the
door in his wake.
Case Vignette 2
Kevin and Louise are also in couples counseling. They have frequent, physical
altercations. When asked what he sees as the reason that their fights, Kevin
states I know it gets bad at times. Louise angrily retorts, thats what you always
say, but we can never get past this. Last time you only came with me to
counseling for two sessions. Ive had it with this. Kevin states Im here arent I?
The transtheoretical model of behavior change is aptly named. It is a treatment

model centered on the premise that clients can change otherwise dysfunctional
behaviors. Although this idea is at the heart of the transtheoretical model, the
model does not assume that maladaptive behaviors are immediately amenable to
change. As with many clients, a degree of ambivalence may be apparent. As
Kevin says Im here, arent I? Being here is not necessarily equivalent to being
ready to dive into treatment and make changes.
In contrasting the two cases presented above, its apparent that each of these

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couples is in a very different place in terms of readiness to make changes. But

significant changes do need to be made. Some of these changes include the
couple communicating more effectively, the abusive partners using anger
management strategies, and both parties recognizing that abuse in any form is
not allowable. How, then, does the therapist collaborate with the client to move
them forward?
Assessment of Readiness
Case Vignette
Carla is a 45-year-old woman in a relationship with Bob. Carla works for a
pharmaceutical company is a fast-paced position. In her first session with Dr.
David, Carla reveals a history of long-term emotional abuse. Dr. Davis states that
in order to heal, Carla will need to end the relationship with Bob, and points out
that in her work life she often has to make difficult decisions. Carla angrily
responds that she does not need anyone else browbeating me and does not
return for a subsequent session.
A central tenet of the transtheoretical model is the assessment of an individual's

readiness to act on a new healthier behavior. According to Wahab (2005), the
intention behind assessing motivation, readiness and confidence levels for
change is to tailor the intervention accurately to the clients stage of change at
any given moment. As the case above illustrates, there are times that therapists
do not take into consideration a clients readiness for change.
The transtheoretical model conceptualizes behavior change as a process with

various stages. The stages represent distinct categories along a continuum of
motivational readiness. The stages include precontemplation, contemplation,
preparation, action, maintenance and relapse.
According to Prochaska and DiClemente (1982) precontemplation is the state in

which an individual is not yet considering the possibility of change. People who
are in this stage may classically be labeled as resistant or unmotivated. In the
case study, for example, Toms verbalizations and actions are suggestive of a
person at the precontemplation stage of change.

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The next stage in the continuum is contemplation. People in the contemplation

stage have the intention or express the desire to change and existing behavior or
to initiate a new behavior. While people in this stage are contemplating change,
there is no clear plan of how or when to initiate changes. Kevin fits the profile of
someone in the contemplation stage. He recognizes that changes need to be
made, but his plan of simply being there in the sessions is not indicative of
immediate action.
Preparation is a state characterized by an intention to change in the immediate

future, usually within the next month. There is a clear plan in place that includes
steps that will facilitate change. This generally leads to action, the stage where
the person takes action in order to achieve a behavior change. In the examples
at the beginning of this section, an example of action would be actively practicing
anger management strategies, such as identifying triggers or taking a time-out.
Maintenance is the stage where the individual strives to maintain and integrate a
behavior that has been successfully started or changed. This stage is one in
which fosters the consistency of newly developed behaviors. People at this stage
report greater self-efficacy and resistance to relapse.
At any point in the change process, a person may exhibit signs of relapse.
Relapse is not exactly synonymous with the definition from the additions field. A
person is considered to be in the stage of relapse when he or she re-engages the
undesired behavior and/or stops the desired behavior. For example, a goal of
change may be for a client to communicate feelings to his or her partner rather
than using alcohol to self-medicate. If a client has mastered this skill, but then
begins to isolate and not communicate feelings, this would be considered
indicative of relapse, whether or not substance use is involved.
The transtheoretical model employs a specific set of techniques, known as

motivational interviewing, to move people from one stage of change to the next.
These techniques are supportive in nature, but also focus on pointing out the
dissonance between what a person desires or knows to be productive and the
current behaviors he or she is exhibiting. A discussion of motivational

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interviewing is contained in the next section of this training material.
Motivational Interviewing Strategies
Motivational interviewing is a therapeutic approach based on the recognition that

clients who need to make changes are at different levels of readiness to change.
Motivational interviewing strategies engage clients in the therapeutic process,
mobilizing intrinsic motivation by developing cognitive and behavioral
discrepancies and by exploring and resolving sources of ambivalence that inhibit
change.
While the idea of therapeutic alliance is important with all clients, with men and
women affected by domestic violence it is key. Clients may seek therapy
unwillingly, or with little real hope for change. They may also have been in
domestic violence systems that have contributed to the already disempowered
way that they feel. Motivational interviewing uses empathic listening, affirming
clients autonomy and choice and matching interventions to the clients own level
of readiness to change. As such it is nonjudgmental. Clients therefore feel
accepted despite unacceptable behavior.
According to Murphy and Maiuro (2009), Motivational interviewing involves four

therapeutic principles:
1. Assessment of clients stage of change, which allows the therapist to

better communicate understanding, empathy and congruence.
2. Development of cognitive/attitudinal discrepancies. How does the client
want to live their life? What is their life currently like? What are the
potential benefits of change?
3. Acceptance of resistance/defining client defenses.
4. Support of self-efficacy by allowing the client his or her autonomy
Some of the characteristics of Motivational interviewing include:
o Expressing empathy through reflective listening

o Noting discrepancies between current and desired behavior
o Evocation; drawing out rather than imposing ideas

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o Avoiding argumentation
o Collaboration to build rapport and facilitate trust
o Encouraging belief in the ability to change
o Communicating respect for and acceptance of people and their
feelings
o Establishing a nonjudgmental relationship
o Developing and action plan to which the client can commit
o Using affirmations and language that affirms clients strengths
o Providing summaries that highlight important aspects of the
discussion, shift the direction of conversations that become "stuck"
o Communicating interest and understanding of an individual's
perspective
o Belief in the autonomy of the client rather than the authority of the
therapist
Specific techniques include:
o Use of open-ended questions

o Asking permission to explore topics
o Affirmation of client strengths
o Expressing appreciation of client difficulties
o Reflections to express empathy and facilitate change
o Summaries
Sample client conversation and use of techniques
Therapist: Hello Maria, it is nice to meet you. I imagine based on

what we discussed in our phone call that you may have some
mixed feelings about being here. Could we spend some time
exploring your situation (ask permission)?
Maria: Yes, its very hard to be here.
Therapist: Im sure it is. Could you tell me about the specific

incident that brought you here (open-ended question)?
Maria: Well, my husband hit me. He was angry. He likes for me to

have the kids in bed before her comes home and to have dinner on
the table waiting. The kids were so crazy, and time got away from
me. I could tell as soon as he walked in that he was mad.

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Therapist: He came home and was angry that the kids were up and
dinner wasnt ready? What happened next?
Maria (crying): I hate for my kids to see that. It was right in front of
them. He promised to stop (crying harder). He pushed me down
and was screaming and hitting. I would hear them crying in the
background. I was begging him to stop. I was scared the neighbors
would hear, and that they would call the police again.
Therapist: You were concerned about the kids because you hate
for them to see that? And also that the police may come (reflecting
emotion)?
Maria: Yes. I love him. I didnt want him to get into trouble, I didnt
want the kids to be scared.
Therapist: It sounds like even though your husband has hit you, you
love him (reflection).
There are a number of differences apparent in this conversation. First, although

the therapist may be concerned about the information she is learning about
Marias situation, she is non-reactive, and takes time to explore Marias situation.
The therapist does not use words like abuse, or jump immediately to safety
planning. The therapist is also respectful of the fact that Maria loves her
husband, even though her husband is violent. While conducting this
conversation, he therapist would be aware of some of the targets for change and
where the client is in terms of readiness for change.
Sample assessment of readiness for change:
Therapist: It sounds like even though your husband has hit you, you
love him (reflection/summary).
Maria: Yes. Weve been together since we were both 16 (laughs).

Things were so different then. Then the kids came along. Hes a
good provider and loves the children. He has never laid a hand on

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them. My friend tells me I should leave him, but I could never do

that.
Therapist: You have a long, complicated history together. He has

many qualities that are important to you. Tell me a little more about
why you would never leave him. What are the benefits of staying
(assess pros/cons of present behavior)?
Maria: When this happened before, he didnt hit me for a long time.
He was so sweet to the kids. If I stay I dont need to worry about
money, or getting a job. I can stay home and be a good mom to my
children.
Therapist: So now that hes hit you, things will be better. Its also
more financially secure for you and for the children. Is there
anything else?
Maria: Nothing that comes to mind.
Therapist: Are there any disadvantages to staying with your

husband?
Maria: Next time may be worse. He could even kill me. I know it
probably sounds crazy to you, but I still think that staying is better
than leaving.
Therapist: On the positive side the finances are taken care of if you
stay. You wouldnt have to worry about looking for work or not
being home for the kids. On the other hand, your husband may kill
you someday. Its a risk you are willing to take (summarize, create
discrepancy.)
Therapist: Where does this leave you now (support self-efficacy.)
Maria: Im not sure. I know all the reasons I should leave, just pack
up the kids and leave. I often want to leave. But I stay. Crazy, right?

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Change Talk
An important aspect of motivational interviewing is the clinicians reinforcement of

change talk. Change Talk refers to the clients mention and discussion of his or
her Desire, Ability, Reason, and Need to change behavior and Commitment to
changing. Clearly Maria is aware of the need to change. She may even desire to
leave. It is not fully clear from the session, however, how much of the focus on
change is self-motivated, versus coming from her well-meaning friend or a
response to what Maria thinks her new therapist would like to hear. It makes
sense that when people talk about change themselves; they are more likely to
change than if someone else talks about it.
Listening for and appreciating the clients ambivalence about change is a

significant aspect of motivational interviewing. While many of us may be
ambivalent when confronted with the need for life changes, for clients affected by
domestic violence not making changes is often dangerous.
Change talk is divided in five categories: Desire, Ability, Reason, Need, and
Commitment:
Desire: Why would you want to make this change?

Ability: How would you do it if you decided?
Reason: What are the three best reasons?
Need: How important is it? And why?
Commitment: What do you think youll do?
Central to motivational interviewing is the consistent emphasis on client

autonomy and self-determination. This is helpful for victims of domestic violence,
who often feel as if systems, including the mental health system, are autocratic
and reinforce dependency. Perpetrators of domestic violence also benefit from
feeling as if changes are those they want to make, rather than are forced to
make. With motivational interviewing, the client has the freedom and
responsibility to contemplate and engage in change.

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Working with Perpetrators of Domestic Violence
While the case example provided above dealt with a victim of domestic violence,
Motivational Interviewing is also an effective technique for working with
perpetrators of domestic abuse.
Researchers have looked at the utility of using Motivational interviewing with this
group. Kistenmacher & Weiss (2008) conducted a small-scale study of the
potential effectiveness of motivational interviewing in changing the way
perpetrators think about their violent behavior. They studied thirty-three men who
were court-mandated to treatment for domestic violence. The motivational
interviewing group demonstrated generally more improvement on stages of
change as well as a significantly greater decrease in the extent to which they
blamed their violence on external factors. Similarly Musser et al. (2008) studied
motivational interviewing as a pre-group intervention with perpetrators. They
found that the motivational intake led to more constructive in-session behavior
during the early phase of group CBT, greater compliance with group CBT
homework assignments, higher late session therapist ratings of the working
alliance, and more help seeking outside of the domestic violence program.
Alexander et al. (2010) also looked at motivational interviewing and compared it
with standard CBT approaches when working with perpetrators. They found that
motivational interviewing led to significant reductions in female partners' reports
of physical aggression at follow-up.
These studies demonstrate that motivational interviewing is an effective

technique. While some of the challenges of with this group are apparent from the
literature, it is helpful to review these prior to looking at a case example.
According to Worden (2000), some of the challenges and areas of intervention
with perpetrators of domestic violence include:
1) System Blaming: Many perpetrators of domestic violence believe

that the systems (such as the criminal justice system, child
services, etc) treat men unfairly in domestic violence cases and that
women abuse the laws.

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2) Problems with Partner/Partner Blaming: Perpetrators of domestic

violence and blame the partner for the violence.
3) Problems with Alliance: Use of direct confrontation in therapy

results in and inability to help the clients who have been abusive to
feel understood, safe, and supported.
4) Social Justification: Perpetrators of domestic violence often

believe that change would be difficultor impossiblein ones
environment, given social and religious norms and expectations.
5) Hopelessness: Perpetrators of domestic violence often feel

hopeless, overwhelmed, depressed or anxious about making
changes.
6) Isolation: Perpetrators of domestic violence often lack support

from family and friends because of social isolation, distrust, or
discomfort seeking help.
7) Psychological Reactance: Perpetrators of domestic violence

often respond to pressure to change with an angry stance.
8) Passive Reactance: Perpetrators of domestic violence may

respond with pressure to change by participating only superficially,
without meeting expectations or responding appropriately.
Motivational interviewing can help to support change by addressing many of

these issues. The following example demonstrates its utility in working with this
population. Note that the therapist does not confront or challenge Tom, but
instead allows his story to unfold. While doing so the therapist assess Toms
readiness to change his behavior.
Therapist: Hello Tom, it is nice to meet you. Could you tell me a

little bit about why youre here (ask permission)?

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Tom: My wife thinks I need anger management.
Therapist: Youre here at the request of your wife? Is there a

reason that she thinks you need anger management (open-ended
question)?
Tom: I know that I get really angry sometimes. All the men in my
family have tempers.
Therapist: Youre aware of your tendency to get angry. Could you

tell me more about what happens when you get angry (restatement,
open-ended question)?
Tom: She can be a bitch too you know.
Therapist: You feel like your wife can also be angry?
Tom: You got that right. One time she was angry because I stayed
out late. She raised her voice right in front of my son, disrespecting
me.
Therapist: What happened then?
Tom: Well, I had to be a role model for my son. I popped her one.
She shut up real fast. Didnt want to do that, you know, but all that
disrespecting.
Therapist: You want to be a role model for your son, and to feel like
your wife respects you (reflection).
Tom: You got that right.
Therapist: So when you hit your wife, you feel more respected. Are
there any negatives about taking that action?
Tom: She gets really upsets and cries and says shell leave me.
This time she packed the kids up. Shes at her moms now. I

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havent seen her or my boys in a week. I miss them.
Therapist: So, even though putting her in her place felt good, your
wife leaving has been a negative. You miss your wife and kids
(summarize, create discrepancy).
Tom: Thats why Im here. I want them back. Maybe I do need to

work on my anger.
Working with Victims of Domestic Violence
Domestic violence victims can also benefit from motivational interviewing

strategies. While victims of domestic violence often need to make a number of
changes in behavior, a continuing theme is that they do not recognize the
dangers of remaining with an abusive partner.
Several researchers have looked at the use of motivational interviewing in

working with victims of domestic violence. These have included Simmons et al.
(2008), Burke et al (2001) and Burkitt & Larkin (2008). These studies have been
small in scale but have demonstrated promising effects on victims use of
community resources, cessation of ongoing abuse, and utilization of mental
health and social supports.
Burke et al. (2001) conducted research into the transtheoretical model as a

conceptual framework for understanding how women end abuse in their intimate
relationships. In-depth interviews were conducted with 78 women who were
either currently in or had recently left abusive relationships. Women talked about
the following five stages of behavior change:
Precontemplation The woman does not recognize abuse as a problem and

is not interested in change
Contemplation The woman recognizes abuse as a problem and has an
increasing awareness of the pros and cons of change
Preparation The woman recognizes abuse as a problem, intends to
change, and has developed a plan

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Action The woman is actively involved in making changes

related to ending the abuse
Maintenance The abuse has ended and the woman is taking steps to
prevent relapse
In the example we viewed earlier involving Maria, Maria was in the contemplation
stage. While Maria may not yet be ready to develop a plan or take action
Maria: Im not sure. I know all the reasons I should leave, just pack
up the kids and leave. I often want to leave. But I stay. Crazy, right?
Therapist: This is a hard time for you. There are advantages and
disadvantages to leaving. Whatever you decide to do is your
choice. Im confident that you will make the best choice for yourself
(support self-determination).
While Maria does not yet appear to be ready to leave her husband, there may
be other avenues to explore, such as why she may want to make this change, or
how she could do it if she decided to do so:
Therapist: Im confident that you will make the best choice for
yourself (support self-determination). If you did decide that leaving
was the best choice, what steps would you need to take?
Maria: Remember, my friend I told you about? She told me I could

stay with her. My husband would never try to interfere if I went
there. Hed be too embarrassed. Id feel bad about asking her for
help, but I know she would help me.
Summary
This training material reviewed some of the strategies of motivational interviewing

in supporting change in victims and perpetrators of domestic violence. While the
complexity of target behavior in this group is readily apparent, research indicates
that many of these behaviors are amenable to these supportive strategies, which
affirming client autonomy and empower them to make changes in their lives.

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References
Alexander, P.C. (2010). Stages of change and the group treatment of batterers: a
randomized clinical trial. Violence and Victims, 25(5), 571-87.
Brown, J. (1997). Working toward freedom from violence. Violence Against

Women, 3, 5-26.
Bundy, C. (2004). Changing behaviour: using motivational interviewing

techniques. Journal of the Royal Society of Medicine, 97, 4347.
Burkitt, K.H. & Larkin, G.L. (2008). The transtheoretical model in intimate partner
violence victimization: stage changes over time. Violence and Victims, 23(4):411-
31.
Daniels, J. W., & Murphy, C. M. (1997). Stages and processes of change in

batterers treatment. Cognitive and Behavioral Practice, 4,123145.
Kistenmacher, B.R, & Weiss, R.L. (2008). Motivational interviewing as a

mechanism for change in men who batter: a randomized controlled trial. Violence
and Victims, 23(5):558-70.
Murphy, C.M. & Maiuro, R.D. (2009). Motivational interviewing and stages of
change in intimate partner violence. New York: Springer Publishing.
Musser, P.H. (2008). Motivational interviewing as a pregroup intervention for

partner-violent men. Violence and Victims, 23(5), 539-57.
Simmons, C.A. (2008). A comparison of women versus men charged with

intimate partner violence: general risk factors, attitudes regarding using violence,
and readiness to change. Violence and Victims, 23(5):571-85.
Wahab, S. (2005). Motivational interviewing and social work practice. Journal of

Social Work, 5(1): 4560.

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Chapter 6: Legal and Ethical Issues
Introduction
Case Vignettes
Carrie is a 38-year-old mother of two preteen children. She has been dating Jack
for the past year. When they initially met, she felt that she had finally met the
man of her dreams, but now it seems like a constant nightmare. Shortly after the
start of the relationship, Jack became physically abusive. Her children have
recently witnessed the violence, and her youngest has urged her to call the
police. Carrie is fearful of police involvement, however, many of the fears
centering around whether her children will be removed from the household.
Domestic violence is a pattern of coercive tactics perpetrated by one person

against an intimate partner, with the goal of establishing and maintaining power
and control. Domestic violence includes physical, psychological, sexual,
economic, and emotional abuse. Domestic violence occurs across a spectrum of
intimate relationships, including married couples, dating couples, couples who
live together, people with children in common, same-sex partners, people who
were formerly in a relationship with the person abusing them, and teen dating
relationships.
Carries story is not an isolated one. Given the prevalence of intimate partner
violence, mental health clinicians will likely encounter a survivor in his or her
practice. An estimated 5.3 million cases of intimate partner violence are reported
each year (CDC, 2003). These incidents result in 486,000 emergency room visits
and 18.5 million therapy sessions each year (CDC, 2003). While these numbers
may seem high, and they certainly are, they are gross underestimates. According
to 2006 Bureau of Justice statistics, less than one-fifth of victims reporting an
injury from intimate partner violence sought medical treatment following the
injury. Similarly, many domestic violence victims do not report incidents of abuse
to law enforcement due to perceived risks of removal of children, dual arrest
policies, homelessness, embarrassment or deportation.
Mental health clinicians may be placed in the role of helping to facilitate such
reports. They may serve as a lifeline for patients, providing them with information
on resources, advocacy and helping them negotiate the justice system. While
clinicians cannot be experts on all fronts, it is important to have an understanding
of the systems in which victims may need to operate. Additionally it is critical that
clinicians be aware of their ethical obligations to domestic violence victims and
their children.
This is not always easy. According to the American Psychological Association

Task Force on Violence and the Family, the legal system is fraught with
numerous problems. The report states: Most victims of family violence will have

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some contact with the legal system that is not well designed to handle such
cases. In addition, inequities in the application of the law, racial and class bias,
and inadequate investigations have harmed rather than helped many families.
The low priority given to funding for implementation of child protection laws
results in a legal system that frequently fails to work. Many battered women find
themselves in dangerous positions because the courts often do not give
credence or sufficient weight to a history of partner abuse in making decisions
about child custody and visitation. Racial bias often influences the court's
decision about whether to order treatment or to imprison offenders.
It is important that mental health professionals find ways to negotiate sometimes

faulty systems. The first step is in understanding needs of the victim and
clinicians professional obligations.
This course will provide an overview of risks, a discussion of why survivors are
reluctant to disclose abuse, the legal resources available to clients and ethical
obligations. It will also contain an appendix with helpful information, including a
summary of state laws on mandatory arrest and a sample safety plan.
The terms domestic violence and intimate partner violence will be used
interchangeably in this training material.
1. Discuss the scope of the problem, including intimate partner homicide,

lethality assessment and nonfatal injuries
2. Discuss reasons why victims often fail to report intimate partner violence
3. Define mandatory arrest and dual arrest and describe the implications of
each
4. Describe issues related to empowerment and advocacy
5. Discuss navigating the various systems related to domestic violence
6. Discuss ethical and legal issues related to domestic violence
Scope of the Problem
Prior to looking at the legal aspects of intimate partner violence, it is helpful to

look at the history in the impact of domestic violence and its connection to the
criminal justice system. While domestic violence is certainly not new, it is only
recently that it has been considered a violation of the law. Prior to about the
1970s (and sometimes even currently), domestic violence was seen as a
"normal" part of marriage or intimate relationships.

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A significant factor in the why the criminal justice system has undergone reforms
is how dangerous domestic violence is. The statistics cited in the introduction tell
only part of the story. Domestic violence presents a number of concerns related
to safety. Mental health providers should be careful not to minimize safety
concerns, and assessment of safety and risks should be an ongoing component
of therapy.
Intimate Partner Homicide
April 4, 2011 Orlando, Florida. Police arrested a man they said killed two
people at an Orlando apartment complex on Sunday night. Officers said 45-year-
old Eligio Isalgue shot his estranged wife and her new boyfriend. Isalgue was
arrested in the complexs parking lot. Investigators said they found a gun inside
the apartment. Two other people, including Isalgues 13-year-old daughter, were
in the apartment. The others were not injured. Investigators said the husband
and wife had not lived together for about two months.
Intimate partner homicide is defined as a homicide perpetrated against a current

or former spouse, cohabitant, or romantic partner by his or her intimate partner.
Here is a summary of some key findings (Catalano et al., 2009):
In 2007 intimate partners committed 14% of all homicides in the U.S. The
total estimated number of intimate partner homicide victims was 2,340,
including 1,640 females and 700 males.
Females were killed by intimate partners at twice the rate of males.

Females are generally murdered by people they know. In 64% of female
homicide cases, females were killed by a family member or intimate
partner. 24% of female homicide victims were killed by a spouse or ex-
spouse; 21% were killed by a boyfriend or girlfriend; and 19% by another
family member.
Men were more likely than women to be killed by strangers. Among male
homicide victims, 16% were murdered by a family member or intimate
partner. Of male homicide victims, 2% were killed by a spouse or ex-
spouse and 3% were killed by a girlfriend or boyfriend. Over half (54%)
were killed by others they knew, and 29% were killed by strangers.
Prior domestic violence is a strong risk factor for intimate partner homicide.
Campbell and Glass (2009), who conducted a study of female victims of intimate
partner homicide, found that approximately 80% of women had been a victim of
physical and/or sexual intimate partner violence or stalking prior to their murder
and 42% were seen in the healthcare system the year before they were killed.
While the women themselves are not always good at assessing their own risk,

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Campbell and Glass state that healthcare professionals, including those in the
mental health fields, can be a resource for identifying women who are at risk.
Currently about 20 states have fatality review teams, which comprehensively look
at each death. These teams promote prevention and track patterns of homicides
and suicides resulting from intimate partner homicide.
Collectively these review teams have found some common warning signs of
intimate partner homicide. These include (Campbell et al., 2003):
A prior history of domestic violence and injuries

Attempts to break away from the abusive partner (such as a protective
order, pending divorce, or moving out of the house
Stalking or threatening behaviors
Previous police involvement
History of mental illness
History of drug or alcohol abuse (abusive partner or victim)
Assessing Safety
Safety planning is an important component of treatment. Experts on trauma work

such as Herman (1997) and Bloom (1997) state that creating safety for trauma
survivors is key to recovery. With survivors of domestic violence, this often
involves assessing lethality and developing a safety plan. This training material
will discuss safety planning later in this chapter. Mental health professionals can
use the warning signs of intimate partner homicide in their safety assessment.
Additionally safety assessments involve asking clients about:
Increases in frequency of violence

Means of violence (physical violence, presence of guns)
Threats of violence
Presence of a child that is not the abusers
Control
Threats of suicide
Stalking or spying behavior
Other Losses
Case Vignette
A case making breaking news in New York is that of the death of Mary Kennedy,
who committed suicide. Her death came on the heels of husband Bobby
Kennedy filing for divorce. Bobby Kennedy alleges that he was the victim of
domestic violence. Marys family alleges that she was a victim.

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In addition to homicide of victims of intimate partner violence, there are also other
losses. Suicide attempts/completed suicide is another loss associated with
domestic violence. Suicide.org estimates one out of every four women who are
the victims of domestic violence attempt suicide.
Non-fatal Injuries
While the discussion of intimate partner homicide provides a frightening picture,

in terms of sheer numbers, the number of men and women who suffer non-fatal
injuries is significantly higher. In 2008 females age 12 or older experienced about
552,000 nonfatal violent victimizations (rape/sexual assault, robbery, or
aggravated or simple assault) by an intimate partner (a current or former spouse,
boyfriend or girlfriend). In the same year, men experienced 101,000 nonfatal
violent victimizations by an intimate partner. About two-thirds of reported
victimizations occur at home. After the incident, less than one-fifth of victims seek
medical care (Catalano et al., 2009).
Reporting Intimate Partner Violence
Many victims of domestic violence fail to report abuse to the police. Research
has show gender differences in reporting rates, as well as some of the reasons
that victims choose not to make a police report. Males victims of domestic abuse
are actually more likely to report violent conflicts. In 2008, 72% of the intimate
partner violence against males and 49% of the intimate partner violence against
females was reported to police. Stalking victimization was equally likely to be
reported to police whether the victim was male or female. Thirty-seven percent of
male and 41% of female victimizations were reported to the police by the victim
or another person aware of the crime (Catalano et al., 2009).
A recent study from the Bureau of Justice statistics found that the major reasons
for not reporting abuse to police were: fear of reprisal (15%), belief that police
cannot help (6%), and a feeling that violence is private (28%). Additionally
many victims of intimate partner violence are extremely isolated from sources of
support, and lack the support networks to leave abusive environments. They may
be faced with the prospect of homelessness or family separation.
This distrust of the legal system also extends to healthcare professionals. This
may be particularly true when children are involved or children witness or are
victims of family violence. One source of controversy are failure to protect
statutes. These statutes may be enforced if victims choose to remain with
abusers as they place children in harms way. In some states, children can be
removed from the family in this situation.
Many victims of domestic violence also hide the abuse from health care
providers. What is unfortunate is that by doing so they may be cutting themselves

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off from potential resources and sources of help. It is important that mental health
professionals be aware of signs of domestic violence and include questions
about the possibility of domestic violence in their screenings. It is important to
ask these questions outside the presence of the potentially abusive partner.
Mandatory and Dual Arrest Policies
In understanding domestic violence and the law it is important to understand the

legal context of domestic violence. The U.S. Department of Justice defines
domestic abuse or violence as, "a pattern of abusive behavior in any relationship
that is used by one partner to gain or maintain power and control over another
intimate partner."
Since the 1970s, many states have implemented so called warrantless arrest
policies in an effort to deter domestic violence. While these laws have been
helpful in increasing rates of arrest, prosecution, and conviction of perpetrators of
domestic violence (National Research Council, 2004), they have led to some
problems. State laws vary with regard to circumstances under which warrantless
arrests can be made. For example, some stipulate that arrests can be made in
cases of felonies, within a certain number of hours of the incident, and/or if the
persons involved are married, blood-related, living together or have a child
together. A listing of these policies can be found in the appendix of this training
material.
Mandatory arrest policies mean the police officers are required by law to make
arrests based on probable cause that domestic violence was committed. Some
states that have mandatory arrest provisions include: Alaska, Arizona, Colorado,
Connecticut, Iowa, Kansas, Louisiana, and the District of Columbia. Preferred
arrest policies are less strict; they encourage but do not mandate arrest as the
favored action when probable cause exists. States with preferred arrest
provisions include: Arkansas, California, Massachusetts, Montana, North Dakota
and Tennessee. Discretionary arrest Policies allow greatest leniency when
confronted with domestic violence. The statutes stipulate that the officer "may"
arrest under certain circumstances where probable cause is evident. Those
states with discretionary arrest provisions include: Michigan, Minnesota,
Nebraska, New Hampshire, New Mexico, North Carolina, Oklahoma,
Pennsylvania, Texas, Vermont, West Virginia and Wyoming.
With these policies, an important (but subjective) determination is the idea of

primary aggressor. Responding officers often have to sort out varying stories of
what occurred. In situations where there is a lack of clarity, officers make a dual
arrest. In this instance, both victim and perpetrator are arrested, and the court
makes the determination. These policies have come under fire by domestic
violence advocates, such as Eleanor Pence, developer of the Duluth Model of
intervention. She states that contemporary domestic violence intervention, far too

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often, is one-size-fits-all, and can allow some chronic violent abusers to avoid
proper punitive sanctions for their long-term violent behavior.
Buel and Hirst (2009) believe that healthcare professionals can be instrumental
in helping victims to advocate for themselves when threatened with dual arrest.
They can serve as translators to help victims of domestic violence to voice what
occurred. While this role is an important one, the overall feeling is that dual arrest
policies can be detrimental to victims of intimate partner abuse.
Advocacy
As Buel and Hirsts (2009) comments suggest, one role that mental health
professionals can play in working with domestic violence is advocacy. Victims of
intimate partner violence generally feel disempowered and overwhelmed by the
many systems and legalities associated with trauma. They may be struggling to
create physical and emotional safety.
What is empowerment? Wilson and Martin (2006) define the word empower as
increasing the control people have over their lives. They include components of
feeling powerful, competent and worthy of self-esteem. These authors also states
that there needs to be a modification of the structural conditions in order to
reallocate power.
The Advocacy Wheel for domestic violence (The Missouri Coalition Against
Domestic Violence, n.d.) follows. Based on the Duluth Wheels, this graphic
provides a schema that describes the role of the clinician-advocate. The central
goal of the wheel is to help promote empowerment for victims of domestic
violence.

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While clinicians will have differing roles with regard to advocacy, this wheel is
broad enough to cover many of these. A synopsis and explanation of each
follows:
Confidentiality: As a first step, the clinician must establish confidentiality.

Discussing the possibility of victimization must occur in private. A victim of
domestic abuse will not typically disclose a history of violence in the presence of
her perpetrator or other family members. If she discloses the violence in his
presence, it is likely she will suffer retaliation. When there may be limits to
confidentiality (discussion will follow), these must be verbalized at the outset. It is
helpful to emphasize that the goal of any intervention is providing help.
One area that can be particularly tricky is balancing the role of advocating from a
victim of abuse and the mandate to report child abuse.
Case Vignette
Maureen Quinto, a licensed social worker, is employed at a
community mental health center. She completed an intake with

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Mary, a new client seeking help for depression. Mary reported to

Maureen that her husband would often beat her and the children.
Maureen complied with agency procedures, and reported the child
abuse. She received a distraught and angry phone call from Mary,
stating that her children had been removed from the house.
Case Vignette
Trudi Hayes, a licensed social worker, is employed at a community
mental health center. She meets with a new client, Maribeth. Prior
to the intake, she discusses confidentiality, including the limits
around child abuse reporting. Maribeth states that she is frightened
to tell her what has been happening at home because I dont want
to lose my kids. Trudi explains that if a parent initiates a call to
Child Protective Services, they are less likely to take the children,
stressing that there are resources that can help her. She does not
make any guarantees. Maribeth tearfully describes how her
husband Tom beats her and the kids. Together they call Child
Protective Services, who supports Maribeth in her efforts to take
the children to a domestic violence shelter.
These two cases illustrate the importance of managing confidentiality issues in a

way that is sensitive and also affirms the role of the non-abusing parent as an
integral role.
Validation: Validating that violence perpetrated against the victim is true. Victims
of domestic violence may be fearful that they will not be believed if they report
abuse. In many households where there is domestic violence, and abusive
partner can look very normal or be considered by others to be an upstanding
citizen.
Acknowledge the Injustice: Victims of domestic violence often feel that abuse is
their fault. Be aware of blaming statements and respond appropriately. There is
often a great deal of self-doubt and blame.
Autonomy: Empowering advocacy is based on the core belief that victims of

domestic violence have the right to control their own lives. In the process of
victimization, control has been taken away from them. Clinicians should provide
victims with autonomy by guiding, but allowing victims to make their own
decisions.
Safety Planning: What are the victim's options? Safety is critical. According to the
American Psychological Task Force on Violence and the Family (1996) (as
summarized by Wilson & Martin, 2006) the following strategies will help ensure
safety:

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Calling the police

Calling a shelter
Leaving the home or scene
Superficially complying with the abusers demands
Talking to friends
Hiding
Avoiding the abuser
Seeking professional help
Avoiding conflict and keeping the peace
It is also important to remember that the victim is often the ultimate expert on
how an abuser will respond. For example, leaving the house may not be an
option because it will further incense the abuser. According to Wilson and Martin
(2006), two important questions to ask are: What are some of the cues or
behaviors that are present before a violent incident occurs? and What have you
done in the past to successfully protect yourself and your children.
Clinicians can also use the sample safety plan (contained in the appendix), a
detailed roadmap for victims. It is important to discuss safety procedures, and
review them frequently.
Promote Access To Community Services: Know the resources in your

community. If you are able to do so, provide victims with a written list that they
can refer to.
Navigating the Systems
A key component in working with domestic victims is in helping them to navigate

the various systems they encounter. In addition to the mental health system,
some of these systems include: legal, medical, social service, and child
protective. When making a referral to any of these systems it is helpful to provide
victims with a sense of what they can expect.
While each state varies with regard to the systems in place to prevent and
respond to domestic violence, there are some similar agencies that many states
have in common. The following is a summary of some of these systems. It is
important to know the resources in your home state.
Offices for the Prevention of Domestic Violence
These systems support local and state domestic violence efforts. While many of
their efforts have to do with grants and funding, they can be a resource for

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learning about availability of domestic violence training and a clearinghouse of

other services.
Offices of Victim Services
Many states have offices of Victims Services. These can be invaluable in

supporting victims. Victims Services compensates victims of crime for
unreimbursed out-of-pocket expenses, which can include expenses for mental
health counseling (including counseling for children and relatives). These
systems provide funding to victims of spousal abuse, sexual assault and child
abuse. In some states these program includes other victims of violent crime.
In addition to victim compensation, most offices of victim services provide

advocates help victims of violent crime by notifying them of their rights and by
providing information and assistance. These advocates:
Provide information to the victim about the criminal case and criminal
justice system
Act as a liaison between victims and court personnel
Escort victims and their family members to court proceedings
Advocate for victims during court proceedings
Provide victims with social service referrals
Assist victims and their family members in preparing and delivering a
victim impact statement
Criminal And Civil Courts
This system is the legal arm of domestic violence. Many states have dedicated
domestic violence courts that act on criminal complaints pertaining to domestic
violence. This ensures consistent responses to domestic violence. Domestic
violence is no longer treated as a simple battery. Consequently, our system
imposes enhanced and specialized sentences for these offenses.
One important function of civil courts involves the issuance of protective orders.
An order of protection (also called a restraining order) is an official document that
outlines provisions that limit contact between an abusive partner and the victim.
There are generally two types of protective orders: protection from abuse (PFA)
and protection from harassment (PFH). According to Buel & Hirst (2009) the
orders may include provisions that:
Prohibit future abuse against victims and any children in the home
Maintain a 100-yard distance from the victim, home, workplace or other
appropriate location
Refrain from contacting the victim in any way
Determine who may stay in residence

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Pay compensation for damages

Award custody of the child
Require supervised visitation
Enforce payment of spousal and child support
Prohibit purchase of a gun and relinquishment of guns during the
enforcement of the protective order
Require appropriate counseling or treatment for the abusive partner
While the process for filing a protective order will vary from state to state, there
are some similarities. In most places, once appropriate paperwork is completed,
a temporary (ex parte) protective order is issued. This order keeps the abusive
partner away from the victim for a specified period of days (usually about 5-7)
until a formal hearing is held. At the hearing, the judge decides if the protection
order will be canceled or continued.
While it is not mandatory that the victim bring any proof with her to court, it is
generally helpful. Proof of abuse or harassment may include:
Photographs of injuries (and if possible the person who took the

photographs)
Threatening notes, email, phone messages.
A witness who saw or overheard the abuse, even though in some courts
only the parties are allowed to testify.
A victim advocate may be helpful to provide additional support.
Once a protection order has been issued, its effectiveness in ensuring the
continuing safety of the protected person depends in large measure on the
enforcement of that order. Enforcement must occur smoothly and routinely in
order to work as a deterrent to continued domestic violence. States and
municipalities establish rules around the enforcement of protective orders. The
Federal Violence Against Women Act (VAWA) makes protection orders
enforceable across state lines. If a victim believes that an order of protection has
been violated, he or she should call police immediately. In many states, violators
of protective orders are immediately arrested and jailed.
Family Courts
Intimate partner violence is a common issue in custody, visitation, and divorce

cases. Family courts are often called upon to assess the impact of family
violence with regard to these types of court cases. Since custody and visitation
cases often involve mental health issues, expert testimony from mental health
providers may be required.
Departments of Health

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These systems include direct medical services. Rape crisis centers are also
housed within departments of health. These systems generally also provide
direct crisis counseling.
Child Protective Services (CPS)
While most clinicians know the term child protective services, it is often not until
a client is involved in this system that CPS functions are truly understood. Many
women who have been abused by an intimate partner are also involved with
CPS, and by extension, treating clinicians will be involved as well. In defining
CPS, the Family Violence Prevention Fund states: The child protection system is
a bureaucratic government institution responsible for ensuring that various laws,
regulations and policies regarding the protection of children are enforced.
While state laws vary with regard to what is reportable to CPS, in many states
clinicians are mandated to report to CPS any reasonable suspicion of child abuse
or neglect.
Most women fear the possibility of a report being filed with CPS. While there are
cases in which children are removed from an abusive household, more often
efforts are made to keep children with a non-abusing parent. This may mean that
a parent is referred to a shelter or short-term housing. CPS often also runs
support groups and can refer women to additional resources. The following types
of services are available:
Family support services are community-based services that assist

and support parents in their role as caregivers. Family support
services promote parental competence and healthy child
development by helping parents enhance their strengths and
resolve problems that can lead to child maltreatment,
developmental delays, and family disruption.
Family preservation services are short-term, family-focused, and

community-based services designed to help families cope with
significant stresses or problems that interfere with their ability to
nurture their children. The goal of family preservation services is to
maintain children with their families or to reunify them, whenever it
can be done safely.
Ethical Considerations: Confidentiality
Dr. Markin is working with Patricia, a registered nurse, who has recently
separated from her husband Gerald. Patricia has two daughters, ages 8 and 10.
Gerald sees his daughters on weekends. Gerald has been abusive to Patricia in
the past, but she denies any current incidents. Patricia has worked hard to

________________________________________________________________
increase her autonomy, and has stated that she will not condone any type of
abuse to herself or her daughters. Following the separation, Patricia purchased a
handgun and has taken shooting lessons. Patricia phones Dr. Markin for an
emergency session. She tells Dr. Markin that her older daughter came home
from a weekend visit with bruises, stating that her father had hit her because of
her foul mouth. Patricia is incensed, stating that she plans to kill that son of a
bitch.
What are Dr. Markins obligations here? Should she report Gerald to child
protective services? Does she have a duty to warn Gerald about the threat to his
safety?
Mental health professionals are confronted with a wide range of ethical and legal
issues concerning in their treatment of victims of domestic violence. As the case
above illustrates, many ethical issues arise as a result of balancing the roles of
therapist, advocate, and mandated reporter. Mental health functions frequently
intersect with other disciplines, which can lead to conflicts in maintaining
confidentiality. For example, a common issue that arises in treatment of domestic
violence victims is the need to interact with the various systems discussed in this
material, such as the criminal justice system, child protective services, etc. The
case vignette provided an example of potential disclosure of confidential therapy
discussions to child protective services. Questions may arise regarding whether
clinicians can maintain the confidentiality of patient information or whether they
must comply with police or court requests for access to health records or reports.
Another common issue is whether mental health professionals should breach
confidentiality in relation to patients they consider at risk of harming themselves
or others. This section will discuss several of these issues. It is important,
however, to be aware of the specific guidelines of the state in which you practice.
To begin, lets look at the obligation to maintain confidentiality, a standard shared

by all professional codes. An example of this guideline is contained in National
Association of Social Workers (NASW) standard 1.07, which states: Social
workers should respect clients right to privacy. Social workers should not solicit
private information from clients unless it is essential to providing services or
conducting social work evaluation or research. Once private information is
shared, standards of confidentiality apply.
That does not mean, however, that social worker, psychologists, and counselors
cannot share confidential information. When an appropriate authorization is in
place, and clients consent to sharing information, this is allowable. Examples that
may apply to domestic violence cases are: interacting on the patients behalf to
obtain housing, sharing information with courts to support an order of protection,
or coordinating with a childs school teacher or counselor.

________________________________________________________________
Compelling Reasons to Break Confidentiality
Professional codes of ethics allows disclosure of confidential information when

there are compelling professional reasons. These reasons include serious,
foreseeable, and imminent harm to a client or other identifiable person. This is a
broad dictate, and can include (but is certainly not limited to) harm to a minor
child, harm to an elder, harm to oneself, or harm to others. Should a clinicians be
required to break confidentiality, he or she should disclose the least amount of
confidential information necessary to achieve the desired purpose; only
information that is directly relevant to the purpose for which the disclosure is
made should be revealed and when possible, inform clients of the disclosure in
advance.
While the confidentiality standards discussed in the previous paragraph are

ethical mandates, a closely related legal function is the clinicians role as a
mandated reporter. Simply put, being a mandated reporter means that an
individual is required to report suspected cases of abuse. All states have passed
some form of mandatory child abuse and neglect reporting law in order to qualify
for funding under the Child Abuse Prevention and Treatment Act (CAPTA). In
addition to child abuse reporting laws, many states also have laws pertaining to
mandatory reporting of elder abuse (for more about older adults and domestic
violence please see Issues in Domestic Violence: Special Populations.) The
laws apply to mental health providers working both in private practice and
institutional settings.
One common question is how certain about clinicians need to be in order to

make a report of abuse. Although this is something that each clinician needs to
decide for his or herself, Pass (2007) observes that if a clinician witnesses only
behavioral symptoms of child abuse (e.g., sudden changes in behavior or school
performance, hypervigilance, concentration problems) it is best for the clinician to
document their observations and continue to assess the situation. When a
professional observes physical symptoms (e.g., bruises or other marks) it is best
to consult with a colleague and also to speak with a parent or guardian. When a
clinician notices a combination of physical and behavioral symptoms, however,
an immediate report is indicated. On a therapeutic level it is important to consider
the potential consequences of reporting, and thoroughly assess the situation.
There is no timeframe; a 2-3 week assessment is ok if the child is not in
immediate danger.
In addition to issues regarding suspected child abuse, clinicians are ethically

bound to disclose information in situations in which they believe a client will harm
themselves or another identifiable person. With the link between domestic
violence and suicidal thoughts/attempts (see Devries et al., 2011) it is important
to keep in mind that a clinician may need to seek help for a client, even if it
means breaking confidentiality. Additionally they may be compelled to seek help
for an intended victim, even if that victim is an abusive partner. The treating

________________________________________________________________
professionals duty to warn is discussed in a subsequent section.
Confidentiality and Privilege
Case Vignette
Carla Varnis, a clinical social worker, is working with Pamela. Pamela has been a
victim of domestic abuse. Carla receives subpoena for medical records from
Pamelas husbands attorney. Pamelas husband has filed for custody, stating
that Pamela is crazy and unfit to be a parent. Carla recognizes that her
therapy notes likely do have some information about Pamelas past mental health
history that could be prejudicial. What should she do?
As this case illustrates, the intersection of the court system and mental health
system can prove to be challenging. In some cases, such as when a clinician is
providing information that a client has requested that a court representative
receive, it is simple. For example, if a client requests that her own lawyer receive
a summary of therapy sessions, such information can be provided by having the
client sign a release form authorizing this disclosure. This is covered by NASW
ethical standard 1.07b Social workers may disclose confidential information
when appropriate with valid consent from a client or a person legally authorized
to consent on behalf of a client and by similar standards with the other
professions. It is still important, however, to explain to the client the potential
consequences of the disclosure prior to releasing the records to a third party.
NASW ethical standard 1.07d states Social workers should inform clients, to the
extent possible, about the disclosure of confidential information and the potential
consequences, when feasible before the disclosure is made. The standard goes
on to clarify that clinicians should still educate the client about the potential
effects of disclosures on the basis of a legal requirement or client consent.
While other ethical codes (such as the APA code) are not as specific about the
need to provide psychoeducation, it is good clinical practice.
A question that frequently arises is the distinction between confidentiality, an

ethical and legal requirement, and privilege, a legal term. Psychotherapists have
an ethical and legal requirement to maintain the confidentiality of disclosures
made by clients during the course of treatment.
In the case of the vignette presented at the outset of this section, in which an
attorney subpoenas treatment records a clear conflict exists for the clinician. The
therapist in the vignette, Carla, has several duties to Gloria, one of which is to
maintain the confidentiality of their communications. In order to do so, Carla must
assert psychotherapist-patient privilege. By asserting privilege, Carla is
communicating to the court that she recognizes her duty to respond to the
subpoena asking her to provide information to the Court (which is a legal
obligation), but that she has a competing duty to the patient to keep her therapy
disclosures confidential. Further by invoking privilege Carla is asserting the belief
that her duty to maintain patient confidentiality outweighs the duty to provide

________________________________________________________________
information that could be used as evidence. Asserting privilege acts as a request

to the court to be exempted from the duty to provide this confidential information
(Clinical Lawyer, n.d.).
While the opposing lawyer can continue to fight to see Glorias records, most
courts err on the side of privilege. It is helpful to speak to legal experts from the
state licensing board that governs your profession.
Treating Professionals Duty to Warn
Another ethical issue is the treating professionals duty to warn. Lets return now
to the case vignette that introduced this section:
Dr. Markin is working with Patricia, a registered nurse, who has recently
separated from her husband Gerald. Patricia has two daughters, ages 8 and 10.
Gerald sees his daughters on weekends. Gerald has been abusive to Patricia in
the past, but she denies any current incidents. Patricia has worked hard to
increase her autonomy, and has stated that she will not condone any type of
abuse to herself or her daughters. Following the separation, Patricia purchased a
handgun and has taken shooting lessons. Patricia phones Dr. Markin for an
emergency session. She tells Dr. Markin that her older daughter came home
from a weekend visit with bruises, stating that her father had hit her because of
her foul mouth. Patricia is incensed, stating that she plans to kill that son of a
bitch.
What are Dr. Markins obligations here? Should she report Gerald to child
protective services? Does she have a duty to warn Gerald about the threat to his
safety?
There are clearly a number of issues involved in this case, including therapeutic,
ethical and legal concerns. Lets take each of these duties separately. From a
therapeutic standpoint, Dr. Markin has a duty to provide a safe environment in
which Patricia can work through her feelings about her relationship with Gerald.
Such safety is especially critical to allow victims of domestic violence to heal from
their traumas and to move forward with their lives. According to the Advocacy
Wheel depicted earlier it is critical to respect confidentiality, promote safety and
validate the victims experiences. Given these important concerns, it is important
that any decision that would involve breaking confidentiality be fully considered.
Ethically, Dr. Markin could, if he feels it is indicated, make a disclosure based on

the limited details of the case. According to APA Ethical Standard 4.05B
Psychologists disclose confidential information without the consent of the
individual only as mandated by law, or where permitted by law for a valid purpose
such as to (3) protect the client/patient, psychologist, or others from harm. While
Dr. Markin could disclose information for the reason of protecting Gerald, it would
clearly come into conflict with his ability to act in a therapeutic manner.

________________________________________________________________
Tarasoff v. Regents of the University of California (1976) is the case that

established the duty to warn in California and iterations of the duty to
warn/duty to protect laws have been passed in most states across the
country. The idea behind these laws is that by accepting responsibility for
the care of a client in need of mental health treatment, the clinicians may
owe a duty to protect third parties from harm threatened by the client. The
Tarasoff ruling states: When a therapist determines, or pursuant to the
standards of his profession should determine, that his patient presents a
serious danger of violence to another, he incurs an obligation to use
reasonable care to protect the intended victim against such danger
(Tarasoff, 1976, p. 340).
What makes the question of what Dr. Markin should do even more
confusing is that there are state variations in duty to warn requirements.
The following categories apply (NASW):
Mandatory Duty to Warn. Some states establish a mandatory

duty to warn. These are: Arizona, California, Colorado, Delaware,
Idaho, Illinois, Indiana, Kentucky, Louisiana, Maryland,
Massachusetts, Michigan, Minnesota, Montana, Nebraska, New
Hampshire, New Jersey, Ohio, Tennessee, Utah, Virginia, and
Washington. A number of these states also have court decisions
that have interpreted the duty to warn laws.
Permissive Standard. Some states give permission in state

statutes for therapists to warn of serious threats. These states are:
Alaska, Arkansas, District of Columbia, Florida, Hawaii, Iowa,
Mississippi, Missouri, New Mexico, New York, Oklahoma, Oregon,
Rhode Island, South Carolina, South Dakota, Texas, Virgin Islands,
West Virginia, and Wyoming. In some states, such as Texas, the
permission to warn is limited to notifying medical or law
enforcement personnel, not the threatened person or persons.
No Statutory Standard. A third set of states does not provide any

statutory language addressing the duty to warn, but some of these
have implemented the duty through court decisions. Connecticut,
Pennsylvania, Vermont and Wisconsin do not have statutory
provisions, but have established a duty to warn through court
decisions. States that are silent as to the social workers duty to
warn are Georgia, Kansas, Maine, Nevada, North Dakota, and
Puerto Rico.

________________________________________________________________
While these variations make it hard to determine a one-size fits-all approach to

what to do in the case study, there are some recommended standards for
decision making. According to the NASW publication Social Workers and State
Duty to Warn Laws, some of the key issues to review in a case involving a
possible duty to warn are:
Whether the client is the individual who represents a threat to self or

others
Who has disclosed the threat and under what circumstances
How much time has passed since the threat was made
Whether the client possesses the means and capacity to carry out
the threat
Whether the duty to warn has been established as a mandatory
requirement in state law
Whether the threat of harm is to a specific individual or represents a
general threat to the public at large
Whether the criteria for involuntary commitment may apply
Whether the state permits disclosure of a threat even if it is not
mandatory
Who needs to be warned to effectively discharge the duty to warn
(e.g. Law enforcement, the intended target, the department of motor
vehicles, a treating physician, a responsible family member).
Sample conversation with Patricia (state variations will occur)
After allowing Patricia time to talk about feelings:
Dr. Markin: I am concerned about some things that you said

earlier. You said that you wanted to kill that son of a bitch.
Do you still feel that way?
Patricia: I dont want to see my daughter being abused the

same way I was.
Dr. Markin: Thats understandable. But meeting violence with

violence is not the answer. If you went to prison, your
daughters would have no one to care for them.
Patricia: I know that. I just feel so powerless.
Dr. Markin: I think that one thing that may help is to make a
call together to Child Protective Services. They will help us to
make sure that both you and the girls stay safe.

________________________________________________________________
Patricia: I know youre right. Im angry, thats all. Lets make

the phone call.
In this situation, Dr. Markin used his clinical judgment to diffuse a potentially
dangerous situation. Had Patricia been less cooperative and he felt that a
credible threat still existed, enlisting the support of the authorities may have been
necessary.
Summary
This training material discussed many of the legal and ethical issues related to
supporting victims of domestic abuse. While clinicians cannot be experts on all
facets of domestic violence competent care is grounded in the ethics and
standards of the profession. Mental Health professionals need to be aware of
ethical and legal standards and they also need to develop and maintain the
professional skills necessary to work with victims and families affected by
domestic violence.

________________________________________________________________
Appendix
Domestic Violence Safety Plan
Victims of domestic violence need to plan in advance for safety. The following
considerations are important ones, and can be discussed in a therapy session.
Things to think about and have ready:
1. Important phone numbers. These may include hotlines, clergy, school

contacts, friends and the local domestic violence resources and shelters.
2. Friends or neighbors that could seek help on your behalf. Ask them to call
the police if they hear angry or violent noises. If you have children, teach
them how to dial 911. Make up a code word that you can use when you
need help.
3. Safe exit from home. Practice ways to get out quickly if need be.
4. Safer places within home. Think about places where victims can go to be
away from the abuser.
5. Remove all weapons from the house if possible.
6. Even if clients are not open to the idea of leaving, it is still important to,
have them consider where they could go. An exit strategy is also helpful.
This strategy may involve a way to leave the house, such as walking the
dog or going to the store. It is also helpful to have a bag of everyday items
packed, but well hidden.
7. Encourage clients to go over their safety plan often.
Other considerations:
1. Have clients think of three or four places they could go if they leave home.
2. Have clients think about people who might help if they left. These may
include people who could keep a bag for them, who could loan them
money, or who could help with children. It is also important to make plans
for pets.
3. Clients may consider getting a prepaid cell phone to pack in a bag.
4. Clients may consider opening a bank account or getting a credit card in
their name only.
5. Clients should consider issues regarding children. There may be times
when it is safer to leave without children.
Things to take
Order of protection
Money
Keys to car, house, work

________________________________________________________________
Extra clothes
Medicine
Important papers
Birth certificates
Social security cards
School and medical records
Bankbooks, credit cards
Driver's license
Car registration
Welfare identification
Passports, green cards, work permits
Lease/rental agreement
Pictures, jewelry, things that are meaningful
Items for children (toys, blankets, etc.)

________________________________________________________________
States with Mandatory Arrest Provisions
Alaska Probable cause to believe that a crime

of domestic violence was committed
within past 12 hours.
Arizona Domestic violence involving infliction of
physical injury or use/threatening use
deadly weapon.
Colorado Probable cause to believe a crime of
domestic violence was committed.
Connecticut Speedy information that family violence
was committed in jurisdiction.
District of Columbia Probable cause to believe that an
intrafamily offense was committed that
resulted in physical injury including
pain or illness or caused or was
intended to cause reasonable fear of
imminent serious physical injury or
death.
Iowa Probable cause to believe that
domestic abuse assault committed that
resulted in bodily injury, or was
committed with intent to inflict serious
injury, or with use or display of
dangerous weapon.
Kansas Probable cause to believe a crime has
been committed.
Louisiana Reason to believe family or household
member has been abused and (1)
probable cause exists to believe that
aggravated/second degree battery was
committed or (2) aggravated or simple
assault or simple battery committed
and reasonable belief in impending
danger to abused.
Maine Probable cause to believe there has
been a violation of aggravated assault
statute between members of same
family or household.
Mississippi Probable cause to believe that within
24 hours offender knowingly committed
a misdemeanor act of domestic
violence.
Missouri Called to same address within 12 hours

________________________________________________________________
and probable cause to believe same

offender has committed abuse or
assault against same or other
family/household member.
Nevada Probable cause to believe that within
24 hours battery was committed.
New Jersey Probable cause to believe that
domestic violence has occurred and
either victim shows signs of injury or
probable cause that a weapon was
involved.
New York Probable cause to believe a felony has
been committed against a member of
the same family or household or,
unless victim requests otherwise, a
misdemeanor family offense
committed.
Ohio Reasonable cause to believe that
offender committed felonious assault.
Oregon Probable cause to believe that a
felonious assault or an assault resulting
in injury occurred or action has placed
another to reasonably fear imminent
serious bodily injury or death.
Rhode Island Probable cause to believe the
following: felonious assault: assault
resulting in injury: action was intended
to cause fear of imminent serious
bodily injury or death.
South Carolina If physical injury is present and
probable cause to believe person is
committing or has freshly committed a
misdemeanor/felony assault or battery.
South Dakota Probable cause to believe that within
previous 4 hours, there has been an
aggravated assault, an assault
resulting in bodily injury, or an attempt
by physical menace to place in fear of
imminent serious bodily injury.
Utah Probable cause to believe that an act
of domestic violence was committed
and there will be continued violence or
evidence perpetrator has recently
caused serious bodily injury or used a
dangerous weapon.
Virginia Probable cause to believe assault or

________________________________________________________________
battery on family or household

member.
Washington Probable cause to believe a person 16
years or older within the previous 4
hours assaulted a family or household
member and believes (1) felonious
assault occurred, or (2) assault
resulting in bodily injury occurred
whether injury is visible or not, or (3)
any physical action occurred which was
imminent serious bodily injury or death.
Wisconsin Probable cause to believe a person 16
years or older within the previous 4
hours assaulted a family or household
member and believes (1) felonious
assault occurred, or (2) assault
resulting in bodily injury occurred
whether injury is visible or not, or (3)
any physical action occurred which was
imminent serious bodily injury or death.
Coded Relationships: (A) current/former spouse, (B) current/former cohabitant,
(C ) child in common, (D) Dating relationship, (E) related by marriage or blood
Source: U.S. Department of Justice

________________________________________________________________
References
APA Online (n.d.). Violence and the Family: Report of the APA Presidential Task
Force on Violence and the Family -- Executive Summary. Retrieved June 13,
2012 from http://www.nnflp.org/apa/APA_task_force.htm
Bloom, S. (1997). Creating sanctuary. New York: Routledge.
Buel, S.M. & Hirst, E.M. (2009). Obstacles and Remedies for Criminal and Civil
Justice for Victims of Intimate Partner Violence. In C. Mitchell and D. Anglin
Intimate Partner Violence. New York: Oxford.
Campbell, J. et al. (2003). Assessing risks for intimate partner homicide. National
Institute of Justice, 250, 14-19.
Catalano, S., Smith, E., Snyder, H., & Rand, M. Female victims of violence
(2009). Retrieved June 9, 2012 from http://www.ojp.usdoj.gov/bjs/ abstract/fvv.fm
Clinical Lawyer (n.d.). Confidentiality versus privilege: What is the difference?

http://clinicallawyer.com/2007/04/confidentiality-vs-privilege-what-is-the-
difference/
Devries, K. et al. (2011). Violence against women is strongly associated with

suicide attempts: evidence from the WHO multi-country study on women's health
and domestic violence against women. Social Science Medicine, 73(1):79-86.
Family Violence Prevention Fund (n.d.). Advocacy Matters: Helping others and
their Children Involved with the Child Protection System.
Herman, J. (1992/1997). Trauma and recovery. New York: Basic Books.
National Association of Social Workers (NASW). Code of ethics. Retrieved

August 2, 2012 from http://www.naswdc.org/pubs/code/code.asp
National Association of Social Workers (NASW). Social workers and duty to warn
state laws. Retrieved August 8, 2012 from
http://www.socialworkers.org/ldf/legal_issue/2008/200802.asp?back=yes
Pass, S. (2007). Child abuse and neglect: Knowing when to intervene. Kappa
Delta Pi Record, 133-138.
Polowy, C. and Gorenberg, C. (1997). Client confidentiality & privileged

communications, NASW General Counsel Law Note Series. Washington,
DC.

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Smith, S. (2007). Mandatory reporting of child abuse. Retrieved September 21,

2008 from http://www.smith-lawfirm.com/mandatory_reporting.htm
Tarasoff v. Regents of the University of California, 551 P.2d 334 (1976).
Tjaden, P. & Thoennes, N. (2000). National Institute of Justice and the Centers of
Disease Control and Prevention, Extent, Nature and Consequences of Intimate
Partner Violence: Findings from the National Violence Against Women Survey.
U.S. Department of Justice, Bureau of Justice Statistics, Intimate Partner

Violence in the United States, December 2006.
Wilson, K.J. & Martin, D. (2006). When violence begins at home. New York:
Hunter House.

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Spousal or Partner Abuse, 1

Chapter 1: Introduction and Theories

The National Coalition Against Domestic Violence defines domestic violence as

This course will provide an introduction to domestic violence, including

Upon completion of this chapter you will be able to:

1. Define domestic violence and the term intimate partner.

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Defining Domestic Violence

Domestic violence is often called battering or wife beating, however, domestic

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Examples of domestic violence include (Berry, 2000):

Intimidation or emotional abuse. Emotional abuse (also called

Economic or financial abuse. Abusive partners may use access to

Sexual abuse is any situation in which force or threat is used to obtain

Stalking can be defined as the willful and repeated following, watching

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Nearly 60 percent of women and 30 percent of men are stalked by a

As in the case vignette, stalking can be seen as "a course of conduct

With increasing use of technology, cyberstalking has become more

Like other forms of domestic violence, stalking usually escalates. It is a

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Prevalence of Domestic Violence

How widespread is domestic violence? Domestic violence is one of the most

Some of the key findings are:

Physical assault is widespread among adults: An estimated 1.9 million

Approximately 1.3 million women and 835,000 men are physically

Violence against women is primarily intimate partner violence: 64.0

Stalking is more prevalent than previously thought: 8.1 percent of

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Almost one-third of female homicide victims that are reported in police

Theories on Domestic Violence

Group Population studied Conceptualization

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Although many of these systems may seem to offer contradictory views of

Social Learning Theory

Although the relationship is not entirely straightforward, there does seem to be

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adults. Women who were physically or sexually abused as children, however,

Cognitive-Behavioral theorists look at how a person perceives, interprets, and

A common CBT intervention is an anger log. This log encourages individuals to

Feminist/Domestic Violence Movement Framework

Emphasis on the importance of addressing domestic violence dates to the 1970s,

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As an outgrowth of other research, domestic violence professionals have

Jealousy History of past battering

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Cruelty to animals or children Extreme highs and lows

In addition to identifying the characteristics of abusive men, domestic violence

Tension Building Phase

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The Socio-Ecological Model

The Socio-Ecological Model (Heise, 1998) attempts to integrate many of these

When applied to domestic violence prevention, this framework allows for

Warning Signs of Abuse

Psychological warning signs of abuse

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General warning signs of domestic abuse

Warning signs of physical abuse

Warning signs of isolation

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Alabama Coalition Against Domestic Violence. Why do abusers batter?

Crowell, N.A. (1996). Understanding violence against women. Washington, D.C.:

Domestic Violence Group Action Project. Domestic violence: Theories of