Professional Documents
Culture Documents
Spousal Abuse Material
Spousal Abuse Material
________________________________________________________________
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.
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.
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.
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
domestic violence and the shame that men may feel in identifying themselves as
abuse survivors.
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.
Case Vignette
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.
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.
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.
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.
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).
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).
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
Cognitive-Behavioral Theories
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.
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.
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.
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.
Integrative Models
The following warning signs may alert practitioners to the possibility of abuse.
References
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.
Dollard, J. et. al., (1939). Frustration and aggression. New Haven: Yale
University Press.
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.
Gelles, R.J. & Straus, M.A. (1988). Intimate violence. New York: Simon and
Schuster.
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.
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.
Walker, L.E. (1979) The Battered Woman. New York: Harper and Row.
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
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.
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
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
Each of the following criteria must have been met, with individual
symptoms occurring at any time during the course of the
disturbance.
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
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.
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
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.
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.
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.
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
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).
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
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.
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.
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 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).
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.
of the descriptors on the wheel mirror the Domestic Violence Wheel (see
Introduction to Domestic Violence).
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).
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
Emotional
Behavioral
Social
Physical
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.
References
Bonomi, A.E., Thompson, R.S., & Anderson, M. (2006). Intimate partner violence
and womens physical, mental, and social functioning. American Journal of
Preventive Medicine, 30(6), 458-466.
Briere, J., Woo, R., McRae, B., Foltz, J., and Sitzman, R. (1997). Lifetime
victimization history, demographics, and clinical status in female psychiatric
emergency room patients. Journal of Nervous and Mental Disorders 185, 95-101.
Bryer, J. B., Nelson, B. A., Miller, J. B., and Krol, P. A. (1987). Childhood sexual
and physical abuse as factors in adult psychiatric illness. American Journal of
Psychiatry 144, 1426-1430.
Coker, A.L., Davis, K.E. & Arias, I. (2002). Physical and mental health effects of
intimate partner violence. American Journal of Preventive Medicine, 23(4), 260-
268.
Fantuzzo, J., Boruch, R., Beriama, A., Atkins, M., & Marcus, S. (1997). Do-
mestic violence and children: Preva- lence and risk in five major U.S. cities.
Journal of the American Academy of Child and Adolescent Psychiatry, 36, 116-
122.
Friedman, S.H. & Lou, S. (2007). Incidence and prevalence of intimate partner
violence by and against women with severe mental illness. Journal of Womens
Health, 16(4), 471-480.
Kaufman, J., & Henrich, C. (2000). Exposure to violence and early childhood
trauma. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed.) (pp.
195-207). New York: The Guilford Press.
Kemp, A. Rawlings, E.I. & Green, B.L. (1994). Posttraumatic Stress Disorder in a
Battered Womens Shelter, Journal of Traumatic Stress, 1991(4), 137-148.
Lutenbacher, M., Cohen, A., & Conner, N. M. (2004). Breaking the cycle of fam-
ily violence: Understanding the perceptions of battered women. Journal of
Pediatric Health Care, 18, 236-242.
Ornduff, S. R., Kelsey, R. M., & OLeary, D. (2001). Childhood physical abuse,
personality, and adult relationship vio lence: A model of vulnerability to
victimization. American Journal of Orthopsychiatry, 71, 322-331.
Peedicayil, A., Sadowski, L.S., Jeyasee-lan, L., Shankar, V., Jain, D., Suresh, S.,
et al. (2004). Spousal physical violence against women during pregnancy. BJOG,
111, 682-687.
Scholle, S. H., Rost, K. M., and Golding, J. M. (2008). Physical abuse among
depressed women. Journal of General Internal Medicine 13, 607-613.
Surrey, J., Swett, C., Jr., Michaels, A., and Levin, S. (1990). Reported history of
physical and sexual abuse and severity of symptomatology in women psychiatric
outpatients. American Journal of Orthopsychiatry 60, 412-417.
Street, A. E., and Arias, I. (2001). Psychological abuse and posttraumatic stress
disorder in battered women: examining the roles of shame and guilt. Violence
and Victims 16, 65-78.
Woods, S.J. & Wineman, N.M. (2004). Trauma, posttraumatic stress disorder
symptom clusters and physical health symptoms in postabused women. Archives
of Psychiatric Nursing, 18, 26-34
Introduction
Case Vignettes
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.
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.
This course will examine the issue of intimate partner sexual abuse. Upon
completion of this chapter you will be able to:
of inquiry and the questions included in research, affect the wording of questions
and guide sample selection.
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
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.
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:
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).
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).
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
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.
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.
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.
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.
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.
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.
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.
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.
REFERENCES
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
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 Violence Against Women Survey (1996). Downloaded May 3, 2012 from
http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/datasources.html
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.
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:
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
3. Discuss domestic violence in later life, including factors that may play a role
Prevalence
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):
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):
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.
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.
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):
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.
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.
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
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).
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.
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.
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).
Mandated reporting
Please be aware of your states mandated reporting laws, and whether elder
abuse is a mandated reporting issue.
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.
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).
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.
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.
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.
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
National Center on Elder Abuse (2005). Domestic violence: Older women can be
victims too.
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.
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
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.
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.
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.
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?
In contrasting the two cases presented above, its apparent that each of these
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.
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.
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.
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
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).
Therapist: It sounds like even though your husband has hit you, you
love him (reflection/summary).
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: 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.)
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?
Change Talk
Change talk is divided in five categories: Desire, Ability, Reason, Need, and
Commitment:
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.
Tom: I know that I get really angry sometimes. All the men in my
family have tempers.
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.
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).
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
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).
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?
Summary
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.
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.
Murphy, C.M. & Maiuro, R.D. (2009). Motivational interviewing and stages of
change in intimate partner violence. New York: Springer Publishing.
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.
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.
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.
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.
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
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.
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.
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.
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,
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):
Assessing Safety
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.
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
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
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.
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.
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.
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:
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
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.
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.
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:
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.
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.
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
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
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
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:
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
Departments of Health
These systems include direct medical services. Rape crisis centers are also
housed within departments of health. These systems generally also provide
direct crisis counseling.
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:
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.
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.
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.
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
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.
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.
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):
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.
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
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.
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.)
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
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
Family Violence Prevention Fund (n.d.). Advocacy Matters: Helping others and
their Children Involved with the Child Protection System.
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.
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.
Wilson, K.J. & Martin, D. (2006). When violence begins at home. New York:
Hunter House.