The Common Clinical Problem of Adult Intimate The Common Clinical Problem of Adult Intimate Partner Violence:Partner Violence:

Learning How to Incorporate Routine AssessmentsLearning How to Incorporate Routine AssessmentsInto Your PracticeInto Your Practice

Kathy McCloskeyKathy McCloskeyUniversity of HartfordUniversity of Hartford

Graduate Institute of Professional PsychologyGraduate Institute of Professional Psychology200 Bloomfield Avenue200 Bloomfield Avenue

West Hartford, CT 06177West Hartford, CT 06177860.768.4442860.768.4442

mccloskey@hartford.edumccloskey@hartford.eduhttp://kathymccloskey.net/http://kathymccloskey.net/

APA-Approved Pre-Conference Workshop (4 CEUs)APA-Approved Pre-Conference Workshop (4 CEUs)33rd Annual Conference of the Association for Women in Psychology 33rd Annual Conference of the Association for Women in Psychology

(AWP)(AWP)March 13, 2008March 13, 2008San Diego, CASan Diego, CA

Over a decade ago, Harway & Hansen (1993) and Hansen, Over a decade ago, Harway & Hansen (1993) and Hansen, Harway, & Cervantes (1991) showed that therapists were Harway, & Cervantes (1991) showed that therapists were not effective in identifying intimate partner violence (IPV) not effective in identifying intimate partner violence (IPV) issues using a clinical case vignette.issues using a clinical case vignette.

The case vignette was modeled after a real-life scenario The case vignette was modeled after a real-life scenario where the male partner in the couple ultimately raped and where the male partner in the couple ultimately raped and then killed his female partner (see below).then killed his female partner (see below).

In their findings, Harway and colleagues found that In their findings, Harway and colleagues found that psychologists addressed conflict in the vignette only about psychologists addressed conflict in the vignette only about half of the time, while other mental health therapists did so half of the time, while other mental health therapists did so only about 38% of the time.only about 38% of the time.

Overall, 40% of all therapists in their sample failed to Overall, 40% of all therapists in their sample failed to address conflict at all.address conflict at all.

Lethality was not once addressed by therapists in their Lethality was not once addressed by therapists in their sample.sample.

The Need for Training in IPV

Case VignetteCase Vignette Carol and James have been married 10 years. They have two Carol and James have been married 10 years. They have two

children: Dana, 9, and Tracy, 7. James is employed as a foreman in children: Dana, 9, and Tracy, 7. James is employed as a foreman in a concrete manufacturing plant. Carol is also employed. James is a concrete manufacturing plant. Carol is also employed. James is upset because on several occasions Carol did not return home from upset because on several occasions Carol did not return home from work until two or three in the morning and did not explain her work until two or three in the morning and did not explain her whereabouts to him. He acknowledges privately to the therapist whereabouts to him. He acknowledges privately to the therapist that the afternoon prior to the session, he had seen her in a bar with that the afternoon prior to the session, he had seen her in a bar with a man. Carol tells the therapist privately that she has made efforts a man. Carol tells the therapist privately that she has made efforts to dissolve the marriage and to seek a protection order against her to dissolve the marriage and to seek a protection order against her husband because he has repeatedly been physically violent with her husband because he has repeatedly been physically violent with her and the kids and on the day prior, he grabbed her and threw her on and the kids and on the day prior, he grabbed her and threw her on the floor in a violent manner and then struck her. The family had the floor in a violent manner and then struck her. The family had made plans to go shopping, roller skating, and out to dinner after made plans to go shopping, roller skating, and out to dinner after the session.the session.

Initial questions included the following:Initial questions included the following:1.1. What is going on in this familyWhat is going on in this family? ? 2.2. Using the most recent version of the DSM, what diagnosis Using the most recent version of the DSM, what diagnosis

would you makewould you make? ? 3.3. How would you interveneHow would you intervene? ? 4.4. What outcome would you expect from your interventionWhat outcome would you expect from your intervention? ? 5.5. What are the legal/ethical issues raised by this caseWhat are the legal/ethical issues raised by this case??

The Need for Training (cont.)The Need for Training (cont.)

Since the studies by Harway and colleagues, IPV and Since the studies by Harway and colleagues, IPV and domestic violence issues in general have become domestic violence issues in general have become more visible within society as well as the mental more visible within society as well as the mental health professions.health professions.

For instance, child abuse and neglect and elder For instance, child abuse and neglect and elder abuse have become important ethical issues, abuse have become important ethical issues, especially since the advent of mandatory reporting especially since the advent of mandatory reporting statutes.statutes.

It is expected that, over a decade later, mental It is expected that, over a decade later, mental health service providers would be able to identify the health service providers would be able to identify the issues surrounding IPV in a more effective manner.issues surrounding IPV in a more effective manner.

Indeed, this is what Raphael, McCloskey, & Kustron Indeed, this is what Raphael, McCloskey, & Kustron (in press) found recently when they replicated (in press) found recently when they replicated Harway and colleagues’ study.Harway and colleagues’ study.

The Need for Training (cont.)The Need for Training (cont.)

Even though almost 85% of today’s clinicians Even though almost 85% of today’s clinicians identified the conflict as the main focus of identified the conflict as the main focus of treatment, treatment, only one only one identified lethality as a possible identified lethality as a possible outcome of the scenario.outcome of the scenario.

Only about Only about half half of today’s clinicians suggested crisis of today’s clinicians suggested crisis intervention (including basic safety planning) of any intervention (including basic safety planning) of any sort as the intervention of choice.sort as the intervention of choice.

Because of this, it is important that clinicians Because of this, it is important that clinicians become more aware of the issues surrounding IPV become more aware of the issues surrounding IPV for all clients.for all clients.

Indeed, as will be shown below, Indeed, as will be shown below, clinicians should clinicians should expect and plan to deal with clients expect and plan to deal with clients that are that are presenting with IPV issues (either from the past, or presenting with IPV issues (either from the past, or in their lives now).in their lives now).

BackgroundBackground

Prevalence and Severity: Gender AsymmetryPrevalence and Severity: Gender Asymmetry

IPV victimization is primarily a genderized IPV victimization is primarily a genderized phenomenon – that is, women are disproportionately phenomenon – that is, women are disproportionately victims of IPV and men are disproportionately the victims of IPV and men are disproportionately the perpetrators, resulting in gender asymmetry. perpetrators, resulting in gender asymmetry.

While there have been controversies over IPV gender While there have been controversies over IPV gender asymmetry in the literature (see Malloy, McCloskey, asymmetry in the literature (see Malloy, McCloskey, Grigsby, & Gardner (2003) for a recent review), Grigsby, & Gardner (2003) for a recent review), research overwhelmingly supports the notion that research overwhelmingly supports the notion that women are more negatively impacted when it comes to women are more negatively impacted when it comes to the consequences of IPV. the consequences of IPV.

Regional surveys:Regional surveys: Washington StateWashington State: 23.6% of women reported experiencing IPV : 23.6% of women reported experiencing IPV

compared to 16.4% of men, and 21.6% of women reported compared to 16.4% of men, and 21.6% of women reported experiencing injury during IPV compared to 7.5% of men experiencing injury during IPV compared to 7.5% of men (Washington State Department of Health, 2000).(Washington State Department of Health, 2000).

Gender Asymmetry (cont.)Gender Asymmetry (cont.) South CarolinaSouth Carolina: 25% of women reported a lifetime : 25% of women reported a lifetime

prevalence of IPV at the hands of a partner compared prevalence of IPV at the hands of a partner compared to 13% of men (South Carolina Department of Health to 13% of men (South Carolina Department of Health and Environmental Control, 2000). and Environmental Control, 2000).

U.S. national surveys:U.S. national surveys: National Survey of Families and Households (NSFH)National Survey of Families and Households (NSFH): :

of those injured as a result of IPV, 73% were women and 27% of those injured as a result of IPV, 73% were women and 27% were men (Zlotnick, Kohn, Peterson, and Pearlstein, 1998). were men (Zlotnick, Kohn, Peterson, and Pearlstein, 1998).

National Crime Victimization Survey (NCVS)National Crime Victimization Survey (NCVS): : rates of IPV victimization were 7.7 per 1,000 for women but rates of IPV victimization were 7.7 per 1,000 for women but

only 1.5 per 1,000 for men, and that over 50% of female IPV only 1.5 per 1,000 for men, and that over 50% of female IPV victims were injured as a result of IPV (Bureau of Justice victims were injured as a result of IPV (Bureau of Justice Statistics, 1999; Rennison and Welchans, 2000).Statistics, 1999; Rennison and Welchans, 2000).

within this data set the proportion of male homicide victims within this data set the proportion of male homicide victims due to IPV dropped significantly from 1976 to 1998, while the due to IPV dropped significantly from 1976 to 1998, while the proportion of female homicide victims increased.proportion of female homicide victims increased.

Gender Asymmetry (cont.)Gender Asymmetry (cont.) National Violence Against Women Survey (NVAWS)National Violence Against Women Survey (NVAWS): :

lifetime prevalence of physical assault and/or rape at the hands lifetime prevalence of physical assault and/or rape at the hands of an adult intimate was 25% for women and 7.6% for men; men of an adult intimate was 25% for women and 7.6% for men; men reported virtually no sexual violence in this sample. reported virtually no sexual violence in this sample.

45% of women versus 20% of men reported fear of serious injury 45% of women versus 20% of men reported fear of serious injury or death at the hands of an intimate partner.or death at the hands of an intimate partner.

women sustained injury, required medical treatment, were women sustained injury, required medical treatment, were hospitalized, sought mental health treatment, lost work time, hospitalized, sought mental health treatment, lost work time, reported IPV to the police, and obtained a protection order at reported IPV to the police, and obtained a protection order at greater rates than did men. greater rates than did men.

women were 22.5 times more likely to be raped than men, 8.2 women were 22.5 times more likely to be raped than men, 8.2 times more likely to be stalked, and 2.9 times more likely to be times more likely to be stalked, and 2.9 times more likely to be physically assaulted by an intimate partner than men. physically assaulted by an intimate partner than men.

11% of women co-habiting with women experienced IPV 11% of women co-habiting with women experienced IPV compared with 30.4% of women co-habiting with men, and 7.6% compared with 30.4% of women co-habiting with men, and 7.6% of men co-habiting with women experienced IPV compared with of men co-habiting with women experienced IPV compared with 15% of men co-habiting with men -- co-habiting with a male 15% of men co-habiting with men -- co-habiting with a male increased the risk of IPV for both men and women (Tjaden & increased the risk of IPV for both men and women (Tjaden & Thoennes, 2000a; 2000b).Thoennes, 2000a; 2000b).

Gender in the Therapy Room:Gender in the Therapy Room:Clients Are Most Likely Women and Women Are Most Likely Clients Are Most Likely Women and Women Are Most Likely

Survivors of IPVSurvivors of IPV

Because most recent research suggests that about one-quarter Because most recent research suggests that about one-quarter of all women in the U.S. have been victims of IPV at some time of all women in the U.S. have been victims of IPV at some time in their lives, in their lives, service providers should not only expect but service providers should not only expect but prepare for women presenting with problems directly related to prepare for women presenting with problems directly related to IPVIPV. .

This is especially important because women tend to access This is especially important because women tend to access mental health services at greater rates than men (Addis & mental health services at greater rates than men (Addis & Mahalik, 2003; Mahalik, Good, & Englar-Carlson, 2003; Rhodes, Mahalik, 2003; Mahalik, Good, & Englar-Carlson, 2003; Rhodes, Goering, To, and Williams, 2002).Goering, To, and Williams, 2002).

Possible reasons for this gender discrepancy? Possible reasons for this gender discrepancy? impact of male gender roles (the strong, stoic, silent type) on impact of male gender roles (the strong, stoic, silent type) on

help-seeking behavior.help-seeking behavior. the inhibition of emotional awareness needed to identify and the inhibition of emotional awareness needed to identify and

own a personal problem (e.g., Moeller-Leimkuehler, 2002). own a personal problem (e.g., Moeller-Leimkuehler, 2002).

Contextualization: Psychological Effects of IPV Contextualization: Psychological Effects of IPV VictimizationVictimization

Walker (1994) and Herman (1992) provided reviews of Walker (1994) and Herman (1992) provided reviews of the literature showing that up to 60% of women the literature showing that up to 60% of women seeking mental health services also had a history of seeking mental health services also had a history of physical abuse, although they tended not to be physical abuse, although they tended not to be diagnosed or treated specifically for IPV.diagnosed or treated specifically for IPV.

Walker (1994) suggests that the historical Walker (1994) suggests that the historical “invisibility” of victimization within the mental health “invisibility” of victimization within the mental health field is because providers field is because providers simply do not ask questions.simply do not ask questions.

If the context of IPV is absent, the psychological If the context of IPV is absent, the psychological sequelae of IPV in women masquerade as mental sequelae of IPV in women masquerade as mental health symptoms which can lead providers to health symptoms which can lead providers to misdiagnose. misdiagnose.

Thus, clinicians must put the CONTEXT back Thus, clinicians must put the CONTEXT back into IPV by providing a complete and thorough into IPV by providing a complete and thorough assessment.assessment.

Contextual Factors and Possible Mental Contextual Factors and Possible Mental Health SequelaeHealth Sequelae

FearFear In couples reporting IPV, women exhibit significantly more fear In couples reporting IPV, women exhibit significantly more fear

of their partners than did males. of their partners than did males. Both men and women report that, overall, men are not fearful of Both men and women report that, overall, men are not fearful of

their female partners and tend to laugh or make fun of women’s their female partners and tend to laugh or make fun of women’s aggression.aggression.

On the other hand, women report significant long-term levels of On the other hand, women report significant long-term levels of fear toward their male partners (Cantos, Neidig, & O’Leary, fear toward their male partners (Cantos, Neidig, & O’Leary, 1994; Dasgupta, 1999).1994; Dasgupta, 1999).

Mental Health SymptomsMental Health Symptoms Traumatic brain injury due to repeated physical assaults may Traumatic brain injury due to repeated physical assaults may

present as cognitive deficits (e.g., Jackson, Philp, Nuttall, & present as cognitive deficits (e.g., Jackson, Philp, Nuttall, & Diller, 2002).Diller, 2002).

Elevated scores on standard personality assessment tools may Elevated scores on standard personality assessment tools may be found (e.g., Morrell & Rubin, 2001). be found (e.g., Morrell & Rubin, 2001).

The psychological sequelae of IPV in women can present as The psychological sequelae of IPV in women can present as “cognitive disturbances, high avoidance or depression “cognitive disturbances, high avoidance or depression behaviors, and high arousal or anxiety disturbances” (Walker, behaviors, and high arousal or anxiety disturbances” (Walker, 1994, pg. 70).1994, pg. 70).

Contextual Factors (cont.)Contextual Factors (cont.)

Bloom & Reichert (1999), Herman (1992), and Walker Bloom & Reichert (1999), Herman (1992), and Walker (1994) have documented the following symptoms that may (1994) have documented the following symptoms that may arise as a result of IPV victimization: arise as a result of IPV victimization:

cognitive attentional deficits that may bring about a dissociative cognitive attentional deficits that may bring about a dissociative state, state,

a chronically pessimistic cognitive style sometimes linked to a chronically pessimistic cognitive style sometimes linked to depressive presentations, depressive presentations,

neurological deficits as a result of repeated head beatings and head neurological deficits as a result of repeated head beatings and head shaking, shaking,

avoidance behaviors including seclusion/isolation, denial, avoidance behaviors including seclusion/isolation, denial, minimization, and repression of traumatic memories, minimization, and repression of traumatic memories,

high arousal symptoms including anxiety, phobias, sleep disorders high arousal symptoms including anxiety, phobias, sleep disorders and nightmares, sexual dysfunctions, panic attacks, nervousness, and nightmares, sexual dysfunctions, panic attacks, nervousness, heart palpations, hypervigilance, hypersensitive startle responses, heart palpations, hypervigilance, hypersensitive startle responses, and obsessive/compulsive behaviors, and and obsessive/compulsive behaviors, and

somatic sequelae from chronic exposure to abuse that can result in somatic sequelae from chronic exposure to abuse that can result in a breakdown of the immunological system, stomach/intestinal a breakdown of the immunological system, stomach/intestinal disease, susceptibility to infection, chronic headaches, and other disease, susceptibility to infection, chronic headaches, and other physical diseases.physical diseases.

Contextual Factors (cont.)Contextual Factors (cont.) Common MisdiagnosesCommon Misdiagnoses

schizophrenia (particularly paranoia)schizophrenia (particularly paranoia) clinical depression clinical depression generalized anxiety disorder generalized anxiety disorder obsessive/compulsive disorder obsessive/compulsive disorder psychosexual disorders psychosexual disorders somatoform disorders somatoform disorders dependent personality disorder dependent personality disorder borderline personality disorder borderline personality disorder all all without regard to the context of abuse (Dienemann et without regard to the context of abuse (Dienemann et

al., 2000; Gleason, 1993; Rathus and Feindler, 2004; al., 2000; Gleason, 1993; Rathus and Feindler, 2004; Walker, 1991; 1994). Walker, 1991; 1994).

Obviously, IPV victimization can lead to Obviously, IPV victimization can lead to psychological symptoms that may be psychological symptoms that may be misdiagnosed if the context of victimization is misdiagnosed if the context of victimization is neither recognized nor understoodneither recognized nor understood..

Summary of Background InformationSummary of Background Information

Victims of IPV are overwhelmingly women, and thus are Victims of IPV are overwhelmingly women, and thus are likely to suffer from psychological symptoms as a result likely to suffer from psychological symptoms as a result of IPV victimization.of IPV victimization.

Women constitute the majority of clients presenting for Women constitute the majority of clients presenting for mental health services.mental health services.

Thus, chances are QUITE HIGH that victims of IPV will Thus, chances are QUITE HIGH that victims of IPV will be on your caseload.be on your caseload.

There are clear, predictable psychological symptoms There are clear, predictable psychological symptoms that result from IPV victimization which may be that result from IPV victimization which may be commonly misdiagnosed by a clinician who does not commonly misdiagnosed by a clinician who does not understand or assess the context of IPV.understand or assess the context of IPV.

It is important that mental health clinicians understand It is important that mental health clinicians understand this shortcoming and educate themselves about IPV so this shortcoming and educate themselves about IPV so that effective assessment, diagnosis, and initial safety-that effective assessment, diagnosis, and initial safety-planning strategies may be used. planning strategies may be used.

IPV Assessment OverviewIPV Assessment Overview

Below is presented a clinical assessment approach based on Below is presented a clinical assessment approach based on conceptual and theoretical issues that heavily emphasize conceptual and theoretical issues that heavily emphasize safety, as well as years of clinical experience within the field of safety, as well as years of clinical experience within the field of IPV.IPV.

It should be noted here that this approach is designed It should be noted here that this approach is designed specifically for use by non-forensic practitioners in the regular specifically for use by non-forensic practitioners in the regular course of therapy and assessment.course of therapy and assessment.

Use in forensic arenas may require a higher level of empirical Use in forensic arenas may require a higher level of empirical support than currently available here.support than currently available here.

This approach would likely be most effective when used for This approach would likely be most effective when used for all all adult clientsadult clients, not just female clients presenting for treatment., not just female clients presenting for treatment.

While it has been shown that women are the most common While it has been shown that women are the most common victims of IPV, men can also be victims -- it is helpful to keep victims of IPV, men can also be victims -- it is helpful to keep this in mind throughout the this in mind throughout the

IPV Assessment FlowchartIPV Assessment Flowchart

Presenting Client(s) – 1st Session.

Individual Couple/Family

A. Screen for Presence of IPV. (see text for explanation)

Yes No

Separate Adults and Interview Each Privately (SAFETY)

Stop IPV Screening Return to IPV

Questions During Later Sessions

Yes No

Full-Scale Assessment of IPV (see text for explanation).

B. History Taking

C. Primary Batterer and Victim Assessment

D. Lethality Assessment

Initial Assessment ScreeningInitial Assessment Screening

Clients presenting for services should be asked a series Clients presenting for services should be asked a series of basic questions related to IPV issues. of basic questions related to IPV issues.

As part of routine clinical practice, adults within couples As part of routine clinical practice, adults within couples or families should be separated and screened privately or families should be separated and screened privately for the presence or absence of IPV issues.for the presence or absence of IPV issues.

It cannot be overstated -- It cannot be overstated -- safetysafety is the reason for is the reason for separating adult partners during couple/family therapy separating adult partners during couple/family therapy for IPV assessment procedures (Rathus & Feindler, for IPV assessment procedures (Rathus & Feindler, 2004).2004).

For some clients, this may be the first disclosure to any For some clients, this may be the first disclosure to any official social agent, and can represent extreme danger official social agent, and can represent extreme danger to the victim (Bograd & Mederos, 1999; Davies, 1994; to the victim (Bograd & Mederos, 1999; Davies, 1994; McCloskey & Fraser, 1997).McCloskey & Fraser, 1997).

Initial Screening (cont.)Initial Screening (cont.) It is not unusual that disclosure by the victim is It is not unusual that disclosure by the victim is

followed by severe levels of violence from the followed by severe levels of violence from the perpetrator.perpetrator.

This crucial safety issue This crucial safety issue mustmust be kept in mind by the be kept in mind by the clinician during the initial contact, as well as throughout clinician during the initial contact, as well as throughout all future contacts with either the victim or perpetrator all future contacts with either the victim or perpetrator (Bograd & Mederos, 1999; Campbell, 2002; Davies, 1994).(Bograd & Mederos, 1999; Campbell, 2002; Davies, 1994).

During the initial contact, if the individual adult denies During the initial contact, if the individual adult denies that IPV is present in her/his life, that IPV is present in her/his life, stopstop the initial screening the initial screening process for that session.process for that session.

However, since many victims (and especially perpetrators) However, since many victims (and especially perpetrators) do not initially admit to IPV when first asked due to do not initially admit to IPV when first asked due to numerous valid reasons such as fear, shame, and guilt numerous valid reasons such as fear, shame, and guilt (Campbell, 2000; 2002), revisiting the screening process (Campbell, 2000; 2002), revisiting the screening process whenever appropriate throughout later sessions is very whenever appropriate throughout later sessions is very helpful. helpful.

Initial Screening (cont.)Initial Screening (cont.)

Relationship content brought up by the client throughout Relationship content brought up by the client throughout later sessions presents an ideal opportunity for the later sessions presents an ideal opportunity for the clinician to once again complete an IPV screening. clinician to once again complete an IPV screening.

Should the client disclose IPV concerns later in therapy, Should the client disclose IPV concerns later in therapy, the full-scale assessment can be completed at that time. the full-scale assessment can be completed at that time.

The IPV screening is a series of questions that asks The IPV screening is a series of questions that asks about arguments between partners that have occurred about arguments between partners that have occurred in a client’s relationship, beginning in a general sense in a client’s relationship, beginning in a general sense and becoming quite specific in terms of partner and and becoming quite specific in terms of partner and client behavior. client behavior.

These questions can be converted into standardized These questions can be converted into standardized interview questionnaires that the clinician follows during interview questionnaires that the clinician follows during session, or can be memorized with practice by the session, or can be memorized with practice by the clinician to eliminate the need for a written format. clinician to eliminate the need for a written format.

Initial Screening (cont.)Initial Screening (cont.)

To save time, some clinicians may be tempted to create a client To save time, some clinicians may be tempted to create a client IPV “paper-and-pencil” screening questionnaire to be filled out IPV “paper-and-pencil” screening questionnaire to be filled out during standard paperwork intake procedures.during standard paperwork intake procedures.

However, it has been shown that clients tend to self-disclose However, it has been shown that clients tend to self-disclose painful and sometimes shameful IPV material at a greater rate painful and sometimes shameful IPV material at a greater rate during face-to-face interviews than on paper-and-pencil during face-to-face interviews than on paper-and-pencil questionnaires (Campbell, 2000; Murphy & O’Leary, 1993). questionnaires (Campbell, 2000; Murphy & O’Leary, 1993).

Thus, the recommendation remains that the screening be Thus, the recommendation remains that the screening be completed interpersonally between therapist and client, completed interpersonally between therapist and client, perhaps supplemented with paper-and-pencil questionnaires.perhaps supplemented with paper-and-pencil questionnaires.

The IPV screening questions given below assume that clients The IPV screening questions given below assume that clients are presently in an intimate relationship with an adult partner. are presently in an intimate relationship with an adult partner. If clients are not in a current relationship, therapists should If clients are not in a current relationship, therapists should still complete the screening because past victimization can still complete the screening because past victimization can influence current psychological symptom presentation and influence current psychological symptom presentation and concerns.concerns.

Screening QuestionsScreening Questions

How do arguments usually begin? Why do you think these arguments keep happening? During your last argument, where were you? (Give as much detail as you can, such as where you were standing and

where your partner was located). How long did the incident last? How did it end? What happened when it was over? During your arguments, did you or your partner ever (be VERY specific):

Slap Grab Punch Kick Bite Push Push to ground Pin to ground/wall Pull hair Hold Twist arm Hit with an object Break objects Tear clothes Throw food Punch fist thru wall Break down door Strangle/choke you Beat up Use gun Use knife Use other weapons Force sexual activities Threaten to hit Threaten to kill Harm/neglect kids Harm/neglect pets Threaten kids/pets Threaten others Threaten suicide

IF CLIENT SAYS THAT NONE OF THE ABOVE VIOLENCE OCCURRED, ask if it has EVER occurred since

the relationship started, or in past relationships.

(a) IF NO, you may end the screening. Go on to the other partner and complete the next screening. (b) IF YES, complete the full-scale assessment (see below).

Full-Scale AssessmentFull-Scale Assessment

Once the therapist has determined there is indeed Once the therapist has determined there is indeed the presence of IPV in a client’s life, a full-scale the presence of IPV in a client’s life, a full-scale IPV assessment can be completed. This IPV assessment can be completed. This assessment consists of three sections:assessment consists of three sections:

History takingHistory taking Determination of the primary batterer and Determination of the primary batterer and

victimvictim Degree of lethality Degree of lethality

These three areas help the clinician assess the These three areas help the clinician assess the frequency, duration, and intensity of IPV as well as frequency, duration, and intensity of IPV as well as possible avenues for effective intervention.possible avenues for effective intervention.

History TakingHistory Taking

History-Taking questions are further History-Taking questions are further grouped into three content areas: grouped into three content areas: (a) IPV across time in context (including (a) IPV across time in context (including

injuries)injuries)

(b) Intervention by others (including the (b) Intervention by others (including the criminal justice system)criminal justice system)

(c) Co-occurrence of drug-use or other (c) Co-occurrence of drug-use or other mental health issuesmental health issues

History Taking: IPV Across TimeHistory Taking: IPV Across Time

What is the FIRST incident you remember? What is the WORST incident you remember? What happened during the MOST RECENT incident? Where there any injuries? If so, to who and what kind?

How were they handled? Where children involved in these incidents, or did they

observe what happened? Where you (or your partner) pregnant during any of

these incidents? Have your (or your partner) ever been stopped from

getting help or accessing emergency services (locked in house, phone pulled from wall, etc.)?

Where you afraid for your safety? Why or why not? Are you (or your partner) currently considering leaving

the relationship? Are you currently separating? If your partner were here, how would he/she describe

the incident(s)?

History Taking: Intervention by OthersHistory Taking: Intervention by Others

Was there any outside intervention during the incident(s)? Did someone try to stop it (children, family, friends, neighbors, police, etc.)?

Have the police ever been called to your home? Why? Were the police called after any of these instances? If yes, have you seen the police report? If I had the police report in front of me,

what would it say? Have you (or your partner) ever been arrested/convicted of domestic violence? If

so, where and when? Have you (or your partner) ever been arrested/convicted for any other criminal

activity? If so, what, where, and when? Have you (or your partner) ever hurt someone or been violent in front of others? If

so, who, where, and when? Have you (or your partner) ever threatened or harassed family members, friends, or

co-workers? If so, who, where, and when? Have you (or your partner) ever obtained a protection order against the other? If so,

where was it obtained, and for what? Have you (or your partner) ever violated a protection order, or ignored the orders of

a police officer, judge, or probation/parole officer? If so, where and when?

History Taking: Mental Health/Substance History Taking: Mental Health/Substance

Abuse IssuesAbuse Issues

Were you (or your partner) drinking or using any other drugs at the time of the incident? If so, what and how much?

Have you (or your partner) ever received treatment for a mental health issue? If so, when was it obtained, and for what (consider obtaining release of information)?

Have you (or your partner) ever received treatment for domestic violence? If so, when and with whom (consider obtaining release of information)?

Have you (or your partner) ever been treated for depression or past suicidal thoughts/ attempts? If so, when, where, and how (consider obtaining release of information)?

Have you (or your partner) ever said you would kill self or others? If so, when, where, and how?

Do you (or your partner) have access to weapons of any sort, or received weapons training in the past?

Determination of Primary Batterer and VictimDetermination of Primary Batterer and Victim

Determining the primary perpetrator and the Determining the primary perpetrator and the victim is sometimes very obvious from the results victim is sometimes very obvious from the results of the initial screening as well as the history of the initial screening as well as the history obtained earlier from portions of the full-scale obtained earlier from portions of the full-scale assessment. assessment.

However, there may be controversy concerning However, there may be controversy concerning the person responsible for the continuing abuse the person responsible for the continuing abuse in the relationship, especially with same-sex in the relationship, especially with same-sex intimate partners, or some opposite-sex partners.intimate partners, or some opposite-sex partners.

Sometimes, determining the pattern of control Sometimes, determining the pattern of control and intimidation becomes difficult. and intimidation becomes difficult.

This section of the full-scale assessment is This section of the full-scale assessment is designed to specifically address this issue. designed to specifically address this issue.

Primary Batterer/Victim (cont.)Primary Batterer/Victim (cont.)

Even though the victim’s identity may be Even though the victim’s identity may be obvious from earlier clinical data, it is still obvious from earlier clinical data, it is still recommended that the following be recommended that the following be completed. completed.

This is so the psychological effects of IPV can This is so the psychological effects of IPV can be more completely described for each client, be more completely described for each client, and to aid in diagnosis. and to aid in diagnosis.

This section provides:This section provides: questions to elicit the way clients attribute questions to elicit the way clients attribute

meaning to the IPV incidents, and meaning to the IPV incidents, and conceptual factors to help the clinician organize conceptual factors to help the clinician organize

each client’s viewpoints and IPV attributions so each client’s viewpoints and IPV attributions so that the primary batterer and victim can more that the primary batterer and victim can more easily be determined.easily be determined.

Primary Batterer/Victim (cont.)Primary Batterer/Victim (cont.)

These conceptual factors are primarily the work of victim These conceptual factors are primarily the work of victim advocates from the Artemis Center for Alternatives to Domestic advocates from the Artemis Center for Alternatives to Domestic Violence (1992) and McCloskey and Fraser (1997) that Violence (1992) and McCloskey and Fraser (1997) that represents a liberal adaptation, integration, and expansion of represents a liberal adaptation, integration, and expansion of their original presentations.their original presentations.

These factors are given so that the clinician may categorize These factors are given so that the clinician may categorize client responses in a reasonable fashion. client responses in a reasonable fashion.

It should be noted that for both primary batterers and victims, It should be noted that for both primary batterers and victims, there are important “exceptions to the rule” for every indicator. there are important “exceptions to the rule” for every indicator.

Thus, therapists may wish to use this information in a check-list Thus, therapists may wish to use this information in a check-list format so that the preponderance of clinical evidence drives format so that the preponderance of clinical evidence drives their determination. their determination.

For example, if a particular client fits a majority of indicators in For example, if a particular client fits a majority of indicators in the victim list, then it bolsters clinician confidence that the the victim list, then it bolsters clinician confidence that the client indeed is the primary victim in the relationship.client indeed is the primary victim in the relationship.

Meaning-Making and Victim/Perpetrator Meaning-Making and Victim/Perpetrator Determination Determination

(adapted from Artemis Center for Alternatives to Domestic Violence, 1992 and (adapted from Artemis Center for Alternatives to Domestic Violence, 1992 and McCloskey and Fraser, 1997)McCloskey and Fraser, 1997)

Since the violence has been going on for a while, what is different right now that you’ve sought help? How is this a problem for you? What do you think has caused the violence? What seems to keep the violence going? What needs to change for the violence to be reduced or solved? What do you think will happen if the violence is not stopped? What do you want to see happen? What is the best/worst that could happen? What would be the long-term result of the best/worst that could happen? What would the best/worst outcome say about you, your partner, your children, your family, etc.? What has been tried to stop the violence? Who tried it? Was it successful? Why or why not? Who else knows about the violence? Why do others know, or why not? If your partner (parents, children, friends, neighbors, etc.) were here, what would she/he say about the violence? Do you think this relationship will continue? How are decisions made in your relationship? What do you expect of your partner? What would happen if you changed your regular role in the relationship? What has been the effect on you?

o Changes in eating, sleeping, weight, activities, energy, anxiety, depression, time alone, work or school activities, friendships, etc.

How do you explain these effects on you? Who is responsible for the violence, as well as the effects on you?

Primary VictimPrimary Victim

Indicator Exceptions Fear – expression of genuine fear of what partner will do next, may give long-standing pattern of living in fear of partner behavior.

Batterers may express fear if believes it will convince others of own victimization, or in presence of victim weapons.

Takes Responsibility – assumes responsibility for partner’s violence: e.g., “I said the wrong thing…I knew not to do that…I started the argument.”

Batterers rarely take initial responsibility although possible in latter stages of treatment.

Admission of Own Violence – admits to own violence in self-defense or retaliation, will also admit to hitting first.

Batterers rarely admit own violent behavior in the absence of confronting evidence.

Pattern of Abuse – usually report numerous violent or abusive incidents and can identity a pattern of escalation and what typically precedes the incidents.

Batterers rarely perceive a pattern unless pointed out by others, cannot identify preceding situations.

Being Threatened – reports that partner has threatened to harm them, children, pets, family members, co-workers, etc.

Batterers may identify partner statements of ending the relationship as a threat, in extremely violent situations the victim may also issue physical threats to the batterer in self-defense.

Primary Victim (cont.)Primary Victim (cont.)

Indicator Exceptions Trauma Effects – reports dissociation, somatic complaints, depression, anxiety, sleep problems, hypervigiliance, startle response, etc.

Batterers rarely report trauma effects unless believes it will convince others of own victimization.

Goal of Services – typical goal is to “stop the abuse” and keep the relationship intact, may wish to access help in getting safe or to leave the relationship.

Batterers rarely address the violence in goal-setting, usually wants help to keep things the same in relationship.

Patterns of Injury – reported injuries are consistent with being attacked by another, black eyes, bruises on head, back, stomach, thighs, upper arms, grip/slap marks on skin, etc.

Batterers easily report injury yet usually of a defensive nature, do not use alone since determination accurate only by comparison to partner injury.

Strangled/Choked – reports of being strangled by partner at some time in relationship are common, visible injury not apparent until a few days later (if ever) while there is the report of defensive injuries on batterer.

Batterers rarely report being strangled/choked by victims.

Primary Victim (cont.)Primary Victim (cont.)

Indicator

Exceptions

Admission of Arrests – victims will admit criminal history and give details, can describe socially unacceptable behaviors towards police during incident that may have led to arrest (for women, there may have been a gender bias operating at time of arrest)

Batterers rarely admit to criminal history, exceptions include justification for own violence or victim use of weapons.

Criminal Investigation Sounds Incomplete – if applicable, arrest of a victim usually results from the lack of a full narrative, incomplete evidence, failure to interview witnesses.

Batterers may also report or show incomplete investigative reports, thus do not use alone.

Primary BattererPrimary BattererIndicator Exceptions

Calm, Cool, and Collected – overly calm, confident, no fear or apprehension about violent incident (or court process, if applicable).

Victims may dissociate or present with little or no emotion. Cultural barriers can also cause this.

Vague Accounts and Inconsistent Chronologies – vague generalized accounts lacking in detail, timelines that do not hold, may say: “Partner just acts crazy.”

Victims may have memory impairment or under the influence at time of incident. Cultural barriers may also result in reduced disclosure.

Denial – outright denial of violence against partner.

Victims may deny presence of violence due to fear, shame, guilt, etc.

Minimization – if confronted with evidence of own violent behavior, will minimize the impact: “I didn’t do it, but if I did it was no big deal” or “I may have put my hands around partner’s neck, but didn’t squeeze.”

Victims rarely deny their own retaliatory or self-defensive violence.

Persuasion – try to convince clinician they are the injured party, ally with therapist, and sometimes ingratiate with “wink and nod” presentations.

Victims beginning to understand their victimization or who blame themselves may also do this.

Primary Batterer (cont.)Primary Batterer (cont.)Indicator

Exceptions

Angry/Demeaning – aggressively criticize partner, name-call, refer to partner in demeaning ways.

Victims fully experiencing anger may do this, although rare.

Ownership of Partner – conveys strong sense of ownership, jealousy, and/or obsession concerning partner.

Victims may feel these things, and should not be considered alone.

Revenge – focused on extra-marital affairs, child custody, money issues, may be smug/gloat over negative results of violence against partner (including criminal charges), ulterior motives common.

Victims may sometimes focus on infidelity or express fears around child custody (especially perpetrator threats to remove children).

Power and Control – states power and control over partner (makes decisions, controls money, sets relationship rules and enforces those rules, etc.).

Victims may control some parts of relationship, or over-report control to feel safe or due to cultural norms (i.e., need to appear “tough”).

Goals of Therapy – to get partner to do what client wants but not necessarily to reduce violence, wants help in convincing partner to stay in relationship, wants to maintain “status quo” in relationship without getting in legal trouble.

Victims may also want help in keeping relationship intact, but also wants violence to stop.

Primary Batterer (cont.)Primary Batterer (cont.)

Indicator

Exceptions

Size Difference Inconsistent With Facts – reports IPV incident inconsistent with their size or that of their partner.

Never use size differential alone, especially with same-sex partners and in instances with weapon use.

Defensive Injuries – scratches around arms/hands, bruised hands/feet, compared to injuries of other partner.

Must be compared to injuries reported from other partner, and cannot be considered alone.

Criminal Record or Court Knowledge – history of arrest/conviction and/or violating court orders, very familiar with the justice system, vague in describing criminal history while partner knows history well.

Some victims have been arrested even though acting in self-defense, and thus know the court system.

Lethality AssessmentLethality Assessment

For safety reasons, the lethality assessment For safety reasons, the lethality assessment mustmust be be completed in every reported instance of IPV, and completed in every reported instance of IPV, and should be updated throughout the course of should be updated throughout the course of treatment (i.e., when new information comes to treatment (i.e., when new information comes to light due to periodic therapist inquiry and/or light due to periodic therapist inquiry and/or spontaneous client self-disclosure). spontaneous client self-disclosure).

Lethality is grouped into six content areas: Lethality is grouped into six content areas:

(a) severity of violence (a) severity of violence (b) obsessive/stalking behaviors (b) obsessive/stalking behaviors (c) psychological risk factors (c) psychological risk factors (d) other criminal behaviors (d) other criminal behaviors (e) failure of past interventions (e) failure of past interventions (f) other (f) other

Lethality Assessment (cont.)Lethality Assessment (cont.)

A predominance of risk factors should help the A predominance of risk factors should help the therapist determine the severity of the situation and therapist determine the severity of the situation and the urgency with which she or he must act. the urgency with which she or he must act.

This lethality assessment is liberally adapted from This lethality assessment is liberally adapted from victim advocacy work (Artemis Center for Alternatives victim advocacy work (Artemis Center for Alternatives to Domestic Violence, 1992), results of community to Domestic Violence, 1992), results of community collaboration within the state of Ohio (Montgomery collaboration within the state of Ohio (Montgomery County Criminal Justice Council, 1996), and empirical County Criminal Justice Council, 1996), and empirical research in the field (e.g., Campbell, 2002).research in the field (e.g., Campbell, 2002).

Besides the standard homicidal/suicidal risk Besides the standard homicidal/suicidal risk assessment items such as intent, plan, time, place, assessment items such as intent, plan, time, place, and means (Bennett, 2003; Sanchez, 2001; and means (Bennett, 2003; Sanchez, 2001; Shneidman, 2001), there are other lethality “red flags” Shneidman, 2001), there are other lethality “red flags” unique to IPV.unique to IPV.

RED FLAGSRED FLAGS

The following batterer behaviors and beliefs should alert the The following batterer behaviors and beliefs should alert the clinician to the clinician to the presence of extreme risk of lethal violencepresence of extreme risk of lethal violence in in order of importance (Campbell, 2002; Kropp & Hart, 1997; order of importance (Campbell, 2002; Kropp & Hart, 1997; McFarlane, Campbell, & Watson, 2002): McFarlane, Campbell, & Watson, 2002):

(a)(a) batterer perception that relationship is threatened and/or ending batterer perception that relationship is threatened and/or ending (infidelity, separation, divorce, etc.) (infidelity, separation, divorce, etc.)

(b)(b) past/present threats by batterer to kill self or partner (including past/present threats by batterer to kill self or partner (including statements such as: “I can’t live without you” and “If I can’t have statements such as: “I can’t live without you” and “If I can’t have you, no one will”)you, no one will”)

(c)(c) batterer unemployment (suggests that batterer has “nothing to batterer unemployment (suggests that batterer has “nothing to lose”)lose”)

(d)(d) past/present batterer violence, including attempted strangulation of past/present batterer violence, including attempted strangulation of victimvictim

(e)(e) batterer stalking and monitoring behaviorbatterer stalking and monitoring behavior

(a)(a) batterer drug/alcohol use batterer drug/alcohol use

IMPORTANT!IMPORTANT!

The presence of The presence of even one of these factorseven one of these factors (especially separation or divorce) is a (especially separation or divorce) is a sign that the clinician needs to be highly sign that the clinician needs to be highly wary of future lethal violence and provide wary of future lethal violence and provide safety plans to both the batterer and safety plans to both the batterer and victim accordingly.victim accordingly.

The presence of all six of the above The presence of all six of the above factors should alert the clinician that factors should alert the clinician that outside help for the batterer is warranted outside help for the batterer is warranted (hospitalization, contacting the police, (hospitalization, contacting the police, etc).etc).

Lethality Assessment ItemsLethality Assessment Items

Severity of Violence Obsessive and/or Stalking Behaviors Serious injury Following (to work, school, store, daycare, etc.) Attempts to kill (partner, children, pets, others) Threats to kill (partner, children, pets, others) Violence/threats in public Use of weapons Threats with weapons Sexual assault/abuse Repeated/escalating violence Strangles/chokes partner Sadistic/terrorist/hostage acts Violence during pregnancy Child abuse Violence in presence of children Threats to abduct child Pet abuse Property damage to intimidate and control Forcible entry to gain access to partner

Watching (frequent drive-bys, drop-ins at work/school, etc.)

Monitoring (checking telephone bills, caller ID, credit cards, computer log-ins, listening in on conversations, etc.)

Enlisting others to follow/watch/monitor Telephone harassment (home, work, etc.) Requiring frequent “check-ins” when partner is

away (work, school, store, etc.) Requiring debriefing after absence (partner must

recount time spent away in great detail) Isolation of partner (physical, social, financial,

etc.) Ownership – partner as property

Lethality Assessment Items (cont.)Lethality Assessment Items (cont.)

Other Criminal Behaviors Psychological Risk Factors Assaults on others Previous homicidal/suicidal attempts Threats/harassment of others (family members, friends,

co-workers, neighbors, etc.) Previous/pending criminal charges History of other criminal behaviors

Homicidal threats Suicidal threats Previous mental health hospitalizations Severe depression External life stressors (job loss, death in family, etc.) Drug/alcohol abuse or addiction

Failure of Past Interventions Other Family members, children, friends, neighbors, co-workers

have intervened but violence continues Numerous police calls Prior IPV arrests/convictions Ignores police/court/probation orders Violates protection or restraining orders Prior IPV treatment

Victim attempting separation from batterer Interference with victim access to emergency services

or other help (pulling phone from wall, etc.) Weapons access/training Any other unusual or concerning behavior reported by

victim

Therapist Knowledge of Barriers in the EnvironmentTherapist Knowledge of Barriers in the Environment

Therapists should also know about the resources available in the Therapists should also know about the resources available in the community and firmly imbed client experiences within the community and firmly imbed client experiences within the surrounding environment (Davies, 1997; Dutton, 1992; Grigsby & surrounding environment (Davies, 1997; Dutton, 1992; Grigsby & Hartman, 1997; McCloskey & Fraser, 1997). Hartman, 1997; McCloskey & Fraser, 1997).

FirstFirst, , therapists should educate themselves about the local therapists should educate themselves about the local criminal justice system response to IPVcriminal justice system response to IPV, most notably regulations , most notably regulations and assumptions of county and state laws that impact their and assumptions of county and state laws that impact their communities. communities.

Due to reasons of safety, therapists should be able to understand their crisis Due to reasons of safety, therapists should be able to understand their crisis intervention options in the face of high risk (e.g., criteria for hospitalization intervention options in the face of high risk (e.g., criteria for hospitalization of the batterer versus police intervention), and convey accurate information of the batterer versus police intervention), and convey accurate information concerning legal options to victims.concerning legal options to victims.

At the very least, therapists should have referral information on hand that At the very least, therapists should have referral information on hand that direct clients to the appropriate resources (IPV court advocates, etc.).direct clients to the appropriate resources (IPV court advocates, etc.).

Knowledge of BarriersKnowledge of Barriers

SecondSecond, , therapists should be cognizant of the effects that therapists should be cognizant of the effects that cultural and gender-based societal expectationscultural and gender-based societal expectations can have can have on clientson clients and how these expectations may present and how these expectations may present barriers to effective intervention. barriers to effective intervention.

For example, negative interactions with socially-sanctioned For example, negative interactions with socially-sanctioned officials in the past by members of minority populations may officials in the past by members of minority populations may create barriers to accessing community services that could help create barriers to accessing community services that could help reduce lethality. reduce lethality.

ThirdThird, , therapists should examine their own psychological therapists should examine their own psychological conceptualizations conceptualizations in order to recognize and honor not in order to recognize and honor not only the dangerousness inherent in IPV cases, but also only the dangerousness inherent in IPV cases, but also the extreme impact that IPV can have on victims and the extreme impact that IPV can have on victims and children. children.

This issue brings a therapist squarely into the reinterpretation of This issue brings a therapist squarely into the reinterpretation of standard assessment techniques within an IPV context. standard assessment techniques within an IPV context.

In other words, clinicians must be able to embed and integrate In other words, clinicians must be able to embed and integrate standard psychological assessment and intervention strategies standard psychological assessment and intervention strategies within the issues shown below.within the issues shown below.

Barriers in the Environment Barriers in the Environment (adapted from Grigsby and Hartman, 1997)(adapted from Grigsby and Hartman, 1997)

Concrete Environmental Forces 1. Legal System and Laws - mandatory arrest laws - mandatory sentencing 2. Police/Court Responses - enforcement of laws - enforcement of protection orders - diversion vs. time served 3. Medical/Mental Health Responses - identifying causes of injury - believing battered women - counseling to keep marriage intact 4. Shelter Availability 5. Advocacy Center Availability 6. Local Social Oppression Against Minorities and/or Immigrants

7. Money - batterers' control over finances - woman's employment - permanent food and shelter for family - transportation - social and legal aid - knowledge of resources 8. Batterer Himself - woman physically isolated (locked in house) - woman socially isolated due to batterer's influence - increased risk of death/extreme violence by batterer during attempts to leave - threats and violence against children

Barriers in the Environment (cont.)Barriers in the Environment (cont.)

Family and Socio-Cultural Roles 1. Good Woman = put yourself last 2. Good Mother = never raise children w/o father 3. Religious Beliefs and Norms - pastoral counseling to keep marriage intact - beliefs about women's place

4. Family Beliefs and Norms - breaking rules of family of origin 5. Beliefs About Divorce 6. Violence as Normal Within Relationship 7. Definition of Self as "Victim" 8. Degree of Cultural Identification

Barriers in the Environment (cont.)Barriers in the Environment (cont.)Consequences of Battering Relationship

1. Brainwashing - results of repetitious violence and control - psychological warfare 2. Post-Traumatic Stress Disorder (PTSD) - denial and numbing - terror and fear are normal states - exhaustion - low emotional resources 3. Learned Helplessness - low self-esteem and self-worth - extreme self-doubt and/or immobilization 4. Stockholm Syndrome - identifying with batterer - adopting batterer belief system - bonding with batterer - “prisoner-of-war” syndrome

5. Battered Women’s Syndrome - personality change as result of battering - may present as mental health problem - recovery occurs after violence ends - most women do not enter into another violent relationship 6. Cognitive Deficits/Other Disabilities - head trauma - other physical injuries 7. Forced/Coerced Illegal Activities - prostitution - illicit drug use/sale - other criminal activity

Barriers in the Environment (cont.)Barriers in the Environment (cont.)

Intrapsychic Forces 1. History of Abuse - physical and sexual abuse as child/adult

2. Personal Variables - resiliency - strengths and weaknesses

Initial Safety PlanningInitial Safety Planning

Once the IPV screening and full-scale assessment is Once the IPV screening and full-scale assessment is completed, you will then have a good idea of the level of completed, you will then have a good idea of the level of lethality inherent in the situation. lethality inherent in the situation.

Hopefully, you will also have embedded specific client Hopefully, you will also have embedded specific client information within the possible barriers to safety within the information within the possible barriers to safety within the environment. environment.

For example, in the clinical vignette used by Harway and For example, in the clinical vignette used by Harway and colleagues (Hansen, Harway, & Cervantes, 1991; Harway & colleagues (Hansen, Harway, & Cervantes, 1991; Harway & Hansen, 1993) mentioned earlier concerning the male Hansen, 1993) mentioned earlier concerning the male intimate partner who raped and then killed his female partner intimate partner who raped and then killed his female partner shortly after their family visit to a therapist, shortly after their family visit to a therapist, the partners the partners would have been separated and the IPV screening would have would have been separated and the IPV screening would have commenced. commenced.

You would then complete the full-scale assessment procedures You would then complete the full-scale assessment procedures with each partner, ending with a determination of the primary with each partner, ending with a determination of the primary victim/batterer and completion of the lethality assessment. victim/batterer and completion of the lethality assessment.

Safety Planning (cont.)Safety Planning (cont.)

Once barriers to safety were identified for both Once barriers to safety were identified for both the victim and perpetrator, safety planning the victim and perpetrator, safety planning could then be tailored to the unique could then be tailored to the unique characteristics of both the clients and the characteristics of both the clients and the situation.situation.

There are two major issues that we should also There are two major issues that we should also consider for safety reasons:consider for safety reasons:

FirstFirst, we must have a profound understanding of the , we must have a profound understanding of the barriers in the environment that support on-going barriers in the environment that support on-going violence. If these barriers are not understood, safety violence. If these barriers are not understood, safety planning may well be ineffective or put clients at planning may well be ineffective or put clients at greater risk. greater risk.

SecondSecond, it cannot be overstated that even when a , it cannot be overstated that even when a safety plan is in place, safety plan is in place, there is no guarantee the there is no guarantee the victim will be safevictim will be safe..

Safety Planning (cont.)Safety Planning (cont.)

Furthermore, we may be drawn to first intervene with the Furthermore, we may be drawn to first intervene with the victim of IPV since this individual usually is the most motivated victim of IPV since this individual usually is the most motivated for change (McCloskey & Fraser, 1997), and may be the only for change (McCloskey & Fraser, 1997), and may be the only presenting party in the therapy room.presenting party in the therapy room.

We should always intervene with the primary batterer when We should always intervene with the primary batterer when possiblepossible (such as in couple’s or family therapy), build (such as in couple’s or family therapy), build compliance as much as possible, and be willing to bring in compliance as much as possible, and be willing to bring in outside authorities if lethality is high (similar to managing outside authorities if lethality is high (similar to managing homicidality/suicidality in other clinical situations; Bennett, homicidality/suicidality in other clinical situations; Bennett, 2003; McFarlane, Campbell, & Watson, 2002; Sanchez, 2001; 2003; McFarlane, Campbell, & Watson, 2002; Sanchez, 2001; Shneidman, 2001). Shneidman, 2001).

The engagement of resources by the therapist outside the The engagement of resources by the therapist outside the therapy room (hospitalization, contacting the police, involving therapy room (hospitalization, contacting the police, involving other adult family members, etc.) will be a judgment call based other adult family members, etc.) will be a judgment call based on the level of lethality. on the level of lethality.

As discussed above, presence of the most lethal, high-risk As discussed above, presence of the most lethal, high-risk factors may tell the clinician that outside authorities should be factors may tell the clinician that outside authorities should be contacted in order to keep all parties safe.contacted in order to keep all parties safe.

Safety Planning (cont.)Safety Planning (cont.) If the victim is the only individual presenting for services, If the victim is the only individual presenting for services,

safety plans can still be devised. By discussing with victims safety plans can still be devised. By discussing with victims the safety plan shown below, we underscore the level of the safety plan shown below, we underscore the level of danger the batterer represents and sending the message danger the batterer represents and sending the message that the therapist takes this risk very seriously. that the therapist takes this risk very seriously.

It is possible that we could copy this safety plan as a It is possible that we could copy this safety plan as a handout and give to victims after explanation in session has handout and give to victims after explanation in session has occurred and any possible barriers to implementing the occurred and any possible barriers to implementing the plan are explored. plan are explored.

However, the victim is usually not the family member who However, the victim is usually not the family member who is in most danger of using lethal violence, although it is is in most danger of using lethal violence, although it is possible victims may use violence as a self-defense measure possible victims may use violence as a self-defense measure (Malloy et al., 2003). (Malloy et al., 2003).

While an in-depth discussion of long-term intervention While an in-depth discussion of long-term intervention

strategies is outside the scope of this presentation, the strategies is outside the scope of this presentation, the reader is referred to Campbell (2002), McCloskey and reader is referred to Campbell (2002), McCloskey and Fraser (1997), and Walker (1994) for further discussions of Fraser (1997), and Walker (1994) for further discussions of IPV safety planning, initial treatment plans, and long-term IPV safety planning, initial treatment plans, and long-term interventions, respectively. interventions, respectively.

Safety Planning With Clients Who Are IPV Safety Planning With Clients Who Are IPV VictimsVictims

Call police – 911 (program phone with these numbers) Go to shelter (address and phone number) If currently safe, consider contacting advocacy center (address and phone number) If in same room with abuser and violence occurs, avoid rooms with no outside

doors and those containing weapons (kitchen, bathroom, bedroom, garage) Change locks, code on house alarm system, garage door opener, answering

machine access code, log-in on computer, etc. Identify 2-3 persons who are your main supporters and know of the situation and

who can help you if a crisis occurs Stay with family/friends who will keep you safe – hidden from abuser Inform neighbors of the situation – ask them to call the police if they notice

anything suspicious Obtain protection order against abuser (civil or criminal) Develop safety plan with children such as: (a) stay in bedroom during argument, (b)

leave house and go to friends/neighbors, (c) tell a relative, (d) call 911 Create a “code word” with children, friends, and neighbors so they can call for help Give school/day-care written instructions: (a) who can pick up children, (b) copies

of custody papers or protection orders Pack a “safety bag” and put in safe, accessible place during a crisis - extra cash,

clothes, documents, extra set of car/house keys, bus tokens, quarters for phone calls and laundry

Save a little money each week and hide in a place only you know about (not in a car or a bank the abuser has access to) – open own bank account with statements mailed to a safe place

Safety Planning With Clients Who Are IPV Safety Planning With Clients Who Are IPV Victims (cont.)Victims (cont.)

Important documents: Birth certificates Marriage/driver’s licenses Car title School/medical records Insurance information/forms Bank account/savings passbooks Welfare/immigration cards Divorce papers Other court documents Social Security cards Credit cards/ATM cards Lease/rental agreements House deed/mortgage papers Keys for car/house Keys for safety deposit boxes Medications/prescriptions Clothing (self-children) Comfort items (self-children) Address book (friends, etc.)

THE MOST IMPORTANT THING IS YOUR SAFETY!

MAKE SURE YOU ARE SAFE BEFORE DOING ANYTHING ELSE. IF YOU OR YOUR CHILDREN ARE INJURED,

MAKE SURE YOU ARE TREATED FOR YOUR INJURIES.

REHEARSE THIS SAFETY PLAN REGULARLY. CHANGE AS NEEDED.

TRUST YOUR OWN JUDGMENT ABOUT WHAT IS SAFEST AT THIS TIME – ANYTHING THAT WORKS TO KEEP YOU AND YOUR CHILDREN SAFE.

SUMMARYSUMMARY Concrete intervention strategies were presented, Concrete intervention strategies were presented,

beginning with initial screening procedures and ending beginning with initial screening procedures and ending with in-depth assessment approaches. with in-depth assessment approaches.

The recommended assessment began with very specific, The recommended assessment began with very specific, direct questions concerning IPV as part of screening direct questions concerning IPV as part of screening and history taking which included examination of and history taking which included examination of specific violent behaviors, the occurrence of IPV across specific violent behaviors, the occurrence of IPV across time, intervention by others, and the co-morbid time, intervention by others, and the co-morbid presence of substance abuse or other mental health presence of substance abuse or other mental health issues. issues.

The assessment then moved to questions assessing the The assessment then moved to questions assessing the meaning that clients attribute to IPV as well as the meaning that clients attribute to IPV as well as the effects of IPV, followed by a conceptual model with effects of IPV, followed by a conceptual model with which the therapist can organize all the preceding which the therapist can organize all the preceding information in order to determine the primary victim information in order to determine the primary victim and batterer in the IPV situation. and batterer in the IPV situation.

Summary (cont.)Summary (cont.) Finally, all the information gleaned from the above was Finally, all the information gleaned from the above was

integrated into a lethality assessment as an aid for integrated into a lethality assessment as an aid for determining the seriousness of the violence and the urgency determining the seriousness of the violence and the urgency with which the therapist should intervene, all within the with which the therapist should intervene, all within the context of possible barriers to safety found in the environment.context of possible barriers to safety found in the environment.

The assessment moved from the concrete to the abstract. The assessment moved from the concrete to the abstract. Thus, this approach was designed specifically to incorporate Thus, this approach was designed specifically to incorporate both clinical data collection and conceptualization. both clinical data collection and conceptualization.

It is hoped that this approach will help us all become more It is hoped that this approach will help us all become more mindful of the ubiquitous presence of IPV in clients’ lives. It is mindful of the ubiquitous presence of IPV in clients’ lives. It is also hoped that the presentation of concrete strategies for also hoped that the presentation of concrete strategies for assessing dangerousness will increase the chances that assessing dangerousness will increase the chances that therapists will assist clients in remaining safetherapists will assist clients in remaining safe

WRAP-UPWRAP-UP

Questions? Questions? Answers? Answers? Comments? Comments?

Suggestions for Improvement?Suggestions for Improvement?