INTIMATE PARTNER VIOLENCE

About the Author Teresa Crowe, PhD, LICSW is a licensed clinical social worker in the District of Columbia and Maryland. She is a professor of social work at Gallaudet University and teaches practice, theory, and research in the MSW program. Her recent research focuses on deaf and hard of hearing populations, especially in the areas of behavioral health, intimate partner violence, telemental health, and help-seeking. Learning Objectives Upon completion of this learning activity, the reader will be able to: 1) Define the different types of intimate partner violence. 2) Recognize indicators of intimate partner violence for each type. 3) Identify different types of intimate partner violence prevention strategies. 4) Explain the value and procedures of screening, immediate intervention, and assessment for IPV. 5) Explain help seeking dynamics, reasons why many victims do not seek help, and the transtheoretical stages of change model. 6) List the components of a safety plan. 7) Recognize the multidimensional levels of trauma individuals exposed to intimate partner violence may experience. 8) Describe trauma-informed treatment and specific interventions for IPV survivors and families. 9) Analyze factors in IPV perpetration, IPV homicide, and perpetrator treatment. 10) Identify legal and mandatory reporting issues relevant to IPV intervention. 11) Recognize cultural considerations in treatment planning. 12) Explain specific intervention techniques and applications for individuals, children, and families. 13) Describe aspects of culture that shape varied meanings of IPV trauma. 14) Explain how minority stress theory applies to victims of IPV. 15) Identify IPV-related issues among survivors of varied cultural/ethnic groups. 16) Recognize special populations that are disproportionately affected by IPV and important factors related to their help seeking.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Syllabus Introduction Myths about IPV and the Truth Types, Terminology, and Definitions US Prevalence Estimates Physical Violence Sexual Violence Stalking IPV-related Homicide Indicators of IPV Perpetrator Traits Prevention Prevention at the Individual-Level Prevention at the Community-Level Prevention at the Society-Level Organizational Practices for Providers Universal Screening Screening Tools and Instruments Screening for Perpetration Risk Tips for Screening Immediate Intervention Crisis Hotlines Intake Assessments Assessment Challenges with “Leaving” Help Seeking Transtheoretical Stages of Change Model Factors Affecting Help-Seeking Behaviors Safety Planning Multidimensional Levels of Trauma Posttraumatic Stress Disorder and Other Problems Associated with IPV Subthreshold Symptoms of PTSD Coping Strategies Problems that May Be a Focus of Clinical Treatment Treatment Integrated or Trauma-Focused Cognitive Behavioral Therapy Concurrent Treatment of Post-Traumatic Stress Disorder and Substance Use with Prolonged Exposure (COPE) Perpetrators of IPV IPV-Related Homicide and Murder-Suicide Perpetrator Treatment Legal Issues Mandatory Reporting Cultural Considerations in Treatment Culture and Trauma

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Cultural and Social Norms That Support Violence Child Maltreatment Community Violence Intimate Partner Violence Child Marriages and Genital Mutilation Cultural and Ethnic Diversity Among IPV Survivors Immigrants and Refugees Latino/a/x Americans African Americans Asian Americans Hawaiian Natives and Pacific Islanders American Indians and Alaska Natives Middle Eastern Americans (Western Asian Americans) Special Populations Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Individuals Adolescents and Young Adults Elders Persons with Disabilities Men Geographically Isolated Individuals Economically Disadvantaged Individuals Provider Self-Care Summary References INTRODUCTION

Intimate partner violence (IPV) is indiscriminate; it occurs across gender, racial, ethnic, geographical, religious, and disability lines. The National Institute of Justice [NIJ] (2019) defines IPV as physical, sexual, or psychological harm inflicted on an individual by a partner or spouse. IPV, also sometimes called domestic violence (DV), can occur in various forms, including physical, verbal, emotional, psychological, economic, and sexual abuse. Survivors of IPV can experience immediate and long-term health, social, psychological, and economic consequences. The complexity of an IPV experience can affect a person across multiple domains, including individual, interpersonal, familial, community, and societal. Because of its broad scope, clinicians should be aware of the many facets of IPV. Chances are that practitioners will work with individuals who have past or current experiences with IPV either as perpetrators or survivors. The purpose of this learning material is to help practitioners learn about the prevalence of IPV, its indicators, and theories about how IPV occurs and why it is perpetuated.

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Individuals, including IPV victims and perpetrators, may unwittingly believe that violence may be necessary at times to control someone’s behavior. Others who are on the outside of abuse may endorse particular prejudices about those who are abused and those who abuse them. These myths, when left unexamined or unchallenged, can perpetuate violence and inhibit some people from seeking help when needed. Common myths about IPV include:

• It is a female-only problem, • It is only physical, • It only occurs among those who are poor and uneducated, • If a domestic abuse victim does not leave the situation, it must be tolerable, and • A person who abuses a partner or spouse is under a lot pressure and then just “snaps”. (Barger, 2019; Paisner, 2019)

The truth about IPV is much more complicated and involves myriad perspectives of the underlying dynamics. Below are recent newspaper reports of domestic violence in various circumstances. These cases highlight the broad range of dynamics at play with issues of IPV.

A 16-year old youth in Georgia choked his 19-year old sister to death after an argument over a wi-fi password. The brother had been playing an X-Box game when the internet speed slowed down. He then aggressively confronted his mother when she tried to remove the game from his room. When the youth’s sister intervened, he attacked and killed her (Woods, 2019).

A 66-year old man from Texas murdered his 24-year old Filipino wife whom he had met online two years earlier. After showing a friend his deceased wife’s body, which he kept in a freezer, he then committed suicide (Miller, 2019).

A celebrity star on the Teen Mom television program was arrested and charged with domestic battery with a deadly weapon against her boyfriend. Additional charges were filed because her violent acts were committed in the presence of her one-year old child (Bacardi, 2019).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com A 57-year old British man shot and killed his wife and daughter before killing himself. The violent behavior had been going on for some time in a rural town in England. Investigators explained that certain rural sociocultural factors were at play in the small community that prevented intervention. Problems with males holding positions of power, limited availability of public services, such as transportation out of the village, and tight-knit communities that hide and protect perpetrators exacerbated the problem (Dodd, 2019).

A prosecutor in Tennessee stated that he would not prosecute domestic assaults between gay or lesbian partners because he does not recognize their unions as a marriage. The prosecutor stated that the rights of LGBT individuals are not God- given rights and therefore, do not have the constitutional rights of married couples (Golgowski, 2019).

A wife experienced emotional and psychological abuse when her husband accused her of not following the Bible. He yelled at her that she was a failure as a wife, a Christian, and as a mother because of her insubordination. He read to her: ‘Wives, submit to your own husbands, as to the Lord. For the husband is the head of the wife as Christ is the head of the church, his body, and is himself its Savior. Ephesians 5:22- 23’ (Baird & Gleeson, 2018).

Singer Chris Brown reached a plea agreement for a felony charge for assault of his girlfriend and singer, Rihanna Fenty. Brown agreed to accept five years of supervised probation and 1,400 hours of community service (Brown & Surdin, 2009).

These incidents illustrate the diverse circumstances under which domestic violence incidents can occur. Perpetrators and survivors can be anyone; they can be male or female, wealthy or poor, young or old; famous or not. Myths about IPV can have broad impact upon those who suffer from abuse. They perpetuate prejudice, oppression, and discrimination and can prevent survivors from seeking treatment. In order to combat the negative effect of these myths, the messages contained in the myths should be analyzed, but more importantly, their veracity should be thoroughly investigated.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Myth 1: IPV is a female-only problem Though some may assume that IPV is a female-only problem, the truth is that men can be the victims of IPV as well. Current data indicate that female victims more often experience severe forms of physical abuse. However, about 25% of men have also experienced some form of physical violence by a partner (National Coalition Against Domestic Violence (NCADV), 2019). One in seven men has experienced severe physical violence, such as beating, burning, and strangling, at the hands of a partner. One in 18 men has been stalked by partners to the point that they feel fearful of harm.

Research about male survivors of IPV is becoming more prevalent in the literature. Studies of male survivors, including men who have sex with men (MSM) and men who identify as heterosexual, offer several important points to consider (Huntley, et al., 2019). Some men:

• experience fear, ambivalence, shame, and denial about their abuse. Both societal perceptions of the abuse and self-perception about masculinity are an important factor in the feelings of fear. Other fears include family break-up, losing custody for their children, adverse financial impact upon the family, and tarnished professional reputation.

• worry disclosing IPV, let alone seeking help for it, will result in being viewed by others as unmasculine or that they will not be believed about the abuse. Men who are larger than their partners fear that others will question their allegations because of the physically dissimilarity.

• want the abuse to stop, but do not want to lose the relationships with their partners. They may fear that loss of the relationship also means loss of their children as well.

• feel less confident, even despondent, about reporting and seeking help for IPV. This is especially true for MSM because they already deal with stigmatization, oppression, and prejudice about their sexuality.

• feel that they are invisible to the community because the problem is seen as a female-only problem. Services and advertisements focus mostly on female

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com survivors, which conveys the message that services are not available to or tailored for men. Reports estimate that 10,000 men are sexually assaulted in the military annually. Many of the male victims are of lower rank than their perpetrators. One air force veteran reported that he was raped by his ranking officer while his fellow recruits were sleeping in the next room. He did not report the crime when it occurred because there were no protections for troops who report assaults. He feared that people would view him as a threat. When he finally reported the multiple assaults by the same officer upon graduation from boot camp, the incidents were never investigated (Philipps, 2019).

Myth 2: Intimate partner violence is only physical

Intimate partner violence is not only physical violence (such as slapping, hitting, burning, strangling, or kicking); it also includes sexual violence, such as sexual touching, non-physical sexual contact (e.g., sexting), or forceful sexual acts upon an individual who does not or cannot consent (Centers for Disease Control, 2019). Stalking, repeated and unwanted attention and contact by a partner that engenders fear of one’s safety or the safety of others close to the person, is another form of IPV. Psychological aggression is also another form of IPV that includes non-verbal and verbal communication with a person with the intent to harm, intimidate, or exert control over another person emotionally. IPV can also emerge as economic abuse - when a partner takes control of or limits access to shared or individual assets, including future potential earning. Examples of economic abuse include, employment- related abuse (i.e., when the abuser prevents a partner from attending a job), coerced debt (i.e., when the abuser forces non-consensual, credit-related transactions), and limited access to existing funds (e.g., demanding that a lease or mortgage be in the abuser’s name) (NCADV, 2019).

A Pennsylvania man was arrested for flying drones with explosive devices attached to them over his ex-girlfriend’s house. He has previously used drones to drop nails on his community, vandalizing cars and roads. During his arrest, law enforcement described the man as being high on methamphetamine (US Attorney’s Office, 2019).

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Myth 3: Domestic violence only occurs among those who are poor and uneducated

Some studies of domestic violence found that individuals, particularly women, with lower socioeconomic status were at a higher risk for IPV (Bhattacharjee & Banda, 2016; Caetano, Schafer, & Cunradi, 2017; Chai, et al., 2016; Oanh, Oh, Choi, To, & Dung, 2016; Reichel, 2017; Vameghi, Akabari, Maid, Sajedj & Sajjadi, 2018). However, other factors also play important roles in its occurrence. For example, alcohol and substance use play a major role, more so than socioeconomic status and education levels alone (Caetano, Schafer, & Cunradi, 2017). Other important variables, such as experiencing child sexual abuse, witnessing violence inside the home during childhood, and witnessing violence outside the home during childhood, are associated with a higher risk for both IPV perpetration and victimization. (Howell, Barnes, Miller, & Graham-Bermann, 2016; Richards, Tomsich, Gover, & Jennings, 2016). Some types of personality characteristics are associated with IPV, such as borderline personality disorder and antisocial personality disorder (Peters, Derefinko, & Lynam, 2017; Bream, Florimbio, Elmquist, Shorey, & Stuart, 2018). Often times factors overlap, illuminating a complex picture of the factors involved with IPV.

The New England Patriots released one of its players after claims that the high-profile NFL player sexually assaulted one woman and sent threatening texts to another woman. The player lost his lucrative promotional contracts with Nike and Xenith following the reports (Pramuk & Mangan, 2019).

Myth 4: If a victim of IPV does not leave the situation, it must be tolerable

Abusive relationships often involve long-term patterns of relational dysfunction. Many survivors stay in abusive relationships for extended amounts of time (Murray, Crowe, & Flasch, 2015; WHO, 2012). There are many reasons for this. Sometimes individuals are financially dependent upon their partners. If children are involved, they may believe that staying in the relationship is better than becoming a single parent. Sometimes individuals fear

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com retaliation from their partners; they may hope that their partners will change. Some may love their partners and want to stay despite continuing abuse. There may be religious beliefs or cultural norms that influence the decision to leave. The decision to leave a partner is not a simple one. Often there are turning points in the courses of their lives that help survivors of IPV leave abusive relationships (Murray, Crowe, & Flasch, 2015; WHO, 2012). Turning points are critical times or shifts in perspective when an individual decides to make permanent changes in one’s life. Leaving a relationship may come as a result of many turning points, different decisions, and multiple paths of working through issues one step at a time. Often this involves a process of realization, a push to react, preparation to leave, and a final exit (Murray, Crowe, & Flasch, 2015). When violence in the relationship escalates, a partner may realize that the children are being affected or that their partners will not change (WHO, 2012). Individuals in abusive relationships may undergo a process of transformation in order to make the leap to leave a relationship.

After being in an abusive marriage for a long time, a woman with physical disabilities decided to leave only to realize that accessible services were lacking. The woman reported that her husband often excused the abuse by telling her that her disability ruined his life. When she “misbehaved,” he would withdraw food, water, and care. He forced her to take medication and prevented her from leaving their home. When she decided to leave the relationship, the shelter she went to was not accessible for people with physical disabilities. Though the shelter had an accessible bathroom, the lack of physical support in the shower made it unsafe. The shelter had bunkbeds, but were difficult for her to manage. While in the shelter, she fell down the stairs repeatedly. Despite the multiple challenges, she still decided not to return to her marriage (Ryan, 2019).

Myth 5: A person who abuses a partner or spouse is under a lot of pressure, then just “snaps”

There is no one-size-fits-all type of IPV perpetrator. Perpetrators can be females or males. They can be of high or low socioeconomic statuses. They can be well-educated or under- educated. They can be young or old. Perpetrators of IPV may share some common risk factors, such as growing up in a violent home, use of alcohol and drugs, and the presence of mental health problems (Kiss, Schraiber, Hossain, Watts, & Zimmerman, 2015; Payne, 2017).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com There are different types of perpetrators with various underlying motivations for their abusive behaviors. Individuals who are aggressive inside the home may not be aggressive with others outside the home (Kiss, Schraiber, Hossain, Watts, & Zimmerman, 2015). Some male perpetrators, such as those who are rigidly tied to traditional notions of gender roles and have abusive attitudes towards women, may show hostility exclusively to female targets. Similarly, those who are violent with individuals outside the home may not be violent inside the home. As age increases, the prevalence of offending decreases (Payne, 2017). Though women are more likely to report abuse, both men and women offend; however, men are more likely to cause more severe physical harm than women (Payne, 2017). The Office of Victims of Crime (OVC) (2017) reports that psychological aggression is the most common form of IPV. Approximately 47% of women and men will experience psychological aggression by an intimate partner in their lifetime.

There are many reasons why victims of IPV do not leave their relationships. One reason is that the violence happens over a period of time, slowly wearing away at the survivor’s soul. One mother was finally freed from abuse only when their daughter killed her father. In an abusive relationship, the abuser uses long-term control and brainwashing tactics to convince the victim that he is more powerful than the system (Gross, 2019).

TYPES, TERMINOLOGY, AND DEFINITIONS

In order to better understand IPV and its associated terms, common definitions are important. The following terms and definitions are provided by Centers for Disease Control for the purpose of gathering data from the National Intimate Partner and Sexual Violence Survey (Smith, et al., 2018).

Physical violence: includes a range of behaviors from slapping, pushing or shoving to severe acts that include hitting with a physical object or something hard, kicking, hurting by pulling hair, slamming against something, trying to hurt by choking, suffocating, beating, burning on purpose, or using a knife or gun.

Sexual violence: includes acts of violence, such as rape, penetration of someone else, sexual

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Stalking: includes a pattern of harassing or threatening tactics used by a perpetrator that is both unwanted and causes fear or safety concerns in the victim. Stalking tactics include unwanted phone calls, text-messages, or hang-ups, emails, social media messages, observation from a distance, spying with a listening device or camera or GPS system, appearing in unexpected places, placement of strange or potentially threatening items for the victim to find, and sneaking into the victim’s home or car and doing things to scare the victim.

Psychological aggression: includes behaviors that are intended to monitor and control or threaten an intimate partner, such as name-calling, insulting, humiliating, and coercive controlling. IPV vs. domestic violence: Both IPV and domestic violence refer to physical, sexual, psychological, or stalking behaviors toward partners in a relationship. However, domestic violence can also encompass abuse toward a child or elder in the family; whereas, IPV refers specifically to the partner or spouse in a relationship (World Health Organization (WHO), 2012).

U.S. PREVALENCE ESTIMATES

The prevalence of IPV in the United States is astounding. Estimates of the U.S. population indicate that IPV, including physical, emotional, stalking, and sexual acts, affect approximately 25% of women and 10% of men (CDC, 2019; NCADV, 2019). The CDC (2019) reports that IPV can start early in the lifespan and continue throughout. A U.S. sample of high school students reported high incidence of dating violence, often a precursor to IPV in adulthood.

According to the U.S. Federal News Service (2017), a U.S. Air Force member was discharged because of physical and emotional abuse to his wife. He abused her by using suffocation and strangulation. During one incident, he repeatedly kicked her and stomped on her neck; on another occasion he broke her arm because he became angry about the way she folded money. He was also convicted for emotional abuse because he tried to control her personal and work relationships and restricted her ability to leave the house (“Former Air Force Member,” 2017).

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● IPV accounts for about 15% of all violent crime (NCADV, 2019). ● Approximately one in five women and one in seven men experience severe physical violence in their lifetime by an intimate partner (CDCa, 2019). ● About 19% of domestic violence involves a weapon (NCADV, 2019).

A second-grade school teacher attempted to run over his ex-wife and during another incident, kicked her repeatedly in the ribs. The teacher’s wife explained to a judge that three months into their relationship, her husband had become emotionally and verbally abusive. Within a year, the abuse became physical. The abuse continued after the birth of their child when he shook his wife’s head repeatedly. The teacher’s wife explained that she felt no one would believe her because her husband was a teacher and some family members were law enforcement officers. The teacher was sentenced to one year of probation for domestic battery (Klamann, 2019).

Sexual Violence

• About one in five women and one in 12 men report sexual violence (CDC, 2019). ● About one in five women and one in 14 men are raped in their lifetime (NCADV, 2019; Smith, et al., 2018). ● Approximately half of both, female and male survivors, are raped by an acquaintance; of those, about 45% of women and 29% of men are raped by an intimate partner (NCADV, 2019). ● Approximately 44% of women experience some form of sexual violence in their lifetime and about 21% report completed or attempted rape at some point in their lifetime (Smith, et al., 2018). ● Thirty-seven percent of women report unwanted sexual contact in their lifetime. ● About 25% of men experience some form of unwanted sexual contact in their lifetime; approximately 2.6% of men experience completed or attempted rape in their lifetime (Smith, et al., 2018).

A 2015 survey of IPV in Alaska found that approximately 48% of women in the municipality

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com of Anchorage has experienced IPV. The reasons reported for this involve issues such as the criminal justice system being behind those of other states and a lack of law enforcement in rural communities (“Red Zone,” 2017).

Stalking

● Approximately one in seven women and one in 18 men are stalked by an intimate partner (NCADV, 2019). ● About 16% of women and 6% of men report being stalked by a current or former intimate partner at some point in their lifetime (Smith, et al., 2018). ● Within a 12-month period of time, approximately 3.7% of women and 1.9% of men report being a victim of stalking. A phone application intended as a tool for parents to track the whereabouts of their children can be used for surveillance for other purposes. A Florida man installed an app on his wife’s phone because he suspected her of sending and receiving text messages from a romantic liaison. Several days later, the man killed his wife because, he reported, he found proof of infidelity from tracking her with the app (Valentine-DeVries, 2018).

IPV-related Homicide

● About 72% of murder-suicide incidents involve an intimate partner (NCADV, 2019). ● Approximately 94% of victims in IPV-related murder-suicide incidents are female (NCADV, 2019). ● Of IPV-related homicides, 20% of the victims are not the partners themselves, but the family members, friends, neighbors, responders, or bystanders (NCADV, 2019).

INDICATORS OF IPV

A large proportion of individuals in the U.S. experience some form of IPV at least once in their lifetimes. Approximately 99% of perpetrators against female IPV victims were male according to the National Intimate Partner and Sexual Violence Survey in 2010 (Breiding, Smith, Basile, Chen, & Merrick, 2014). In contrast, men survivors report that the type of abusers varied depending upon the type of violence. Although women are

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com overwhelmingly the victims of male perpetrators of sexual violence, in situations with male victims of unwanted sexual contact and sexual non-contact, the number of male and female perpetrators were more evenly divided. Male survivors of sexual violence reported that female perpetrators were more likely to force men into sexual penetration. Male stalking survivors reported that the perpetrators were evenly split between men and women abusers.

Childhood maltreatment and exposure to household violence are high risk factors for both IPV victimization and perpetration in adulthood (Kiesel, Piescher, & Edleson, 2016). Children who live in families where violence occurs often exhibit significant social, emotional, and behavioral problems. Thus, over the entire lifespan IPV affects social and vocational experiences later in life. Alcohol and drug use, poor mental health, and poverty are also interconnected with IPV (Gibbs, Jewkes, Willan, & Washington, 2018; Hollin, 2016). Women who experience IPV often face complex issues that involve depression, PTSD, and alcohol and/or substance misuse. These particular indicators are also associated with a history childhood physical and/or sexual abuse.

Though IPV can occur across the socioeconomic spectrum, food insecurity, poverty, and limited financial resources are linked to higher levels of stress and conflict within households (Gibbs, Jewkes, Willan, & Washington, 2018). Employment can be a protective factor, in particular for women, in that it engenders a feeling of empowerment and control. IPV, however, can have a negative effect on employment, such as reducing productivity and achievement (Gibbs, Jewkes, Willan, & Washington, 2018; Institute for Women’s Policy Research, 2017).

IPV is also associated with male and female gender inequality (Gibbs, Jewkes, Willan, & Washington, 2018). Male perpetration and female victimization are associated with higher levels of controlling behaviors, more childhood traumas, and increased conflict in their relationships. Thus, the cluster of indicators, signs, and symptoms of IPV are complex and can create a host of problems that are interrelated.

Perpetrator Traits

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com There is no one type of person who becomes an abusive partner. Individuals vary in terms of age, race, socioeconomic status, gender, religion, education, and culture. However, there are common tactics that are used by many individuals who perpetrate abuse. The National Coalition Against Domestic Violence (NCADV) (2019) lists common characteristics of perpetrators of IPV. The abuser may:

● deny the existence or minimize the seriousness of violence and its effects

● objectify the victim and consider her a part of his property or as a sexual object

● externalize the cause of violence and blame their behavior on external circumstances, such as having a bad day, or using drugs or alcohol

● behave in ways that are pleasant and charming in between periods of violence

● be a nice and loving person to those who are outside the relationship

The NCADV (2019) also provides a list of potential warning signs of those who abuse their partners. Perpetrators of IPV may have low self-esteem and feel powerless and ineffective in the world; perpetrators may demonstrate the following behaviors:

● extreme jealousy

● possessiveness

● unpredictability

● explosive temper

● cruelty to animals

● verbal abuse

● controlling behavior

● rigid beliefs about the roles of men and women in relationships

● forced sex or disregard of partner’s unwillingness to have sex

● sabotage of birth control methods

● victim-blaming

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ● sabotage or obstruction of the victim’s ability to work or attend school

● control over finances ● abuse of other family members, including children or pets ● accusations of extramarital affairs or flirting ● demeaning the partner either privately or publicly ● embarrassment or humiliation of the partner in front of others ● harassment

In a county in Michigan, prosecutors revealed a plan for “trauma court.” This program considers the past trauma and abuse that perpetrators of domestic violence have experienced in their lives. It proposes that offenders be given specialized treatment that addresses the root cause of their behavior (Stateside Staff, 2019).

From a clinical perspective, studies show that a high percentage of perpetrators of IPV also show signs and symptoms of personality disorders (Bream et al., 2018; Breiding et al., 2014; Dowgwillo, Menard, Krueger, & Pincus, 2016). Among male perpetrators, eight unique profiles of diagnosed disorders emerge: schizoid, borderline, narcissistic, antisocial PD, passive dependent, and compulsive personality disorders (PD). Individuals who are violent in their relationships are more likely to have personality disorders, increased alcohol use, and higher levels of depression (Simmons, Knight, & Menard, 2015).

Researchers find that violent experiences during early childhood develop along a predictable trajectory across the lifespan and impact individuals as adults (Dowgwillo, Menard, Krueger, & Pincus, 2016). Personality traits associated with the perpetration of IPV are impulsivity, aggression, dominance, and hostility (Dowgwillo, Menard, Krueger, & Pincus, 2016). Individuals who perpetrate violence against their partners report that they use violence in instances of self-defense, retaliation, or difficulty with expressing emotions (Dowgwillo, Menard, Krueger, & Pincus, 2016).

PREVENTION

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com IPV is a multi-dimensional and multi-faceted phenomenon. As such, prevention must be a multi-strategy approach that employs a wide range of short- and long-term strategies. Primary prevention includes multiple intervention points to prevent the occurrence of IPV (CDCa, 2019; Substance Abuse and Mental Health Services Administration (SAMHSA), 2019; WHO, 2012):

Prevention at the Individual-Level

Individual-level interventions are geared towards the improvement of an individual’s well- being and functioning. IPV often occurs at home and affects familial and social relationships that have direct effects on a person’s quality of life. In general, all individual-level prevention interventions should work toward empowering and strengthening the individual and his or her social relationships. This can occur in a variety of broad-focused ways, including

● Strengthening individual household and family financial security and work-family supports.

● Disrupting developmental pathways, such as implementing early childhood home visitation, preschool enrichment programs, parent skills and family relationship programs, and programs for children, youth, and families who are at high-risk.

● Teaching safe and healthy relationships skills to youth, adults, and couples.

Prevention at the Community-Level

Community-level interventions support survivors’ recovery efforts and prevent IPV occurrence in the community by providing access to programs that raise awareness, services that can assist individuals at all levels of the experience, and providers who are trained in the treatment of survivors.

● Supporting survivors to increase safety and lessen the harmful impact of IPV by creating: 1) victim-centered services, 2) housing programs, 3) first responder and civil legal protections, 4) patient-centered approaches, and 5) treatment and support for

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● Incorporating bystander empowerment programs and educating the general public about how to intervene when witnessing IPV or knowing someone who experiences IPV.

● Engaging influential adults and peers, especially men and boys, as allies in IPV prevention.

● Organizing media and advocacy campaigns.

● Designing comprehensive service responses to IPV survivors

● Designing life-skills and school-based programs

● Organizational commitment and initiative for trauma-informed support

● Involvement of key stakeholders, including individuals who have histories of IPV- related trauma

● Review of organizational policies, procedures, and operations to ensure that approach to client or employee care are appropriate

● Provider-consumer collaborations that include community agencies and local services

● Organization quality improvement measures to track service quality and effectiveness

● Ongoing trainings, clinical supervision, and consumer participation and feedback

● Resource allocation for services

Prevention at the Society-Level

● Creating protective environments in schools, organizations, workplaces, and neighborhoods.

● Reforming civil and criminal legal systems.

● Strengthening civil rights related to divorce, property, child support, and child custody

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ● Building coalitions of governmental and civil society institutions.

Organizational Practices for Providers

Providers in organizations who provide trauma-informed services often require specialized training in the treatment of trauma survivors (SAMHSA, 2019). Organizational responsibilities include recruiting, hiring, and retaining trauma-informed staff. Training about evidence-based practices and emerging practices can ensure that staff are properly trained to provide services. Administrators can develop and promote a set of provider competencies that are specific to trauma-informed care. They can offer training and promote practices that emphasize the ethical responsibilities of providers toward their clients. They can also provide trauma-informed clinical supervision to assist providers in supporting their clients.

UNIVERSAL SCREENING

Universal screening for IPV is a protocol for asking all individuals who enter an organization, such as a hospital or doctor’s office, about whether there is violence in the home or relationship. Universal screening for trauma is also warranted. Without screening, clients’ histories of trauma and underlying symptoms can go undetected and untreated (SAMHSA, 2019). Symptom assessment and diagnoses can be mistaken or overlooked thereby causing treatment efforts to be mismatched or inappropriate. Practitioners can help to ensure that client assessments are as accurate as possible by implementing a universal screening process.

Universal screenings should include in-depth assessment of client histories, experiences, and symptoms of trauma at an intake session (SAMHSA, 2019). Selection of specific trauma-informed screening and assessment tools also can be helpful in the process of assessment. Screenings tools should be chosen with the clients’ cultural backgrounds in mind. They can be useful if they include specific aspects, such as native language, race/ethnicity, native language, gender, and culture. Table 1 is a selected list of trauma and screening assessment measures suggested by SAMHSA (2019) and Table 2 is a list of assessment instruments specifically for IPV (Rabin, Jennings, Campbell, & Bair-Merritt,

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Structured organizational guidelines and procedures can help to establish a standardized practice for all practitioners (SAMHSA, 2019). This type of structured process can ensure that all clients are screened and that none are missed because they do not readily volunteer the information. Clients who understand that the screening process is universal also do not bear the shame, humiliation, and stigmatization that often accompanies survivors of IPV.

Table 1 Trauma and Screening Assessment Measures ● Clinician Administered PTSD Scale (CAPS) ● Davidson Trauma Scale (DTS) ● Distressing Event Questionnaire (DEQ) ● Evaluation of Lifetime Stressors (ELS) ● Impacts of Event Scale Revised (IES-R) ● Posttraumatic Diagnostic Scale (PDS) ● PTSD Symptom Scale-Interview (PSS-I) ● PTSD Symptom Scale-Self-Report (MPSS-SR) ● Screen for Posttraumatic Stress Symptoms (SPTSS) ● Trauma Assessment for Adults (TAA) ● Trauma History Questionnaire (THQ) ● Trauma Symptom Inventory (TSI)

Table 2 Assessment Measures Specifically for IPV

HITS (Hurt Insult Threaten and Scream scale): This is a four-question instrument that asks the frequent an individual experiences physical abuse and emotional abuse insults and threats. WAST (Women Abuse Screening Tool): This is an eight-question scale that investigates the frequency that individuals experience tension arguments physical emotional and sexual abuse. PVS (Partner Violence Screen): This instrument was developed for emergency departments where IPV survivors may be seen. This tool includes three questions that ask about recent abuse

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AAS (Abuse Assessment Scale): This instrument is a five-question assessment is specifically for women who are pregnant. It includes questions about the occurrence of physical emotional and sexual abuse.

Screening Tools and Instruments

There are a number of IPV screening measures that practitioners can use for clients.

Below is a list of selected screening measures and descriptions of each.

Hurt, Insult, Threaten, and Scream (HITS)

HITS is a four-item screening tool that questions participants about how often they are physically hurt, insulted, threatened with harm, and screamed or cursed at by their partners

(Sherin, Sinacore, Li, Zitter, & Shakil, 1998). Answers are on a five-point Likert scale from (1) rarely to (5) frequently. This tool was originally developed for health care practitioners and is used across many settings (Rabin, Jennings, Campbell, & Bair-Merritt, 2009).

Woman Abuse Screen Tool (WAST): Short From

WAST is a two-item screening tool that questions individuals about how they would describe their relationship in terms of level of tension and the degree of difficulty that the individual and partner experience when trying to resolve conflicts (Brown, Lent, Schmidt, &

Sas, 2000). Possible answers range from a lot of tension to no tension and from a lot of

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Partner Violence Screen (PVS)

The PVS is a three-item questionnaire that includes questions about whether or not an individual has been hit, kicked, or punched by a partner in the past year (Feldhaus et al., 1997).

It questions an individual about whether or not an individual feels safe in the current relationship. The last question asks whether a partner from a previous relationship is making the individual feel unsafe. Answers are provided using a yes/no format. This tool was developed as a brief instrument to be used in a hospital emergency room (Rabin et al., 2009).

Abuse Assessment Screen (AAS)

The AAS (Weiss, Ernst, Cham, & Nick, 2003) is a five-item tool that questions whether or not an individual has:

1) been emotionally or physically abused by a partner,

2) been physically hurt by someone in the past year,

3) been physically hurt while pregnant,

4) been forced to engage in sexual activities, and

5) felt afraid of a partner.

Answers are in a yes/no format, but also provides an opportunity to list individuals who have been abusive and the frequency with which it occurs. This tool was developed to identify abuse perpetuated against pregnant women (Rabin et al., 2009).

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The Conflict Tactics Scale is an 80-item measure to explore conflict and violence within a family (Straus, 1979). Of the 80 items, 20 are administered to the parent about the relationship with the child; 20 are for the parent about a partner’s interactions with the child; 40 are for the parents about their relationship with one another.

The Danger Assessment

The Danger Assessment is a tool that helps determine the level of imminent lethal danger (i.e., potential for being killed) by an intimate partner (Domesticshelters.org, 2019). The tool has two parts: 1) a calendar to help assess the severity and frequency of abuse, and 2) a 20- item scoring instrument in a yes/no answering format to determine the risk factors associated with intimate partner homicide.

MOSAIC

MOSAIC is a computer-assisted method for conducting comprehensive assessments of domestic violence (MOSAIC, 2019). From the home page, a clinician can choose which assessment to use from a number of choices: a) domestic violence from a male offender, b) domestic violence from a female offender, c) workplace violence concerning a male, d) workplace violence concerning a female, e) threat by a student at a school, f) threat by a student at a university, g) threats to public figures, and h) threats to judicial officials. Participants must

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Adverse Childhood Experiences Quiz (ACE)

The ACE is an instrument that allows an individual to count the types of abuse, neglect, and other adverse childhood experiences. Other negative experiences include mental illness, an incarcerated relative, a mother treated violently, substance abuse, and divorce (Starecheski,

2015). This questionnaire is helpful because adult IPV perpetration and victimization is associated with childhood experiences of abuse and neglect.

Stalking and Harassment Assessment and Risk Profile (SHARP)

The SHARP is an online assessment comprised of 45 questions. It provides a situational risk profile that includes 13 factors that are associated with harm, such as physical or sexual attack, harm to close others, ongoing and escalating stalking and harassment, and life sabotage

(Domesticshelters.org, 2019).

Other Screening and Assessment Resources

The Centers for Disease Control and Prevention (CDC) and the National Center for

Injury Prevention and Control published a 163-page compendium of IPV assessment tools that are broken down into separate victimization scales: physical, sexual, psychological/emotional, stalking; and perpetration scales: physical, sexual, psychological/emotional, and stalking

(Thompson, Basile, Hertz, & Sitterle, 2007).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com The use of screening tools in practice is not a panacea for the different manifestations of

IPV. They are simply tools that can assist a provider with identifying the effects of violence in a client’s life. If a client is not willing or not ready to disclose IPV, then the screening tool will not compel this disclosure. There are other factors that influence the decisions of individuals to disclose IPV to others (Dicola, 2016). Victims of IPV may fear retribution or retaliation by the perpetrator if the violence is disclosed. They may be financially dependent on their partner.

They may feel that by disclosing IPV, they are destroying their families. They may blame themselves or feel deeply ashamed. They may need additional support, resources, and alternatives before disclosing IPV. Even when those resources are available, the individual may still not disclose IPV or the extent to which it occurs.

Screening for Perpetration Risk

A provider can screen for risk of perpetration of violence as well. These screenings can be used by providers, law enforcement, and criminal justice practitioners to predict the likelihood of a negative event, such as re-abuse, by measuring re-arrest (Battered Women’s

Justice Project, 2019). The results of using these types of risk assessments can assist victims and providers to develop better safety plans, help the criminal justice system identify which offenders need additional supervision or conditions for release, educate service providers about how to address perpetrators of domestic violence, and assist perpetrators in receiving the appropriate types and amount of treatment. There are several risk screenings that can be used

(Battered Women’s Justice Project, 2019):

Domestic Violence Screening Instrument (DVSI-R)

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This instrument can be used as an initial screening that can lead to a more in-depth evaluation.

There is strong statistical predictive validity in identifying those who will offend again. It is currently used as a pre-trial evaluation and case manage tool for corrections.

Ontario Domestic Assault Risk Assessment (ODARA)

The ODARA is an instrument that indicates the likelihood that a person who has already committed an assault on a partner will do so again in the future. This tool is a single assessment actuarial system that is available for use in policing, victim support services, health care, and corrections. It ranks the risk for repeat IPV offenses - a higher score means that the offender will commit more assaults, sooner, and with greater injury that a perpetrator with a lower score.

The tool predicts the length of time (speed) until a perpetrator commits a new assault, the number of new assaults he commits, and the severity of new assaults (ranging from none to lethal). Further, the data gathered by the ODARA compares a perpetrator’s risk for repeat IPV to that of other IPV perpetrators. The tool was developed for use by law enforcement to identify high risk domestic violence situations. It is also used to predict recidivism in terms of speed and number of instances as well as the number of injuries that occur.

Spousal Assault Risk Assessment (SARA)

The SARA is a 20-item tool that gathers data from: interviews with perpetrators and victims, standardized measures of physical and emotional abuse, drug and alcohol use, and reviews of police reports, victim statements, and criminal records. This tool is used to predict the likelihood of an offender’s re-assault against a current or former partner.

Tips for Screening

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Social Workers, 2019).

• If a therapist is providing couples or family counseling, interview clients individually.

This provides an opportunity for the survivor to disclose the abuse safely.

• When discussing abuse with the client, use the client’s vocabulary. If a practitioner

uses professional terms, such as IPV or domestic violence, when a client did not use

those terms, this may hinder a conversation about the client’s experiences.

• A practitioner should avoid an approach that can appear like blame. Asking a client

why she stays with the abuser hinders open communication and disclosure.

• A therapist can ask questions about how the client feels about her experiences. • A clinician can ask the client open-ended questions so she can express lived experiences in her own unique way. This also allows providers and clients to understand experiences in a broader way.

Screening instruments should not replace interpersonal interaction between a provider and client. Rather than stand-alone tools, they can be part of a larger, in-depth dialogues with clients about their lives and health. When using a screening tool, a provider should explain the reasons for using the tool (e.g., universal screening procedures) and allow the client to be honest about any feelings about the screening. Practitioners should be aware that there is a potential for unintended negative consequences when a client shares information about violence in a relationship. Knowledge of violence in a client’s life needs to be viewed within the individual’s personal circumstances, culture, vulnerability, and safety.

Screening for IPV is an important part of identifying associated problems and offering assistance to victims. This can lead to a more in-depth assessment process. It is important for clinicians to remember that the use of screening and assessment tools for violence does not

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ensure that an individual will not be fatally harmed by an abusive partner. Sometimes the results of screenings and assessments do not capture all of the nuances of the abuse, including escalation or intent to kill a victim. Below are some indicators of possible symptoms of domestic violence (National Association of Social Workers [NASW], 2019). A client may:

• Express fear of a partner

• Appear anxious about an issue that would not normally cause anxiety, such as

arriving home late or not cleaning the house

• Have an injury or history of injuries that is not the clear result of an accident

• Have less autonomy in the relationship

• Appear isolated from family or friends

• Express homicidal feelings towards a partner

• Express suicidal feelings because of relationship problems

• Have a pattern of missing appointments without a clear reason

Professional assessment of IPV involves recognition of behavior patterns that suggest a client is experiencing abuse in an intimate relationship. The components of a thorough assessment involve gathering detailed information about a relationship, including a history of violence, the current context of the relationship, and specific behaviors of the abusive partner

(NASW, 2019). Some signs that may indicate the potential for serious assaults that could result in severe physical harm or death include: a) a partner’s history of serious violence, b) specific threats to kill or harm a client, a client’s children, pets, or other loved ones, c) history of substance abuse associated with the violence, d) a history of mental illness associated with

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IMMEDIATE INTERVENTIONS

Immediate interventions are those that are introduced within the first 48 hours after a traumatic event occurs (SAMHSA, 2014). During the immediate aftermath of a traumatic event, law enforcement officers or emergency medical personnel are likely to be first-responders. During acute crises, survivor needs should be prioritized. The first and most important need is the survival of the individual in a life-threatening situation. Following survival, safety and security are primary concerns. Security includes obtaining food, shelter, care for physical and mental health needs, and assurances/plans for childcare. Once immediate needs are met, survivors may need to be connected to local services. They may need help with communication with family and friends about their situations.

In an acute, immediate crisis, survivors may need education about resources and services (SAMHSA, 2014). Case management can be a helpful intervention to make referrals and connect survivors to services, such as shelters, faith-based organizations, mental health clinics, medical services, and/or substance use treatment. During the acute phase of crisis, the clinician’s emphasis is on meeting immediate needs, not in-depth, long-term psychological treatment. Professionals providing interventions at the time should be time-limited and concrete while offering empathic listening, support, and comfort.

Basic physical needs may be vital in the initial intervention in a crisis situation. A survivor may have been held captive by an abuser and provided only limited access to food and water. The survivor may be malnourished and/or dehydrated as a result of abuse in the relationship. Medications may have been withheld or interrupted leaving the survivor in need of immediate medical intervention.

Immediate psychological needs include safety and security away from the environment where the abuse occurred. Practitioners during the acute phase of trauma can communicate comfort, protection, and reassurance to traumatized clients. This calm, caring, and supportive approach helps the client de-escalate from extreme psychological distress and set the stage for

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com the development of therapeutic rapport. Addressing the psychological needs of an individual in the acute stage of trauma involves professionals who are aware of and understand trauma, its effects, and reactions. During this phase, practitioners can: a) answer any questions about what is happening or what will happen, b) normalize the feelings of distress and discomfort, c) help survivors become aware of possible symptoms they may experience, and d) provide a positive interaction so survivors are more likely to engage in follow-up treatment (SAMHSA, 2014). A critical aspect of psychological assistance during the acute phase of crisis is to not overwhelm or diminish a survivor’s efforts to cope. Some survivors may immediately want to discuss the event with a provider, but others may not.

“I left after 3 1/2 years of marriage following a huge fight. I had no money except for an ATM card that I was just sure he would cancel quickly, no place to go and no clothes. I left with a bag that had no makeup, hair brush or deodorant - only a toothbrush and a change of clothes. I didn’t really know anyone to call, besides I didn’t want anyone to know… So, I drove to the only hotel in town. The hotel was booked! I couldn’t go to a shelter for fear I would lose my job if they found out, so I slept in my car that night… Most victims would say that you become the queen of appearance. You know how to smile regardless of what just happened and act like everything is fine. The months after I left were horribly hard. I thought I would never get better. I thought I would never be able to support myself, be able to pay my own bills and be a successful adult without him” (National Domestic Hotline, 2013)

Crisis Hotlines

Many behavioral health and domestic violence agencies use hotlines for individuals who need immediate contact with someone who is understanding and supportive. Sometimes individuals who operate the hotline are advocates, clinicians, or volunteers. Some survivors call the hotline for information, referrals, validation of their feelings, or general support (Ferencik & Ramirez-Hammond, 2019). Sometimes individuals use hotlines to learn about the types of services that are available in their communities. When a survivor calls a hotline, this may be the first step in seeking help from someone familiar with domestic violence. She may be uncertain, ambivalent, or guarded about contacting the hotline. She may not be ready to leave a relationship or may be distrustful of professionals and their services.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com A call to a hotline does not allow an advocate or clinician to assess an individual face-to- face as in a treatment session. The clinician does not have an opportunity to convey trust, confidence, and support through body language (Ferencik & Ramirez-Hammond, 2019). The voice and vocabulary of the advocate or professional on the phone call is the tool that is used to engage a survivor, to encourage her to continue seeking support, and help her create a plan for safety.

When a survivor calls for help on a hotline, the advocate engages the person by showing empathy toward the survivor’s experiences (Ferencik & Ramirez-Hammond, 2019). By demonstrating an understanding of the survivor’s emotions, feelings, and experiences, the advocate provides a supportive environment for the individual to disclose her experiences. In a relationship in which there is IPV, the abuser often controls the partner by ignoring her voice and silencing her concerns. Thus, an advocate will need to use empathic interviewing skills to support and encourage the survivor to express her thoughts and feelings.

A domestic violence hotline advocate can demonstrate attentive listening skills by using techniques that convey support and encouragement (Ferencik & Ramirez-Hammond, 2019). On the phone, the advocate can use acknowledgments, such as “ok,” “I see,” “that must have been difficult for you.” Paraphrasing is another technique to show the survivor that the advocate is attentive. Paraphrasing is restating of what the survivor said, but using different words or shortened rephrasing. Professionals can convey understanding and help survivors think deeply by reflecting on the meaning of what the survivor says. An advocate can use open-ended questioning to allow a survivor an opportunity to share more details about her experiences. Successful engagement with a client on a hotline call can lead to the survivor seeking more direct help through treatment or support groups. Responses to a survivor’s disclosure is important because the way an advocate interacts with a survivor can affect the next step the survivor takes.

Examples of techniques to use with a survivor

Empathic Listening “Wow, this must be difficult for you.” “Ok, I hear what you’re saying.” “I can sense that this is not easy for you.”

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Paraphrasing “It sounds like you are most worried about your children being safe.” “What I hear you saying is that you are not sure you want to leave the relationship, but would like some support.”

Reflection “In other words, you feel frustrated that your partner calls your job and checks on you. Right?” “It seems that you feel embarrassed about your situation and don’t want your family to find out. Do I have that right?”

Questioning “How is the situation with you and your partner affecting your relationships with your family? “What can I do to help support you right now?” “What things have you done, even if they’re small, to support yourself during this stressful situation?”

When an advocate, volunteer, or professional is talking to a survivor on a hotline call, the focus needs to be on the feelings and needs of the caller (Ferencik & Ramirez-Hammond, 2019). Survivors can reveal a range of emotions about their experiences. Feelings of fear, sadness, anger, ambivalence, and frustration are normal responses to IPV. The hotline advocate will be faced with different experiences and feelings of the survivors who call. Advocates who have an underlying knowledge of trauma and violence can better serve the needs of hotline callers.

Examples of Trauma Knowledge Needed by the Hotline Advocate

The Survivor… The Advocate...

Shares a story that does not Understands that survivors experience trauma differently. follow a clear, logical flow of Memories may not be easily accessible or difficult to recall. events.

Minimizes and defends the Understands that the healing journey is not always violence that occurs in the straightforward. A survivor may express feelings and relationship. emotions that do not reflect deeper, underlying issues,

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Expresses anger toward the Understands that anger is a common reaction to traumatic advocate for not understanding experiences. The advocate does not take the victim’s anger what the survivor is trying to say. personally. The advocate uses empathic language to paraphrase or reflect the client’s meaning.

Expresses an urgent need to Understands that healing from trauma takes time and does not resolve the problem immediately. necessarily follow a linear path.

Accuses the advocate of Understands that perpetrators of violence use control and supporting the abuser and not domination against their partners. The advocate understands supporting the survivor. that there is an imbalance of power between a professional and a client and seeks to minimize this imbalance.

Avoids answering particular Understands that either the survivor may not want to share questions. the information or that the question may not be important to the caller.

Asks for a place at the shelter, Knows that the shelter cannot accommodate the survivor at but the shelter is full. this time, but can offer assistance with developing alternative plans to remain safe.

Does not express the reason for Understands that a call to the hotline is a major, but often calling the hotline. difficult step. The advocate conveys appreciation and recognition for the brave act of calling.

Does not speak when the Understands that sometimes individuals need a moment of advocate answers the call. silence to gather their thoughts. The advocate waits patiently for the caller to speak.

The Survivor…. The Advocate….

Does not identify the gender of Understands that relationships can be with opposite or same- the abuser. sexed individuals. The advocate uses the neutral term “partner” until the caller identifies or the advocate asks the gender of the partner.

Reveals that the survivor has a Understands that survivors who have disabilities may need physical disability. special accommodations in order to access services. The advocate asks if and what type of accommodations the

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(Ferencik & Ramirez-Hammond, 2019)

Professionals who provide hotline services are often the first contact for survivors of IPV. If they convey compassion, empathy, and understanding, survivors may feel safe to seek further help. Survivors may be unaccustomed to being heard or cared for and as a result, feel attached to the advocate (Ferencik & Ramirez-Hammond, 2019). Survivors may use hotline services multiple times and for prolonged periods before taking steps to seek additional help. However, these initial contacts can provide the support necessary for helping survivors begin their journeys.

“Choosing to leave an abusive partner is arguably the most life-changing and empower decisions a woman can make. Finally, she chooses herself. The National Domestic Violence Hotline can be reached at 1-800-799-7233 or via an instant chat at thehotline.org. The website outlines a safety plan before leaving, while leaving, and after leaving. It includes variations for pregnant women, women with children, and women with pets. It also talks about emotions all victims will experience. I am learning to value the space between the victim and survivor. Some days I am more victim, others I am all survivor. Most of the time, I am both: wounded, healing, and healed. The National Hotline for Domestic Violence website has a list of helpful tips for life after leaving. They recommend cutting off contact with your ex, surrounding yourself with support, and considering counseling” (NCADV, 2019).

Intake Assessments

In order for survivors to receive treatment services, typically clinicians will conduct intake assessments. Trauma-informed assessments, such as intakes for domestic violence programs, are commonly extensive, detailed, and personal (Ferencik & Ramirez-Hammond, 2019). The intake process can be very difficult for some survivors. Some will be triggered by the questions or have distress related to recounting their experiences. Often survivors are in crisis when they seek an initial appointment for services. They are most likely anxious and nervous about seeking help. When they arrive to the intake session, survivors may display a range of coping

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Clinical considerations for Domestic Violence Intakes

Offer reassurance Ensure that the survivor and children are safe.

Offer choices Offer the survivor a range of choices for the day and time for the intake session.

Build on strengths Recognize the survivor’s ability to “walk through the door” to seek services.

Use body language Use body language, such as eye contact and leaning forward, to convey interest and empathy.

Create a safe environment Be mindful of the clinical environment. Allow the survivor to choose the place most comfortable.

Explain steps Explain the intake process and the types of questions that the clinician will ask. Recognize that the questions may be difficult for the survivor.

Convey empathy Use empathic techniques to convey compassion and understanding.

Educate about triggers Explain to the survivor that the clinician understands trauma, its triggers, and responses to help build a sense of safety.

End the session safely To end the intake, ensure that the survivor is feeling emotionally stable and not vulnerable.

(Ferencik & Ramirez-Hammond, 2019)

Disclosing IPV can be difficult and can cause the survivor to re-experience traumatic symptoms and responses (Ferencik & Ramirez-Hammond, 2019). Some survivors may not want the clinician to write down information that is disclosed for fear that the abuser will

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com somehow find out. If an abuser has threatened a survivor with violence if the abuse is disclosed, the survivor may be reluctant to share information. A clinician can acknowledge the difficulty and the sensitive nature of an intake process. The practitioner will ask sensitive and seemingly intrusive questions in order to obtain the information for an accurate diagnosis or assessment of needs.

During the intake session, a clinician should ensure that the clinical space is conducive to a trauma intake. The practitioner can make sure that tissues or water is available. The lighting in the room, if too bright or too dim, can be a trigger for some survivors. The clinical space for the intake should be quiet, private, and safe. A practitioner can offer to change the lighting or play music in order to help the survivor relax. A survivor may be sensitive to where seating is available. If the clinician is sitting close to the door, a survivor may feel trapped or unable to escape if needed.

“It is clear that positive support comes in all shapes and sizes. Some [survivors] describe how beneficial peaceful physical environments are, others talk of the importance of not being alone and the huge benefit of being part of a network of survivors and being able to talk about their own individual abuse, ‘with people who know.’ Essential is the importance of friends and colleagues who provide unconditional support and who perceive the process of overcoming abuse as something valuable - their experience being turned into an asset rather than seen as a deficit or pathology….Someone smiling in the street could make more of a difference than they would ever know” (Survivors Voices, 2019).

Survivors of abuse may express a wide range of emotional reactions (Ferencik & Ramirez- Hammond, 2019). Feelings about the relationship may be conflicting. There may be cultural considerations that need exploration in order to better understand the cultural and social context of the abuse. Clinicians can demonstrate openness and non-judgment by using verbal and non- verbal empathic techniques. A clinician who asks a client to describe her current situation conveys a different message than one who asks why the client has stayed in the abusive relationship and not left.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Children whose parent is being abused may experience extreme anxiety about being separated during an intake interview (Ferencik & Ramirez-Hammond, 2019). They may feel a strong need to check on the whereabouts of their parent in a new, clinical setting. The practitioner can show the child where they will be located and let the practitioner know that if the child needs to interrupt the session to see the parent, it is OK to do so.

A clinician can explain the process of conducting an intake prior to asking the questions (Ferencik & Ramirez-Hammond, 2019). This helps a survivor know what is expected, which can reduce anxiety. The survivor learns in this session that it is OK to stop or slow down the process if needed. Survivors who are allowed to control at least part of the process are aware that they have power to decide the next steps if they are triggered, exhausted, or need to take a break.

Chronic and prolonged exposure to violence often affects the memories of survivors (Ferencik & Ramirez-Hammond, 2019). During an intake, an individual may not be able to recall certain events or describe experiences that do not seem to be logically connected. Trauma affects the cognitions and memory functions. A clinician can record information with a plan for follow-up at a later time. The questions during an intake can feel intrusive and sensitive. A clinician can alter the way questions are asked in order to reduce the level of distress (Ferencik & Ramirez-Hammond, 2019). Below are some examples of how a practitioner can approach an intake assessment:

“During this session, I will ask you a lot of questions that may make you feel afraid or upset. If I ask you something that makes you uncomfortable, you can tell me that you’d prefer to not answer that question, OK?”

“All of the information you share with me will be confidential between you and me only. The only times I am required by law to share information is when a child is hurt or may get hurt or if you indicate that you want to kill yourself or someone else. Otherwise, what we talk about is private. Does this make sense?”

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com “When there is violence in relationships, individuals sometimes force their partners to have sex or perform sex acts when they don’t want to. This is a hard question, but I’m wondering if you have had any experiences like that?”

“People who have trouble in their relationships sometimes are afraid to call the police when violence is extreme. Have you ever experienced situations when you wanted to call the police, but felt like you couldn’t or were afraid to do so?”

Intake sessions are used by clinicians to conduct in-depth and thorough assessments of the client’s experiences and needs. This can often be a frightening or distressing session because it may be the first time a survivor is seeking help. If survivors are unfamiliar with a clinical assessment, the questions can feel intrusive and gratuitous. A practitioner can help prepare a survivor for the intake process by describing what questions will be asked and the types of reactions that can occur. A survivor may not be used to having control over relationships. A clinician can help to empower the client by expressly stating that the survivor can decide the pace and structure of the intake session.

ASSESSMENT

Many individuals who experience intimate partner violence (IPV) never report it. Many victims will only report IPV after a significant event, such as a severe injury, has occurred that makes disclosure necessary. When practitioners screen clients who are seeking services, they increase the likelihood that a survivor may disclose experiences of abuse (Galvin, Thompson,

Fulda, & Spence-Almaguer, 2019). However, there is controversy about whether or not IPV screenings definitively improve positive outcomes; meaning that screening may identify victims of IPV, but identified individuals may not engage in services or engaging in services may not substantially alter the victim’s circumstances (Dicola, 2016). With IPV disclosure, an

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com individual has a higher likelihood for connection with support services. IPV identification can take place in a variety of settings, such as OB/GYN offices, hospital emergency rooms, primary care offices, and community health centers (Sprague, et al., 2016). In health care settings, nurses are most often the practitioners that screen for IPV (Sprague, et al., 2016). However, other professionals, such as midwives, social workers, counselors, IPV coordinators, psychologists, and physicians can also assess clients for IPV.

IPV screening can occur in multiple settings, such as pediatric or medical clinics, schools, and human services settings - during these visits, helping professionals may have opportunities to screen for IPV in a way that does not put a survivor at additional risk (Prakash

& Wood, 2018). IPV screening can be part of a routine encounter where a professional automatically administers a screening tool. Because negative health consequences, such as physical injury, gastrointestinal problems, reproductive problems, and mental health difficulties, are associated with IPV, a health care professional may likely be the first person to come into contact with an IPV victim.

Screening procedures should include a plan for referral and follow-up to ensure that individuals are connected with specialized providers who are trained in IPV issues. Screening will allow providers to identify the presence of potential problems, but once the potential for problems is recognized a more thorough assessment is warranted along with a subsequent plan for treatment. There are several ways practitioners can support or help an individual experiencing IPV including:

• connecting to resources for IPV services,

• making referrals to other agencies,

• offering counseling and advocacy services,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • engaging in safety planning, and

• making home visits.

Individuals from vulnerable populations, such as women of color, immigrants, refugees, migrant workers, elders, and individuals with physical and cognitive disabilities, are especially vulnerable to violence (Prakash & Wood, 2018). Societal norms, such as perspectives on marriage and family, gender, income, and religious values, can affect how IPV is defined and interpreted. Racial, ethnic, and cultural backgrounds of people in the United States vary a great deal, thus making IPV screening challenging for untrained providers. Individuals who come to the United States may emigrate from countries where violence against women is either formally or informally condoned within familial, institutional, social, and cultural practices (Prakash &

Wood, 2018). They may have internalized their original societal values and may have difficulty recognizing the significance of IPV within the context of a new country.

Providers in various settings, from pediatric and medical facilities to community organizations and behavioral health programs, can implement screening procedures for IPV.

The type of IPV screening tool that is used depends upon different factors, such as clinical environment, availability of resources, and provider preference (Prakash & Wood, 2018). In addition, other types of screenings, such as standardized instruments for depression or PTSD, that can assist the practitioner in making a thorough evaluation.

Computer-based screenings are increasingly relevant because they are easy to use and can be integrated with electronic health records (Sprague, et al., 2016). Advanced technological platforms, such as computer programs, applications (i.e., apps), and audio and visual methods, can also be used to screen for IPV (Galvin et al., 2019: Sprague, et al., 2016). One such platform is a demonstration project with the University of North Texas Health Science Center

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com (UNTHSC) - School of Public Health and Family Medicine called TESSA (Technology

Enhanced Screening and Supportive Assistance), which was created to administer IPV screenings to patients in primary care clinics. Primary care clinics are practical places for these screenings because many times survivors need medical care for IPV-related injuries, such as broken bones, sprains, reproductive injuries, and damaged tissue. TESSA is a program that focuses not only on patients in medical clinics, but also clients in IPV-specific clinics. The

TESSA program includes components for screening IPV, assessing risk, linking to support services, and managing referrals across agencies (i.e., case management). TESSA is designed to give voice to victims of interpersonal violence and help survivors feel physically and emotionally safe, noticed and listened to. TESSA began as one of five projects nationwide connected to the Interpersonal Violence Provider Network. TESSA collaborates with health providers, community resources, agencies, and advocate services in the North Texas area to help screen for, identify, and address the needs of interpersonal violence victims. Individuals complete their self-reported screening in the provider’s office via iPad technology. The goal is to identify the needs of these individuals early during health and emergency visits, to connect them to programs and services that may positively impact their long-term physical and mental health (Crocker, 2019).

IPV can start early in the lifespan and is commonly experienced during adolescence when teenagers or young adults are exposed to IPV while they are dating (Niolon et al., 2017).

Individuals who witness or experience violence in childhood are more likely to be victims and/or perpetrators of violence (Howell, Barnes, Miller, & Graham-Bermann, 2016; Richards,

Tomsich, Gover, & Jennings, 2016). Other risk factors associated with the perpetration and victimization of IPV include, low educational attainment, unemployment, childhood history of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com violence between parents, a history of childhood abuse, neglect, and/or sexual abuse (Niolon, et al., 2017). These factors may inform a clinician’s selection of a particular screening tool and are therefore relevant to screening protocols used with individuals of particular groups. For example, a clinician who uses a tool that is not appropriate for a particular individual, such as someone whose native language is not English, may have difficulty in identifying IPV and connecting the person with supportive services.

CHALLENGES WITH “LEAVING”

A survivor is at most risk of violence when the survivor tries to leave a partner (NASW,

2019; National Coalition Against Domestic Violence [NCADV], 2019). A survivor may continue to remain with a violent partner because of threats for further or more severe harm to the individual or her loved ones. Though a relationship may be violent, the survivor often knows the abuser well and the extent to which an abuser may go in order to maintain control

(NCADV, 2019). Sometimes an individual may not be able to safely escape a relationship or protect loved ones. An abuser may harm family members, friends, neighbors, bystanders, or professionals who intervene.

Understanding the dynamics of an abusive relationship includes understanding its complex nature. There are a number of barriers a client can face when trying to leave an abusive relationship (NCADV, 2019). An individual may fear that the violence will escalate or become lethal if the victim attempts to leave. A client may not have a strong network of friends or family, especially if she has been isolated from these individuals. A person may face challenges associated with financial impoverishment or single-parenting. A survivor may see positive aspects of the relationship, such as times of happiness and love, despite the violence; in

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com other words, the survivor may want the violence to stop, but not want to lose the relationship.

An individual may not know how to access resources for safety and support. She may fear losing custody of her children. She may face homelessness once the period of respite in a shelter expires. There may be cultural beliefs and practices that dictate gender roles and expectations.

In addition to challenges that a survivor can face, there are societal barriers that can inhibit attempts to escape a violent relationship (NCADV, 2019). An individual may face legal charges of abandonment of children, which can result in loss of child custody. A survivor may not have the resources apart from the relationship to financially maintain adequate living standards. Some religious clergy and counselors may prioritize saving the relationship over leaving a violent environment. Some law enforcement officials may treat violence as a domestic dispute rather than a crime. Sometimes victims may be arrested for defending themselves against a batterer. Some police officers may dismiss the abuse and discourage survivors from filing charges. Some prosecutors may be reluctant to prosecute cases of abuse.

Some judges may impose only light sentences on those convicted of abuse. Even with restraining orders, abusers can sometimes return and repeat the abuse. Housing for survivors of violence continues to be sparse and difficult to obtain. Despite the barriers and challenges that exist for both clinicians and their abused clients, there are steps that practitioners can take during the assessment process.

HELP-SEEKING

Sometimes survivors of IPV decide to seek help only after a period of time when other personal coping strategies are no longer working (Evans & Feder, 2014). Victims of domestic violence often have limited or nonexistent support networks as a result of perpetrators creating a

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com systematic way of controlling and dominating them. Sometimes survivors feel shame or denial about needing services. Sometimes they do not trust that professionals or law enforcement officers are able to change their situations. Sometimes abuse is tolerated as part of an intergenerational pattern of violence among partners. Many survivors and perpetrators have childhood histories of abuse and violence, which affect their understanding of and willingness to seek help.

“Seeking support may well have come after a history of needs being chronically ‘unmet’ and unseen (often whilst in distress), whether that was at school, at work or within a domestic context. [Survivors] describe how their needs were ignored while at school, how employers could be reticent to offer entitlements for sick leave, or being asked, for example, detailed questions about abuse by an Occupational Health assessor over the phone. Underpinning such stories is the lack of empathy experience by many of the [survivors] on a daily basis and the everyday slights of language, feelings of shame for something that was not one’s own responsibility and the age-old feeling of being judged and for being a ‘bad’ person” (Survivors Voices, 2019).

Sometimes clinicians overlook symptoms of IPV simply by not including trauma-based questions in their assessments (Evans & Feder, 2014). When clinicians do not ask and survivors do not tell, needs may be left unmet in lieu of treating only symptoms, such as depression and anxiety. Disclosure to providers, especially if not specifically asked, can be threatening for survivors. They may lack the confidence that the professional may be able to help. If practitioners are unprepared for their clients’ disclosures of violence, they may inadvertently contribute clients’ feelings of vulnerability and fear.

Disclosure of abuse and help-seeking are complicated and complex situations. There are multiple factors that can affect whether a survivor seeks help. Mistrust and fear can inhibit help-seeking (Evans & Feder, 2014). Reactions from clinicians can also affect help-seeking behaviors. Helpful responses are those that convey emotional support about the abuse and offer

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com tangible help. Unhelpful responses, such as victim-blaming or pressure to act, can make survivors feel reluctant to ask for help.

Survivors of IPV may feel reticent to seek help if they blame themselves for the abuse (Evans & Feder, 2014). If they are socially isolated or made to believe that they caused the abuse, they are likely to internalize these beliefs. Sometimes their perpetrators are so effective in creating isolation that survivors normalize the violence and do not see it as needing formal intervention. Compounded by self-doubt, depression, low self-esteem, and sometimes substance use, a survivor may go without help for quite some time.

Intergenerational transmission of IPV is when there are patterns of abuse in generations of family lines into subsequent generations. Help-seeking can be particularly difficult if families have been immersed in violence for generations (Evans & Feder, 2014). Consequences of abuse, such as imprisonment of perpetrators, may be seen as damaging to the family and as a result, survivors may face difficult life situations, such as homelessness and poverty. Some survivors may fear repercussions of disclosure. They may justifiably fear further violence or trigger acts of revenge (Evans & Feder, 2014).

Disclosure of violence and help seeking are typical responses to crises or series of violent acts that have gotten worse (Evans & Feder, 2014). In these situations, immediate help is needed, such as law enforcement assistance or referrals to shelters and victim support. Survivors may prefer to first disclose the violence to friends or family members. Only later, with support, may survivors feel comfortable with formal help-seeking. Often help-seeking attempts are successful after survivors feel empowered and take planned and strategic actions.

Survivor help-seeking is a complex process that involves internal appraisal and processing of the abuse in combination with assessment of contextual influences (Evans & Feder, 2014). Factors, such as the availability of interpersonal support, formal and informal networks, information, and financial resources, can affect whether a survivor seeks help. A crucial factor is whether or not the survivor recognizes and acknowledges abuse in the relationship. With that acknowledgment, a survivor can decide whether or not to take action and in what ways.

Transtheoretical Stages of Change Model (TTM)

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com She TV Media is a female-owned video production company that focuses on telling untold and inspiring stories about women’s empowerment. Their first documentary series is Scars Unseen, which follows the lives of six men and women who have overcome domestic violence. The series aims to highlight to moments of personal realization, triumph, courage, bravery, and healing of their situations (Yinger & Perez, 2019). The transtheoretical model of change (TTMC), adapted from its application from addiction behavior to survivors of IPV, outlines a series of changes in mental processes (Evans & Feder, 2014). These changes range from pre-contemplation to contemplation, preparation, action, and maintenance. Survivors of violent relationships can move among these stages in a nonlinear fashion, but may ultimately lead toward getting help and leaving abusive relationships. This theoretical model of change is important so clinicians can better understand where their clients are in the process of changing their lives. For individuals whose partners use violence, the change process can be slow and incremental.

The TTM model of change as it applies to IPV helps clinicians to better understand the decisions made by survivors (Murray, Crowe, & Flasch, 2015; Prochaska, Redding, & Evers, 2015). Decisions to leave an abusive relationship are complex and include many factors, such as the type of abuse, financial independence, presence of children, personal characteristics of both the survivor and perpetrator, and personal resources for support. Given these variations, the process of change from survivor to survivor is not linear (Murray, Crowe, & Flasch, 2015). Individuals experiencing partner abuse consider both internal factors, such as self- efficacy, perceived support, and awareness, and external factors, such as finances, availability of services, and support, when making a decision to leave the relationship.

The principles of TTM are that changes are made through a process of stages which can be applied across different theories of intervention. The TTM incorporates six stages of change and a client’s movement through them in a distinct period of time (i.e., six months) (Prochaska, Redding, & Ever, 2015).

The stages of change according to this model are (Prochaska, Redding, & Evers, 2015):

1. Precontemplation: A client is not ready and does not intend to take any action within the next six months.

This stage is delineated by a client’s lack of intention to make any behavioral changes. This

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com lack of intent may be simply because they are uniformed about the consequences of their behavior or have not yet experienced negative consequences. Characteristics of individuals in this stage are resistant or unmotivated to change their behavior. They may have tried to change unsuccessfully in the past or may not have a motivation to change. She may not want to discuss, think, or learn more about any behaviors or situations that may be high risk. She may have tried strategies unsuccessfully in the past and now believe that her circumstances are unavoidable.

2. Contemplation: A client intends to take action within the next six months.

Individuals in this stage of change may be aware of the benefits of changing, but are also immersed in the challenges of changing. Clients in this stage are generally ambivalent about changing their behaviors. Individuals in this stage can feel stuck for long periods of time and procrastinate in taking any steps toward change. In this stage, an individual appears to be ready for making a change. Her thinking patterns may show more readiness to consider life circumstances. She may be more aware of the risks for staying in a violent relationship and understand how they outweigh the benefits. The individual may appear ready for change, but she may struggle with the immediate consequences of making a change. A person in this stage has thought about the desired change and may be willing to acknowledge its importance, but may not be ready to take specific steps at this point.

3. Preparation: A client intends to take action within the next 30 days and has already taken some steps toward change.

In this stage, individuals feel ready to take action sooner rather than later. They may have taken a significant step in the past, such as seeking therapy or reading information on the Internet, and plan to move forward, usually within a month. This is an optimal stage for entering into different types of programs because they are open-minded about change in general.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com She may have taken a significant step towards change, such as contacting a domestic violence agency for resources. She may have devised a plan for the next steps toward change. She may have made smaller, subtle changes, such as creating a safety plan or establishing a savings account, indicating a readiness to take more substantial steps.

4. Action: A behavioral change has taken place, but for less than six months.

Clients in this stage have taken a specific action or made some type of modification in their lives, but this has occurred recently. The specific action can be small, such as reading a self- help book, or large, such as attending a weekly support group. In this stage, the person is ready to take specific steps toward change. She has made a series of observable changes in her life that will support larger decisions, such as leaving the relationship.

5. Maintenance: A behavioral change has taken place and lasted more than six months.

At this stage of change, individuals have a consistent behavioral change over a longer period of time. They may be tempted to revert back to old behaviors, such as blaming themselves for the abuse they’ve suffered, but strive to maintain their steps toward a healthy lifestyle. These temptations may last years. If changes in behavior are maintained, the goal is that eventually they will be integrated into daily living. An individual in the maintenance stage has made the important changes to alter her life. When a person is in other stages she may revert back to an earlier stage, especially if she fears reprisal or serious consequences, such as homelessness. However, when an individual is in the maintenance stage, she is less likely to relapse and is more confident in the knowledge that her choice to leave was the right one. This period in the change process can last from six months to five years or longer.

6. Termination: A long-lasting change has taken place and there is no temptation to relapse.

Clients who are in the termination stage no longer experience temptation that significantly threatens the behavioral change. They are more confident in their ability to maintain the change and may be progressing onto other types of lifestyle changes. Their healthy behaviors are automatic and do not require concerted effort to maintain. A person in the termination stage has made a life-long change in lifestyle. Even if she is feeling depressed, anxious, or unhappy, she

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com is confident that she will not return to an unhealthy, violent relationship. She can understand that the change she made in the months earlier are sound and healthy despite her current feelings.

Moving through stages of change incorporate numerous processes that a client may use. These change processes are strategies that a client can use to help progress in her quest for a healthier lifestyle. The TTM model for change is comprised of ten processes of change (Prochaska, Redding, & Evers, 2015):

Raising consciousness: Becoming aware can help move one forward. Often clients begin their change processes by becoming aware of the causes, consequences, and solutions to a particular problem or problematic behavior. A client can prepare for change by learning how to view a problem in a broad, holistic way. Possibilities can emerge that were not previously considered. They cannot change unhealthy lifestyles if they are unaware of the negative effects particular choices or circumstances have upon their lives.

Dramatic relief: Individuals can become more aware of a problem through grieving, feedback, and media campaigns. Sometimes viewing an issue from another’s perspective can bring into light aspects of the problem that were overlooked. Some clients may benefit from practicing a particular behavior or imagining lives without a particular problem. Clinicians can use interventions, such as role-playing, meeting others who have successfully gone through similar circumstances, and observing a support group, to help clients understand and imagine the relief that they can feel once a change has occurred.

Self-evaluation: As an individual moves toward change, this can be a time of uncertainty and self-doubt. Re-evaluation of one’s values, beliefs, thoughts, and understanding can reinforce positive behavior towards a particular goal. Techniques, such as imagery and contacts with role models, can be helpful. Clients in relationships with violent partners often have created self-images and beliefs about themselves that are negative, demeaning, and distorted. As clients challenge these beliefs and re-evaluate themselves, they can clarify their values and observe actions of healthy role models. Self-evaluation includes examination of thoughts, feelings, and behaviors to see if they are in line with a healthy lifestyle.

Environmental evaluation: Understanding how the current environment affects both the

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com client, and others, such as children and relatives, is important in efforts toward change. An environmental evaluation in concert with a self-evaluation can provide a broader context within which to view the change process. A step toward change can involve an evaluation of the environments in which survivors and/or their children reside. This can include an assessment of environmental resources that can help support survivors as they make lasting changes. Family members can be helpful by providing feedback about the survivors’ lives and offer potential solutions for creating changes.

Self-liberation: The belief that one can change and has the capacity to create change (e.g., self-efficacy) is a vital component of this process. Sometimes this understanding takes a long time to foster because a large part of the motivations of a perpetrator of violence is to eliminate the belief that the survivor has the strength and skills to change. Clients must not only have beliefs that they can change, but also have the will and commitment toward change. They must have a deep desire to change their living situations and become free of unhealthy relationships and lifestyles.

Social liberation: In order for people to change, a person needs to recognize and possess other social opportunities than the ones they currently have. Sometimes this can be as simple as raising awareness that other programs and options exist. Other times individuals have opportunities after successful advocacy efforts. An internal belief and commitment towards a healthy life also requires support from the external environment. There must be social opportunities for clients, especially those still in relationships with violent partners, because they often feel negative and uncertain about their abilities after periods of degradation and negative messages from their abusers. Social opportunities can be created by agencies in their policies and procedures toward survivors of abuse. Systems of help, such as shelters and aftercare programs, can help support survivors as they make changes in their lives.

Counter-conditioning: An individual learns healthy behaviors with the goal of replacing unhealthy or maladaptive behaviors. Overcoming patterns of unhealthy behaviors require first a knowledge that the pattern is unhealthy, and then developing healthy behaviors that can serve as replacements. Often survivors have experienced systematic oppression by their abusers. Counter-conditioning involves learning healthier thoughts, beliefs, and behaviors

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com that can substitute for the negative ones that were created as a part of abusive relationships.

Stimulus control: Similar to counter-conditioning, stimulus control means to understand the triggers or cues that lead one toward unhealthy behavior patterns in the first place. For a survivor of IPV, a trigger that often leads to an unhealthy behavior pattern may be when the perpetrator appears contrite about the abuse. A perpetrator may explain that the behavior will never happen again or offer gifts and other tokens of apology. If a survivor is able to understand that this triggers feelings about sharing the blame or taking responsibility for the perpetrator’s actions, then other steps can be taken to avoid falling into the same behavior pattern. Many survivors, through the course of their abusive relationships, are taught to respond in particular ways to behavioral cues of the abuser. Stimulus control involves re- teaching healthy thoughts, feelings, and behaviors toward environmental stimuli. Learning how to change responses to triggers can help survivors learn how to manage difficult and negative feelings that arise. Contingency management: Contingencies are plans for taking steps in a particular direction. For a survivor of IPV, this can be small rewards for distracting oneself from triggers or seeking support from someone who is committed toward helping the individual. It is helpful to anticipate that the process of change will be difficult and requires continued efforts until an individual has met goals on a consistent basis. Contingency management is a set of strategies for providing rewards for healthy decisions or steps toward healthier lifestyles. Natural contingencies that affirm and support survivors, such as more time with friends and families, can help reinforce positive lifestyle choices.

Helping relationships: Finally, an important step in the change process is to identify relationships in which healthy behaviors are supported. This can include relationships with friends and family, professionals, support groups, and others that will support an individual through the difficult task of healing. Clients who decide to leave unhealthy and violent relationships need individuals who can support these healthy changes. A therapeutic relationship with a practitioner can support healthy behaviors, but so can friend and family support networks.

On September 4, 2019, the governor of New York increased the statute of limitations for civil suits from domestic violence survivors from one year to two years. The decision to file a civil law suit can be a challenge for many survivors of domestic violence. This reflects an understanding that a survivor’s journey to safety is not simple and, along with many other

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com personal choices and changes, the decision to file a civil suit is complicated and can take a lot of time to consider. By allowing more time for survivors to file suits, survivors can focus on their safety first and then seek damages from their abuser (Bianco, 2019).

In the precontemplation stage, processes associated with that stage are: consciousness raising, dramatic relief, and environmental re-evaluation. In the contemplation and preparation stages, self-evaluation is particularly helpful. In the action stage, the self-liberation process is helpful. Finally, in the maintenance stage, the processes counter-conditioning, helping relationships, reinforcement management, and stimulus control are helpful.

Change is created through a series of processes and follows a trajectory through stages. Survivors who want to change their lives go through a series of steps to leave unhealthy lifestyles and move toward healthier ones. As they move through this change process, individuals often weigh the pros and cons of making specific changes (Prochaska, Redding, & Ever, 2015). While weighing the consequences of making changes, they also need to feel a sense of capability and capacity to make and sustain those changes (i.e., self-efficacy). The potential for relapse or regression can be high, especially with changes that may be difficult in the immediate future. For example, if a survivor chooses to leave an abusive relationship, she will need to physically move to another temporary shelter. She leaves a home, that while may be violent, is also familiar and known. Many shelters offer temporary services, which may, after the service period has ended, leave survivors facing homelessness if they are unemployed or have not saved enough money to support themselves financially.

Factors Affecting Help-Seeking Behaviors

Survivors who are in violent relationships often experience high levels of stress, depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD). Several factors are associated with IPV including age, education, employment status, childhood exposure to violence, drug and alcohol abuse, and socioeconomic status (Ferrari, et al., 2016; Semahegn, et al., 2019). The more severe the IPV, the worse mental health outcomes. Symptoms of depression, anxiety, PTSD, sleep disorders, self-injury, and suicidal behaviors are associated with severe IPV. The more severe the symptoms, the higher the likelihood that survivors will seek help.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Survivors of IPV often do not seek help. In fact, less than half of survivors seek medical or psychological care (Fleming & Resick, 2017). Helpful resources for survivors of IPV include both external resources, such as professional and formal resources, and internal resources, such as family, friends, and personal psychological strengths. Often survivors use personal resources because of familiarity and closeness. External resources, such as police, doctors, lawyers, and domestic violence agencies, may be helpful, but are often not the first line of assistance. Sometimes these resources are inaccessible because of language or transportation barriers, experiences with racism, worries about stigma, and concern for the perpetrator’s well-being. Additionally, there can be a lack of services, such as in rural geographical areas.

Further, there are a number of barriers to help-seeking (Fleming & Resick, 2017). Survivors may fear that their abusers will exact retribution. They may feel shame about the violence and/or remaining in an abusive relationship. They may want to protect their partners from arrest and/or imprisonment and/or deportation. They may feel that their children will suffer more in a one-parent household. Many survivors want to keep their personal situation private. They may be members of cultural or ethnic groups that frown upon seeking outside assistance for marriage/relationships problems.

“When you’re in the relationship for a long time, you lose your identity. You believe in the lies you were told. We don’t believe in our ability to live an independent life. You don’t get much sense of freedom and, on average, it takes a woman seven times to leave a relationship for good. I lost the support of my own family and friends. It’s about trying to form a new circle of friends around you for support… And then, there is the shame factor in the whole abuse. So, we find it very hard to open up to anyone. I did have friends at work, a colleague, she was in that type of situation before, but then she realized what was happening to me, because over time, it will get so stressful that you develop the physical symptoms, even though you try to ignore it. Eventually, your body will accumulate enough stress that it manifests itself in physical symptoms. I suffered from excessive bleeding and chronic fatigue, and when that happened, my colleague picked it up because she was in a similar situation before… I didn’t take the support. I tried to find a way to solve the problem on my own. But you’ll never be able to do it alone” (Lee, 2019).

Other factors also affect help-seeking among survivors of abuse (Fleming & Resick, 2017). Many survivors may distrust professional resources. They may feel that if they disclose abuse, providers may perceive the abuse as not serious enough. They may be concerned that

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com professional intervention will lead to more serious consequences for their partners, such as arrest and imprisonment. Impoverishment and/or homelessness can be feared if the abuse is reported to authorities.

Survivors who are of higher socioeconomic statuses, have more economic stability, and a higher number of resources tend to seek help less frequently than survivors with lower incomes and resources (Fleming & Resick, 2017). Survivors’ use of formal help-seeking resources is related to the severity and frequency of abuse; the more severe and frequent, the higher likelihood they will seek help. In addition, survivors’ beliefs about the helpfulness and effectiveness of resources are related to help-seeking behaviors. Survivors who believe they are capable of change (i.e., self-efficacy) and feel empowered to do so are more likely to seek help. Positive attitudes about seeking help are also related to actual help-seeking behaviors. Individuals who experience partner violence and believe they are capable of controlling their situations are more likely to seek treatment and assistance.

Survivors who report higher levels of psychological trauma as a result of abuse are more likely to seek professional help (Fleming & Resick, 2017). Older survivors also are more likely to seek treatment. Other factors are also associated with the likelihood of seeking treatment, such as the belief that the violence is uncontrollable, higher level of coping skills, and beliefs that resources will be helpful. Personal resources and informal help networks are more often used, especially when the length of time in the abusive relationship is longer.

Personal resources are associated with active coping strategies and lower avoidance strategies (Fleming & Resick, 2017). Family and friend support networks can help survivors connect with professional resources. If a survivor believes that services will be helpful and useful, she may be more likely to seek help from professional resources. Professional resources are often used more often when survivors think that there is no other way to control the violence in their relationships. When they feel that the violence is unpredictable and/or out of control, they are more likely to seek help.

SAFETY PLANNING

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com A safety plan is an individualized, written, and practical plan that includes: a) ways to remain safe in a relationship, b) a plan to leave, and/or c) a plan for after an individual leaves a relationship (National Domestic Violence Hotline, 2019). A safety plan is an intervention that is personalized and detailed to the survivor’s needs (Murray, et al., 2015). It is a tool that takes into consideration the needs of the survivor and assesses risks and danger (Ferencik & Ramirez- Hammond, 2019). This written document outlines clear and specific steps that a survivor can use to promote safety. A safety plan is often developed between a professional and a survivor. There is no one document that is used across all practices. The format and type of document will be implemented based on the information and resources available to a survivor.

A safety plan includes short- and long-term needs and goals for survivors (Ferencik & Ramirez-Hammond, 2019; Murray, et al., 2015). It is developed through collaborative dialogue between a practitioner and client. After a thorough biopsychosocial assessment, a clinician can offer help with developing the plan. Sometimes survivors may not be ready to develop a safety plan in the initial stages of therapeutic work. Sometimes they are not at the point where they want to terminate their relationships with their abusers, when this is the case safety plans can focus on ways to increase the safety of the situation without terminating the relationship (e.g., removing weapons from the home). Other times survivors may be ready to discuss the plan immediately as it can bring a sense of self-empowerment and self-efficacy.

Safety planning is an interactive process that can be done over a period of time (Murray, et al., 2015). The components of a safety plan should include general and specific strategies for promoting client safety. It should empower a client and promote autonomy.

The initial steps to safety planning often involve a clinician providing information to a survivor (Murray, et al., 2015). This information can include contact for local and national resources, such as local domestic violence shelters and services, legal services, law enforcement, and social service agencies. The plan can include specific safety strategies for readily enacting a safety plan. Some tips are (Murray, et al., 2015):

1. Keep cash and copies of keys secured and readily available

2. Have supplies for self and children readily available

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4. Remove weapons from the home

5. Discuss the safety plan with a family member or friend

6. Strengthen home security, such as changing locks or installing a security system

7. Create an escape plan

8. Ask neighbors to call the police if they hear or are aware of a violent event

9. Have a code word or sign for neighbors to alert them that help is needed

10. Identify safe rooms in the home to escape from violence

11. Identify and address needs for transportation and communication

12. Create a plan for workplace safety

13. Identify strategies needed to increase the safety of children

When a clinician and client complete a safety planning process, there typically is a written document that outlines the unique needs and strategies for a particular client (Murray, et al., 2015). The plan should include goals and strategies that are simple, realistic, and specific. It should incorporate the context and environment in which the client lives. It can also involve a host of professionals that can intervene at a given time.

The ideal safety plan includes multiple strategies for safety (Murray, et al., 2015). These strategies are often physical, but can include psychological, financial, and interpersonal plans as well. Safety planning can be done at different points in a survivor’s life or in different settings. It can be done during a visit to a physician’s office or in an emergency room. There are technology-based safety planning approaches, such as Safer and Stronger Program (SSP) for deaf and hard of hearing survivors. Information about resources and contacts can be distributed in general public areas, such as grocery stores or coffee shops.

Safety planning is needed because survivors often do not have the knowledge or resources they need to escape a violent relationship. Often survivors face barriers with finances, job skills, housing, transportation, and childcare (Murray, et al., 2015). Survivors may not know about or

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com may not have the skills to use technology-related resources for coping with violence. It is important to note that perpetrators can use technology, such as GPS tracking devices, cell phone location apps, hidden cameras, search histories or computer software to track survivors; if survivors are contending with this form of IPV resources that educate them about such technologies will be essential.

Survivors from diverse cultural and ethnic backgrounds may have unique needs that require contextual planning (Murray, et al., 2015). Victims who are unauthorized migrants may fear deportation if they report abuse or leave a relationship. They may require additional services, such as translators or translated materials. Community members, especially among diverse cultural and ethnic groups, may have cultural norms and beliefs around domestic violence (Murray, et al., 2015). They may have strong community resources, such as churches and congregation members, that can be helpful to a survivor. In contrast, there may be pressure to stay in a marriage and avoid disclosure of abuse.

Survivors from diverse populations, such as lesbian, gay, bisexual, and transgender (LGBT)or immigrant communities, may need additional assistance with planning for safety (Murray, et al., 2015). There may be unmet social, psychological, and interpersonal issues that arise in violent relationships that need additional precautions. Violence among elderly couples may need specialized planning.

Safety planning is also dependent upon the community context (Murray, et al., 2015). Some communities have strong connections with community partners and can offer survivors a variety of services from which to choose. However, many communities lack resources, such as legal aid or low- or no-cost attorneys. Transportation, especially in rural areas, can be a huge barrier.

Practitioners can help survivors of abuse with safety plans by keeping a few key principles in mind (Murray, et al., 2015). The overarching focus of planning is the safety of the survivor. The planning process involves an individualized conversation to address the survivor’s unique and specific needs. When practitioners use an empowerment approach, survivors can come to understand that they have choices that are important and valuable. Clinicians can offer education about aspects of safety planning, such as restraining orders and court procedures, as well as resources to deal with specific issues. Practitioners can educate survivors about the potential for danger and lethality when leaving an abusive partner. The highest risk for lethal

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com violence is when the survivor leaves the relationship. Providers can conduct lethality assessments with survivors to identify risk factors for homicide as part of the safety planning process.

Practitioners can help survivors plan for safety by providing relevant information about shelters (Murray, et al., 2015). Often shelters have extra security measures, such as secret locations, on-site staff, coded key-pads, bullet-proof glass, and security cameras. Practitioners can help their clients locate the nearest shelter and explain the precautions needed to keep themselves and others safe. Further, practitioners can interact with clients in a manner sensitive to clients’ expertise on the trauma they have already experienced. The table below provides examples of trauma knowledge as it relates to safety planning.

Examples of Trauma Knowledge About Safety Planning

The Survivor … The Clinician …

Knows what the potential risks and dangers are Listens to the survivor’s experiences and in her relationship with an abuser. concerns and incorporates this perspective into a safety plan.

May not recall particular events about the Normalizes these thoughts and feelings by violence or may have heightened arousal for explaining that these are common reactions to potential dangers. trauma.

Fears that she will be unable to remember the Acknowledges the survivor’s concerns that in a details of the safety plan. crisis situation, she may not be able to remember everything. The clinician works to develop a simple, intuitive plan that will not create distress for the survivor.

Has a strategy or plan for leaving the Listens to the survivor’s plan and supports the relationship or ensuring safety. efforts made thus far.

Worries that circumstances might arise for Validate the survivor’s feelings and recognize which the survivor is unprepared. that circumstances are complex and change

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Does not understand what particular term Defines a term and describes the steps that are means (e.g., protective order). involved with each level.

(Ferencik & Ramirez-Hammond, 2019)

The National Domestic Violence Hotline (2019) identifies information that is important for a survivor’s safety plan:

• Identify a partner’s use and level of force to assess the risk of physical danger to the victim and children before it occurs.

• Identify safe areas of the house where there are no weapons and there are ways to escape. If arguments occur, victims should try to move to those areas.

• Don’t run to where the children are, as the violent partner may hurt them as well.

• If violence is unavoidable, victims should make themselves a small target by diving into a corner and curling up into a ball with their face protected and arms around each side of their head, fingers entwined.

• If possible, have a phone accessible at all times and know what numbers to call for help. Know where the nearest public phone is located. Know the phone number to a local shelter. Call the police.

• Let trusted friends and neighbors know of the situation and develop a plan and visual signals for when help is needed.

• Teach children how to get help. Instruct them not to get involved in the violence between partners. Plan a code word to signal to them that they should get help or leave the house.

• Tell children that violence is never right, even when someone they love is being violent. Tell them that they, nor the victim, are at fault or are the cause of the violence, and that when anyone is being violent, it is important to stay safe.

• Practice how to get out safely. Practice with children.

• Plan for what to do if a child tells a partner of the safety plan or if a partner otherwise finds out about the safety plan.

• Keep weapons like guns and knives locked away and as inaccessible as possible.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • Make a habit of backing the car into the driveway and keeping it fueled. Keep the driver’s door unlocked and others locked — for a quick escape.

• Try not to wear scarves or long jewelry that could be used to strangle a victim.

• Create several plausible reasons for leaving the house at different times of the day or night.

The National Center on Domestic and Sexual Violence (2019) provides a template that clinicians can use with their clients to develop a safety plan at http://www.ncdsv.org/images/DV_Safety_Plan.pdf. This plan includes an eight-step process for developing a safety plan:

Step 1: Develop a list of strategies a survivor can use to help avoid violent incidents or obtain help when violence occurs. Examples from this step include:

ü I can keep my purse and car keys ready and put them in (location) in order to leave quickly ü If I have to leave my home, I will go to (location) ü When I expect we’re going to have an argument, I’ll try to move to a place that is low risk, such as (location) Step 2: Develop a list of strategies a survivor can use when planning to leave the relationship. Examples from this step include: ü I will keep copies of important documents or keys at (location) ü I will open a savings account by (date) to increase my independence ü I can leave extra clothes or money with (individual) Step 3: Develop a list of ways that a survivor can create safety within the home with an abuser.

Examples from this step include:

ü I can replace wooden doors with steel/metal doors ü I can purchase rope ladders to be used for escape from second-floor windows ü I will tell the people who take care of my children which people have permission to pick up my children and that my partner is not permitted to do so. The people I will inform about pick-up permission include: (name of school), (name of babysitter), (name of teacher), (name of Sunday-school teacher), (names of others)

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Step 4: Develop a list of steps that a survivor can take in order to help police enforce a protective order. Examples from this step include:

ü I will keep my protection order (location or on person)

ü I will give my protection order to police departments in the community where I work, in

those communities where I visit friends or family, and in the community where I live

ü If my partner destroys my protection order, I can get another copy from the clerk’s

office

Step 5: Develop a plan for who will be informed about the abusive situation and ways to remain safe. Examples of this step include:

ü I can ask (name of person) to help me screen my telephone calls at work ü When leaving work, I can (describe)

ü I will go to different grocery stores and shopping malls to conduct my business and shop

at hours that are different from those I kept when residing with my battering partner

Step 6: Develop a plan for drug and alcohol use. Examples of this step include:

ü If I am going to use, I can do so in a safe place and with people who understand the risk

of violence and are committed to my safety

ü If my partner is using, I can (describe) and/or (describe)

ü To safeguard my children, I might (describe)

Step 7: Develop a plan to safeguard emotional well-being. Examples of this step include:

ü If I feel down and am returning to a potentially abusive situation, I can (describe)

ü I can tell myself, (describe) whenever I feel others are trying to control or abuse me

ü I can read (name of book, website, blog, etc.) to help me feel stronger

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Step 8: Develop a list of items to take when leaving the relationship. Examples of this step include: ü Identification cards ü Birth certificates ü School and immunization records ü Checkbook, ATM cards ü Keys (house, car, office) ü Medications ü Welfare identification, work permits, green cards ü Children’s birth certificates ü Social security cards ü Money ü Credit cards ü Driver’s license and registration ü Copy of protection order ü Passports ü Divorce papers ü Medical records ü Address book ü Important phone numbers/emails

A safety plan includes several specific components designed to provide a concrete, detailed, written plan of what to do, when, and with whom when leaving a relationship or even to minimize risk when remaining in the relationship. In general, creating a safety plan includes outlining the steps and strategies one can plan in advance. It can also include having a survivor put together a bag with emergency supplies and important documents (NASW, 2019).

Safety planning is an important part of the assessment process. It is an ongoing process that needs to be reviewed and updated periodically whether the client chooses to remain in the relationship or not (NASW, 2019). The safety planning process identifies and builds upon a client’s existing resources, strengths, and supports that may not be fully known to the client at

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com the time. Practitioners can assist clients in this process by helping to gather information about local domestic violence resources, legal rights, community agencies, and social services.

The Kansas City Kansas Police Department’s victim services unit has served roughly 1,200 victims of domestic violence. It is the first police-based victim services unit in the state of

Kansas. They work on a number of incidents from domestic violence and sexual assault to assisting families of homicide victims. Two advocates assist with protection orders for abuse, sexual assault, and human trafficking. Unit supervisor, Wendy Medina, said that domestic abuse cases make up the majority of their calls. She and the advocates on her team want victims to have the resources they need readily available to them. They talk about safety planning to make sure the victim’s documents are ready when she is ready to leave, have a trusted person whom the victim can call, and have a housing plan in place. They also help with getting an order of protection. The victim services unit assisted with about 600 protective orders for abuse since the beginning of 2019 (Daniel, 2019).

MULTIDIMENSIONAL LEVELS OF TRAUMA

Trauma is a complex and dynamic phenomenon and impacts an individual in multiple ways. The sociocultural model of trauma incorporates factors at varying “levels” that can affect individual reactions to trauma and includes strategies for resilience. These levels include: individual, interpersonal, community and organizational, societal, and cultural impacts

(Magruder, McLaughlin, & Borbon, 2017; SAMHSA, 2019).

Individual-level

Individual-level factors that can affect experiences of and reactions to trauma include age, mental health, temperament, personality traits, education, gender, coping styles, and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com socioeconomic status (SAMHSA, 2019). Individual-level characteristics also play a role in the ability to employ resiliency skills (Sippel, Pietrzak, Charney, Mayes, & Soutwick, 2015).

Processes at the individual-level, such as the capacity for managing stress, cognitive abilities, physical and mental health, problem-oriented coping strategies, an internal concept of purpose in life, and optimism can help a client address the effects of trauma (Sippel, et al., 2015).

Interpersonal-level

Interpersonal-level factors that can help an individual cope with trauma include family relationships, social networks, friends, and interpersonal relationships (Sippel, et al., 2015).

Survivors of IPV have problematic relationships with their partners because of the violence that occurs. However, social systems can help support an individual to deal with aspects of the intimate relationship. Social support can include emotional support that can help a person feel loved, respected and cared for by others (Sippel, et al., 2015). Other elements of social support include such material support as goods and services, that help to resolve practical problems like saving money, obtaining housing, accessing legal services, or helping with transportation needs.

Family and friends can provide supportive information to victims about where to get services or assistance specific to the needs of IPV victims. A lack of interpersonal support and isolation can often result in feeling alone, helpless, and hopeless that the situation will improve.

Survivors of IPV often have experienced or witnessed intergenerational familial patterns of abuse (SAMHSA, 2019). Childhood exposure to trauma can affect development across cognitive, emotional, and social domains and lead to negative mental health and educational outcomes (Magruder et al., 2017). Individuals with personal histories of trauma can view violence in their relationships as normal or something that is familiar. Other forces in their

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com social network can help to reframe aspects of the relationship to portray a broader picture of the negative and dysfunctional effects of IPV.

Community and Organizational Levels

Community and organizational systems can influence the likelihood of trauma occurring and how its effects can be approached. Incidents of general violence are more likely to occur in certain locations, such as metropolitan areas and conflict zones (Magruder et al., 2017).

Community and organizational levels include larger social support networks, such as workplaces, neighborhoods, school systems, behavioral health systems, transportation, and community resources (SAMHSA, 2019). Community education, such as IPV informational resources and awareness campaigns, can bring the signs, symptoms, treatment options, and resources at the forefront to help others identify individuals who may need help and to help survivors gain the information they need to access services.

Societal-level

Societal-level factors that influence IPV relate to policies that either hinder or inadvertently promote violence (Magruder et al., 2017). Policies, procedures, and guidelines for the criminal justice system, including law enforcement, for both survivors and perpetrators are social influences in IPV. Firearm laws and regulations also play a role in societal-level factors.

Policies and guidelines for protective orders and peace agreements are important to provide some level of safety for survivors. Specific laws and policies can influence the level of protection and interventions afforded to individuals from underserved groups, such as lesbian, gay, bisexual, and transgendered (LGBT) individuals or those from diverse racial and ethnic groups. Additionally, societal-level factors such as concerns about the racism in the criminal

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com justice system, fears of deportation, or disparities in healthcare access may affect an individual’s help seeking behaviors and choices about which services to engage with (e.g., seeking shelter services, but not calling the police; or using urgent care centers, but not connecting with non- crisis healthcare services).

Cultural-level

Cultural-level factors can influence how violence is interpreted and can impact how an individual copes with its negative effects. Factors, such as religious beliefs, norms, gender roles and expectations, collective vs. Individualistic norms, and what is considered to be violent behavior are a reflection of an individual’s culture and world view (Murray, Crowe, & Flasch,

2015; SAMHSA, 2019). Individuals who immigrate to the United States and individuals from diverse racial and ethnic backgrounds are disproportionately impacted by IPV (Branco & Rana,

2018; Stockman, Hayashi, & Campbell, 2015), and experiences of racism effect help-seeking behaviors.

Overall, the factors that influence how violence is identified, defined, and addressed are multi-dimensional and multi-systemic. Factors at multiple individual, interpersonal, community, organizational, and cultural levels each have unique roles to either contribute toward a potential for greater trauma or provide a comprehensive system of care for survivors of

IPV.

There are numerous negative effects of IPV on survivors. The frequency and degree to which these factors affect an individual also influences the degree to which one experiences trauma. Health problems, such as cardiovascular, gastrointestinal, reproductive, nervous systems, and musculoskeletal problems can affect survivors of IPV (CDC, 2019). Other types

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com of health problems, such as unintended pregnancies, miscarriages, stillbirths, and a host of reproductive problems can result from sexual violence. Negative psychological outcomes include depression, anxiety, suicide, drug or alcohol addiction, and post-traumatic stress disorder (PTSD). In addition, survivors of IPV may be at a higher risk for engaging in unhealthy behaviors, such as drinking alcohol, using drugs, and having unprotected sex.

For the last 30 years, a group of Minnesota women have collected the names of every victim of domestic homicide in their state. Known as the Femicide Report, it started in 1989 as a way to fill a gap in reporting gender-bias violence against women and girls. No other state or national group is collecting this kind of data. “Every month or so a woman, and or her children, and or her partner or mother or neighbor got killed, and it was like a flash in the pan,” said Julie Tilley, who first decided to start collecting the names as a staff member at the

Minnesota Coalition for Battered Women. “One of our goals was not only to honor the victims of this horrendous violence, but to make this violence visible. It was so clear to us at that time that people weren’t seeing what was happening all around us.” (Bierschbach, 2019).

POST-TRAUMATIC STRESS DISORDER AND OTHER PROBLEMS

ASSOCIATED WITH IPV

The Diagnostic and Statistical Manual, 5th edition (DSM-5) identifies several trauma- and stressor- related disorders that result from exposure to a traumatic or stressful event

(American Psychiatric Association [APA], 2013). Experiences of IPV are often associated with symptoms across several types of diagnostic categories, including depression, anxiety, and substance use disorders. Survivors often exhibit symptoms of one or more of these disorders

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com (Foran, Whisman, & Beach, 2015). However, there are other types of problems that accompany these major mental health disorders.

Post-Traumatic Stress Disorder (PTSD)

Reactions to trauma that arises from violence and life-threatening acts like stalking has a strong negative impact on psychological health and can result in mental health problems, such as depression, anxiety, and PTSD. Individuals who experience multiple forms of trauma, either concurrently or repeated subsequent acts as in the case of chronic IPV, have a higher likelihood of developing more severe symptoms (Simmons, Wijma, & Swahnberg, 2015). Individuals who are exposed to multiple forms of violence can experience fear, betrayal, and helplessness that exacerbate previous traumatic reactions.

Post-traumatic stress disorder (PTSD) is a cluster of symptoms that are associated with the experience of a traumatic event. PTSD symptoms can arise from many different types of trauma, not only IPV. Individuals who experience IPV are especially vulnerable to developing

PTSD (Kessler, et al., 2017). In addition, experiences of trauma in childhood also affect the likelihood of subsequent traumatic experiences (LaMotte, 2016). A child who witnesses violence in the home is at a higher risk of traumatic reactions later in life (Kessler, et al., 2017;

Machisa, Christofides, & Jewkes, 2016; Simmons, Wijma, & Swahnberg, 2015).

The highest risks of IPV-related PTSD symptomology are associated with the following types of abuse: a) rape, b) physical abuse by a partner, c) kidnapping, d) and sexual assault other than rape (Kessler et al., 2017). The highest PTSD risk is associated with traumas occurring as a result of IPV sexual violence. Similarly, lifetime risk of suffering from PTSD is associated with physical abuse by a partner, rape, sexual assault, and stalking. According to an

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com international study conducted by the WHO, intimate partner sexual violence accounts for 9.8% of all lifetime trauma exposures and high risk for PTSD (Kessler et al., 2017). The likelihood of an individual developing PTSD is significantly associated with age, with the highest risk occurring during childhood/adolescence and older adults 65 years or more (Kessler et al., 2017).

Women are more likely to develop symptoms associated with PTSD than men who exposed to the same traumas (Kessler et al., 2017)

Some individuals who experience trauma as a result of IPV exhibit symptoms of dissociative experiences. These experiences can range from an inability to remember the violent events to flashbacks of the violence (LaMotte, 2016). A dissociative episode is when an individual experiences a disruption in the normal process of consciousness, memory, perception, or motor control. Symptoms include: a) a loss of subjective perception and involuntary or unwanted intrusions of awareness and behaviors, and b) an in ability to access internal knowledge or functions that are typically accessible (LaMotte, 2016). A survivor of

IPV may experience depersonalization, that is, a sense that one’s thoughts and feelings have an unreal quality that is disconnected from the self. Other symptoms are flashbacks or amnesia of the violent episodes.

Trauma can sometimes cause these dissociative experiences during the violent episode and sometimes afterward. These experiences can also occur even after the violence has stopped

(LaMotte, 2016). PTSD responses can include dissociative experiences. Symptoms of PTSD can include numerous symptoms, such as intrusive or distressing memories (i.e., flashbacks), avoidant behavior toward anything that reminds a person of the trauma, changes in mood and thinking processes, and hypervigilance for environmental threats.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Individuals who experience PTSD sometimes also have dissociative episodes related to the trauma (LaMotte, 2016). Sometimes these episodes are triggered by flashbacks and intrusive memories that may only be loosely connected to the traumatic event. Individuals with a prior history of trauma are at high risk to develop symptoms of PTSD (Kessler, et al., 2017;

Machisa et al., 2016). Physical abuse in childhood is the strongest predictor of physical and sexual IPV later in life. Early childhood victimization significantly predicts subsequent generalized PTSD symptomology that extends to other types of trauma (Kessler, et al., 2017;

Machisa et al., 2016). The highest risk for PTSD is the recurrent physical violence that is commonly a part of IPV.

About half of individuals suffering from PTSD will experience reduced symptoms approximately six months after violence has ended (Kessler, et al., 2017). However, PTSD symptoms generally last about six years across all types of trauma, ranging from one year for traumas involving a natural disaster to 13 years for combat-related trauma. Specific duration estimates for IPV-related PTSD symptoms vary. According to a study by the WHO, IPV- related symptoms can last years (Kessler, et al., 2017):

• Physical abuse as a child: 4.6 years • Witnessing parental violence: 2.7 years • Physical abuse by a partner: 3.6 years • Rape: 10.2 years • Non-rape sexual assault: 11.7 years • Stalking: 7.6 years Exposure to trauma differs across individual experiences (Kessler, et al., 2017;

Simmons, Wijma, & Swahnberg, 2015). Women are significantly more likely than men to experience IPV. Men are more likely than women to experience overall physical violence and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com accidents. Early exposure to trauma significantly increases the risk of subsequent traumas despite individual differences in personality, coping resources, life circumstances, and lifestyles.

Prior exposure to violence is associated with a general vulnerability to subsequent PTSD. The effects of trauma are especially detrimental if the victimization is recurrent, as is the case in most IPV situations. Similarly, IPV causes symptoms of psychological problems among both male and female victims (Machado, Santos, Graham-Kevan, & Matos, 2017; Simmons, Wijma,

& Swahnberg, 2015).

Male survivors experience the same types of violence as female victims (e.g., psychological, physical, economic, sexual, and stalking) (Machado et al., 2017). They often describe experiencing multiple forms of violence. Male victims of IPV by female partners also experience increased mental health problems, such as PTSD, depression, suicidal ideation, psychosomatic symptoms, and general psychological distress (Machado et al., 2017).

Perpetrators of IPV can be male or female. Some victims of IPV are also perpetrators of violence against their partners (i.e., bi-directional violence) (Simmons, Wijma, & Swahnberg,

2015). Both male and female children who are victims of child abuse have a higher likelihood of later becoming a perpetrator of IPV as an adult (Machisa et al., 2016; McKee & Hilton, 2019;

Simmons, Wijma, & Swahnberg, 2015). Male victims of childhood domestic violence also exhibit signs of mental health problems, including symptoms related to PTSD, binge drinking, and depression. Increased PTSD symptoms are associated with higher substance abuse and depression.

Many survivors who report IPV victimization within the past year are more likely to also report substance abuse (McKee & Hilton, 2019). Recently victimized women have close to a six-fold increase of substance use compared to women who have never been abused. A

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com majority of women who seek substance abuse treatment and have experienced some form of

IPV often report more severe forms of physical abuse compared to men. Furthermore, forced substance use is another form of violence that perpetrators may use to abuse their victims (e.g., compromising or sabotaging a victim’s recovery or sobriety through forced drug and alcohol use which may further economic abuse or risk stable housing environments).

There is a clear connection between substance use and PTSD; however, the answer to the question of which comes first, substance use or PTSD is one that is not fully understood.

The intersectionality of PTSD, substance use, and IPV is also complex. Current theories of this complicated phenomenon focus on three main aspects: risk, vulnerability, and self-medication

(McKee & Hilton, 2019).

• Risk - suggests that substance use places an individual at risk for exposure to

potentially traumatic events because of the behaviors associated with procuring

and using drugs and alcohol.

• Vulnerability - suggests that an individual’s use of substances increases the

likelihood of traumatic reactions to adverse events.

• Self-medication - suggests that substance use is also used to minimize the

symptoms of PTSD.

Additionally, there are theories of neurobiological connections between PTSD and substance use (McKee & Hilton, 2019). Neurobiological characteristics seem to point to an increased sensitivity to stressful life events and connected to substance use. Individuals who experience IPV may incorporate substance use in an effort to manage their symptoms of trauma.

Subthreshold Symptoms of PTSD

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Subthreshold post-traumatic stress disorder (PTSD) is a term used to describe when an individual experiences some symptoms of PTSD, but not in the exact manner necessary to meet the diagnostic criteria for PTSD (Tull, 2019). For example, an individual may experience two or three of the needed DSM-5 criteria for PTSD; yet to qualify for an official diagnosis of PTSD, an individual needs to experience a certain frequency, duration, and intensity of symptoms, such as intrusive memories, avoidance, negative thinking and mood, or changes in emotional reactions. It is important to recognize that individuals with subthreshold PTSD symptoms are suffering and still experience distress and impairment.

The most common definition of subthreshold PTSD is that individuals experience at least one of each of the DSM-5 criteria symptom clusters: re-experiencing (e.g. intrusive thoughts), hyperarousal, negative alterations in mood and cognition, and avoidance

(McLaughlin, et al., 2016). Individual variations in the clusters of symptoms may vary. No matter what the specific cluster of symptoms is, individuals with subthreshold PTSD experience distress and impairment associated with symptoms.

Subthreshold symptoms are more prevalent than full PTSD diagnoses. Subthreshold

PTSD symptoms should be treated and may be a precursor to a full-blown PTSD or other mental health disorders, such as depression, anxiety, or panic disorder (Schmidt, 2015).

However, because individuals can exhibit different symptoms, clinicians may have difficulty with diagnosis, having service authorized, or developing an evidence-based treatment plan. In addition, clients with subthreshold PTSD can also exhibit subthreshold symptoms of other clinical disorders, such as anxiety and depression.

Coping Strategies

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Part of understanding individual reactions to trauma must include an examination of coping strategies. Help-seeking behaviors are a major component of coping with the symptoms they experience as a result of their traumas. Sometimes survivors seek help from those closest to them in their social networks. These IPV survivors who disclose their experiences to individuals in their social networks may in fact be mitigating their symptoms because positive support networks can help survivors manage their negative experiences and help to improve their well-being (Schackner, Weiss, Edwards, & Sullivan, 2017). When friends, family, or practitioners provide support, they can convey positive messages, such as believing the victims and validating their experiences and perceptions. Conversely, negative reactions to IPV disclosure may increase the victim’s isolation and increase the severity of PTSD symptoms.

IPV survivors use different coping mechanisms to deal with their symptoms of trauma.

These mechanisms also influence the choice of coping strategies as well. Survivors who experience negative reactions from others about the IPV are more likely to use avoidance as a coping strategy (Schackner et al., 2017). Conversely, if individuals respond with positive support, survivors are more likely to use non-avoidant coping strategies, such as discussing feelings and fears with others.

Avoidant coping strategies can cause further distress among IPV survivors. By disengaging from support networks and resources, survivors do not access services that could potentially help them (Schackner et al., 2017). Negative reactions from a victim’s social support network can reinforce the shame, distress, and self-blame that often plague victims.

When survivors engage in avoidant coping strategies, they cannot process the traumatic experiences or negative feelings associated with their abuse. Substance abuse is a common avoidance mechanism.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com In addition to psychological and social reactions to trauma, many survivors often experience physical reactions. IPV survivors utilize medical health services, including medications, more often than those who are not exposed to IPV (Dekel, Shaked, Ben-Porat, &

Itzhaky, 2019). IPV is associated with a wide range of medical problems, including chronic pain, cardiovascular, circulatory, and respiratory problems, as well as gynecological problems.

Victims of violence by their partners often report lower health statuses compared to those who do not experience IPV. Psychological disorders that accompany IPV, such as depression and

PTSD, can also influence the degree to which a survivor will access health services.

Problems That May Be A Focus of Clinical Treatment

If children are present in the home, IPV can also present problems with parental adjustment, parenting behavior, and behavioral problems with the children (Foran et al., 2015).

In contrast to families that experience normal levels of daily stress and conflict, families in which domestic violence is present experience greater levels of stress, conflict, and distress.

Domestic violence can also cause additional financial, health, and mental health strain that can follow individuals throughout their development in the lifespan.

In addition, the DSM-5 also includes a section called “Other conditions that may be the focus of clinical attention” (APA, 2013; Foran et al., 2015). IPV-related issues for clinical attention include:

Relational Problems

This section of the DSM-5 addresses important and significant relationships, especially adult partner relationships. Close relationships that are characterized by maltreatment often

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com result in significant medical and psychological negative consequences. Within this section there are several subsections:

Problems related to family upbringing

● Parent-child relational problem: This category includes problems that are associated

with the parent-child relationship. This can be associated with a number of different

circumstances, but families in which children experience or witness violence in the

home can often experiences parent-child relationship problems.

● Sibling relational problem: This sub-category is used when the focus of clinical work is

problems in the interactions between siblings. This can be associated with a number of

different situations, but in household where violence occurs, impaired family

interactions can occur between siblings.

● Upbringing away from parents: This diagnostic category is used when clinical focus is

on issues related to a child being raised away from the parents. This can be associated

when a child is removed from parental care due to safety concerns and placed in foster

care or in kin care.

● Child affected by parental relationship distress: This category is used when clinical

focus is on the negative effects of parental relationship discord. This can be an issue

when there are high levels of conflict and distress on the child in the family.

● Relationship distress with spouse or intimate partner: This category is used when the

clinical focus is the quality of the intimate relationship with a spouse or partner.

Relationship distress is associated with cognitive, behavioral, and/or affective domains.

This category excludes clinical encounters for mental health services for spousal or

partner abuse problems.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ● Disruption of family by separation or divorce: This category is used when partners in an intimate relationship are living apart due to relationship problems; they may be in the process of divorce. ● High expressed emotion level within family: This category is used when there is a high amount of negative expressed emotion, such as hostility, criticism, and emotional over- involvement directed towards a family member. ● Uncomplicated bereavement: This category is used when the clinical focus is the normal reaction to the death of a loved one. Reactions to the death of a loved one include symptoms that are characteristic of a major depressive episode, such as sadness, insomnia, and poor appetite.

Abuse and neglect

This category is sued when there is maltreatment of a family member by an intimate partner or caregiver. There are specific diagnostic codes for the ICD-10-CM (International Classifications of Diseases - 10) Abuse and Neglect for an initial encounter (when a person is receiving active treatment), subsequent encounter (after a client has received treatment for the condition and is receiving care for recovery).

Adult maltreatment and neglect problems

• Spouse or partner violence, physical: This category is used when there are intentional

acts of physical force that can result in physical harm to a partner or that evoke

significant fear in the partner within the past year. The DSM-5 identifies acts of abuse

as: shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, biting,

kicking, hitting with the fist or an object, burning, poisoning, apply force to the throat,

cutting off the air supply, holding the head under water, and using a weapon. This

category does not include acts when a partner is physically protecting oneself.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com - Encounter for mental health services for victim of spouse or partner violence, sexual

- Personal history (past history) of spouse or partner violence, sexual

- Encounter for mental health services for perpetrator of spouse or partner violence,

sexual

• Spouse or partner neglect: This category is use for spouse or partner violence, physical confirmed and spouse or partner violence, physical suspected - Encounter for mental health services for victim of spouse or partner violence,

physical

- Personal history (past history) of spouse or partner violence, physical

- Encounter for mental health services for perpetrator of spouse or partner violence,

physical

• Spouse or partner violence, sexual: This category is used when forced or coerced sexual

acts with an intimate partner have occurred during the past year. These acts include

physical force or psychological coercion or sexual acts with a partner who is unable to

consent. This category is delineated by an egregious act or omission in the past year by

one partner that deprives a dependent partner of basic needs and can result in physical or

psychological harm. This category can be used in a situation where one partner is

dependent upon the care or assistance of another partner.

- Spouse or partner neglect, confirmed - Spouse or partner neglect, suspected - Encounter for mental health services for victim of spouse or partner neglect - Personal history (past history) of spouse or partner neglect - Encounter for mental health services for perpetrator of spouse or partner neglect • Spouse or partner abuse, psychological: This category includes intentional verbal or

symbolic acts that can result in significant harm to the other partner during the past year.

Acts of psychological abuse include: berating or humiliating the victim, interrogating the

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com victim, restricting the victim’s ability to come and go freely; obstructing the victim’s

access to assistance, such as law enforcement, legal, protective, or medical resources,

threatening the victim with physical harm or sexual assault, harming or threatening to

harm people or things that the victim cares about, unwarranted restriction of the victim’s

access to or use of economic resources, isolating the victim from family, friends, or

social support, stalking the victim, and trying to make the victim think that he/she is

crazy.

- Initial encounter or subsequent encounter

- Encounter for mental health services for victim of spouse or partner psychological

abuse

- Personal history (past history) of spouse or partner psychological abuse

- Encounter for mental health services for perpetrator of spouse or partner

psychological abuse

The DSM-5 includes diagnostic categories that can include survivors of domestic violence, but are not exclusive to IPV (APA, 2013). These categories can be used with clients who are experiencing these problems as a result of abuse.

Educational and occupational problems

This category is used when the clinical attention is on the problems associated with education and employment problems in a violence relationship, such as lack of accessibility to education or employment.

Housing problems

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com This category can be used when a survivor leaves a violent relationship and becomes homeless as a result. A survivor who attends a homeless or domestic violence shelter can be considered homeless.

Economic problems

In relation to a survivor experiencing IPV, this category can be used to describe problems associated with lack of adequate food or safe drinking water, extreme poverty, or inaccessibility to financial resources.

Other problems related to the social environment

Related to IPV, this category can be used to describe problems that relate to the social environment, such as life transitions, social exclusions, or target of perceived adverse discrimination. In some communities, survivors of abuse can be stigmatized and excluded from social participation as a result of abuse especially if abuse is condoned in relationships or there are rigid gender roles.

Problems related to crime or interaction with legal system

This category has codes for: being a victim of a crime, or in cases of perpetrators of abuse, a conviction in civil or criminal proceedings without imprisonment or imprisonment, problems with release from prison, or problems related to other legal circumstances.

Problems related to other psychosocial, personal, and environmental circumstances

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com There are several codes in this category that can apply to survivors and perpetrators of IPV:

oProblems related to unwanted pregnancy

oVictim of terrorism or torture

oOther problem related to psychosocial circumstances

oUnspecified problem related to unspecified psychosocial circumstances

Other circumstances of personal history

This category can be used for survivors and perpetrators of abuse and has codes for:

oOther personal history of psychological trauma

oPersonal history of self-harm

oOther personal risk factors

These conditions and problems that can be associated with IPV and part of clinical treatment. Treatment codes correspond with codes from the ICD as well. Symptoms often accompany those of larger diagnoses, such as depression, PTSD, anxiety, and substance use disorders. The conditions for clinical focus are not considered mental disorders in the DSM-5, but may require attention during routine clinical practice (APA, 2013).

TREATMENT

Integrated or Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Cognitive-behavioral therapy (CBT) is a therapeutic approach that addresses two issues: 1) cognitive distortions that lead to maladaptive behaviors, and 2) behavioral changes that can

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com affect cognitions (SAMHSA, 2014). The aim of CBT is to replace maladaptive cognitions and behaviors with healthier thoughts and actions. Traditional CBT approaches emphasize the therapeutic relationship as an important part of treatment success.

CBT is an approach that is used to treat the effects and symptoms of trauma (e.g., post- traumatic stress disorder) and can include substance use treatment as well (SAMHSA, 2014). The goal of TF-CBT is establishing and maintaining healthy cognitions and behaviors and includes several components, such as psychoeducation, parenting skills, relaxation, affect identification and regulation, cognitive coping, trauma narration and processing, in-vivo mastery, conjoint child-parent sessions, and enhancing safety and future development (Medical University of South Carolina [MUSC], 2019).

Psychoeducation

Psychoeducation is a strategy for survivors to normalize their responses to trauma by offering accurate information about what occurred and potential reactions (MUSC, 2019). Psychoeducation content specific to IPV may include:

• Information about different types of trauma and abuse, such as prevalence and frequency, the cycle of abuse • Psychosocial and behavioral reactions that are common to survivors • Common symptoms of trauma exposure • Possible underlying reasons that the trauma can occur • The effects of trauma on children • Possible reasons that offenders use violence • Issues about disclosing abuse • Information that dispels myths and misinformation about IPV • Issues of body awareness • Sex education Often survivors of IPV do not know how to describe what happened, why it happened, and how to cope with distress. Psychoeducation helps to inform not only survivors, but offenders, family members, and friends about the facts of IPV.

Parenting Skills

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Intimate partner violence often occurs in families where children are present. Trauma- focused CBT approaches incorporate knowledge and skills related to effective parenting strategies. These strategies help parents manage their children’s problematic behaviors, such as anger, aggression, and fear, that can be associated with living in a home where IPV occurs (MUSC, 2019). Common problems that are the focus of treatment include: aggression, non- compliance, fears, sleep problems, inappropriate physical and sexual behaviors, and disruptive behaviors. The goal of this type of training is to decrease the incidence of unhealthy, ineffective, and unsafe parenting techniques and increase positive, effective, and safe parenting. Parenting skills that are often taught include:

• Praise and why it’s important • Selective attention and ignoring • Developmental milestones and expectations • Behavior plans, including behavior charts, contingency reinforcement programs, and other reward systems • Limit-setting, including the appropriate use of time-out • The importance of consistency, predictability, and follow-through with requests and consequences In this component of TF-CBT, clinicians teach parents skills and coach them in order to develop, strengthen, and maintain effective strategies. They teach parents how to use these techniques not only in their homes, but also in schools, neighborhoods, and communities.

Relaxation

The relaxation component of TF-CBT includes relaxation and mindfulness. Symptoms of trauma often include physiological sensations that are uncomfortable. Fear, anxiety, and sadness, among others, can often provoke bodily sensations that are uncomfortable. When survivors learn these techniques, they also learn that they can cope with distressing symptoms. Relaxation and mindfulness techniques include:

• Controlled or focused breathing • Progressive muscle relaxation

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • Visualization and imagery • Mindfulness or meditation skills • Calming activities, such as listening to relaxing music, taking a walk, or writing in a journal By teaching relaxation skills, practitioners help survivors to understand that there are common reactions to traumatic stress, including shallow breathing, rapid heartbeats, sweating, muscle tension, head and body aches, and stomach pains. These distressing symptoms can prevent deeper, psychological therapeutic work. By practicing relaxation skills, survivors learn how to control their bodies so they are able to focus on deeper aspects of healing.

Affect Identification and Regulation

Often survivors of IPV have difficulty recognizing, identifying, naming, and expressing their emotions. Affect identification and regulation allows survivors to accurately identify, label, process, express, and regulate emotions, especially negative ones. Components of affect identification and regulation include:

• Learning how to identify and label a range of positive and negative emotions • Building an emotional vocabulary • Understanding the mechanisms of emotions • Practicing appropriate ways of expressing emotions • Identifying emotions that are related to trauma • Learning how to soothe oneself • Learning how to increase the number of experiences of positive emotions • Developing social skills and problem-solving skills Being unable to identify emotions, especially negative emotions, and not knowing how to appropriately express them can cause further disruption in survivors’ lives. When cognitions are distorted and emotions are repressed, maladaptive behaviors can arise to further complicate the situation.

Cognitive Coping

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Often survivors, as a result of their traumatic stress, are unable to make a connection between the idea that cognitive distortions lead to maladaptive behaviors. Practitioners teaching cognitive coping strategies to help survivors understand that thoughts, feelings, and behaviors are connected. Similarly, trauma-related emotions, thoughts, and feelings are often connected to associated behaviors. Survivors of abuse may need to challenge inaccurate and maladaptive thoughts and replace them with healthier, positive ones. Elements in teaching cognitive coping skills include:

• Understanding that there are connections between thoughts, feelings, and behaviors • Identifying the thoughts associated with specific triggering events in their lives • Understanding that the negative thoughts and feelings are connected to negative behaviors • Recognizing that inaccurate or maladaptive thoughts can lead to negative feelings and inappropriate behaviors • Challenging maladaptive beliefs • Obtaining accurate information to determine whether thoughts and feelings are accurate • Replacing negative thoughts and beliefs with healthier thoughts • Building cognitive flexibility that allow for a host of alternative beliefs and thoughts Teaching cognitive coping skills help survivors gain psychological flexibility and develop abilities to recognize and change flawed thinking. With IPV, it is common for offenders to gain control of their victims by systematically changing their victims’ beliefs. Thus, unraveling these distorted beliefs and thoughts can often help survivors develop healthy ways of coping.

Trauma Narration and Processing

When survivors experience IPV, it is common for their offenders to create narratives that will support continued use of violence in the relationship. These narratives are internalized by survivors, which contributes to feelings of helplessness and lack of control. When undergoing treatment, survivors often need to unlearn those harmful narratives and create new ones that will help them cope with their abuse. By developing a new trauma narrative, survivors create an internal space for addressing memories, thoughts, and feelings associated with the traumatic experiences. Elements of trauma narration and processing include:

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • Understanding that gradual, repeated exposure to the memories, thoughts, and feelings associated with traumatic events and in combination with the development of effective coping methods can reduce the power and intensity of the negative feelings and emotions • Developing creative ways of creating healthier narratives around the abuse, such as journaling, writing poems, taking pictures, or creating songs • Practicing coping skills learned on emerging negative thoughts, feelings, and emotions • Helping family members and friends learn to respond in ways that are supportive and helpful • Sharing narratives with family members, friends, and others in the survivors’ lives Practitioners use an array of techniques to help survivors with the negative thoughts, feelings, and beliefs associated with IPV. Survivors learn to reduce levels of intensity and feeling overwhelmed in order to better cope with emotions. Skills learned in this component can help survivors share their stories without becoming disabled by overwhelming thoughts and feelings.

In-vivo Mastery

Survivors of abuse sometimes develop specific phobias in response to triggers, such as fears associated with particular people, places, situations, sounds, smells, objects, or environmental cues. Some of these fears are related to consequences that have previously led to abuse, such as fear of physical abuse for not having the house cleaned. Methods of in-vivo mastery include techniques of exposure (i.e., desensitization), that is, exposing a survivor gradually to people, places, situations, sounds, smelling, objects, or environmental cues in order to reduce overwhelming feelings and more effectively cope.

Conjoint Child-Parent Sessions

Sessions that involve conjoint child-parent sessions to deal with the effects of domestic violence help children to process their thoughts, feelings, and emotions associated with violence. In these sessions, clinicians help parents or caregivers promote positive and healthy communication patterns. Often children need to talk directly to parents about their experiences. Parents need to support their children in doing this. Conjoint sessions typically occur after

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com children and parents have received some separate treatment for their exposure to or experiences of violence in their homes. Conjoint child-parent sessions include topics surrounding communication patterns, including trauma knowledge and education, trauma narratives, feelings and emotions about the trauma, sex education, and personal safety. Practitioners prepare their clients, who can be survivors, offenders, and/or children, before the conjoint sessions in order to protect anyone from re-traumatization.

Enhancing Safety and Future Development

The final component of trauma-focused CBT includes future safety of survivors and children. Survivors learn to identify areas of potential danger for themselves and their children in order to plan for safety. Survivors need to know about the possible dangers in the environment and how to develop safety plans. Learning how to recognize and avoid potential dangers can help protect against abuse by a perpetrator in the future. Survivors learn about the resources that are available should they find themselves in another abusive situation. They learn assertiveness skills and confident body language to be used in situations that could potentially be dangerous. These skills can help reduce the risk of future victimization and improve a survivor’s capacity to avoid and/or manage problematic situations.

Intervention: Trauma-focused cognitive behavioral therapy (TF-CBT) (Kids Mental Health, 2019; National Child Traumatic Stress Network (NCTSN), 2020)

Framework: Cognitive-behavioral therapy

Trauma-focused cognitive behavioral therapy (TF-CBT) for children and adolescents incorporate trauma-informed treatments that follow a cognitive-behavioral framework. This framework is an evidence-based practice with children, adolescents, and families. The approach addresses IPV-related emotional problems, such as symptoms of post-traumatic stress disorder (PTSD), fear, anxiety, depression, psychological distress, attachment problems, cognitive programs, school problems, and behavior problems.

TF-CBT is generally administered over the course of between 12-25 sessions that each last 60- to 90-minutes and are divided equally between youth and the parent or caregiver. The focus

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com of treatment is on domestic violence, sexual abuse, traumatic grief, and multiple or complex traumas. Clients are taught varied TF-CBT skills which focus on:

1) regulating affect, 2) regulating behavior, 3) regulating thoughts and relationships, 4) processing trauma, 5) enhancing safety, 6) building trust, 7) developing parenting skills, and 8) improving family communication.

The key components of TF-CBT establish a therapeutic relationship and integrate methods of exposure therapy. There are several intervention methods, including:

• Psychoeducation • Parenting training • Relaxation • Affect modulation • Cognitive coping • Trauma narrative and processing • Conjoint youth-parent sessions • Safety planning • Traumatic grief processing

TF-CBT can be offered in individual and group sessions. It can be offered in varied settings including in-home/home based services, residential settings, school settings, and outpatient clinics. TF-CBT utilizes a structured approach toward discussing and processing children’s traumatic experiences. Clinicians who use this approach generally complete an in-depth, manualized training (e.g., certificate program) for a total of between 10-30 hours plus consultation. TF-CBT is contraindicated for children and adolescents who are suicidal, psychotic, substance users, or who have intellectual disabilities (NCTSN), 2020).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com This approach has been successful with a number of individuals from diverse religious and ethnic groups. It has been successfully implemented with children in varied settings, including home, school, inpatient, residential, refugee camps, rural, urban, and suburban environments.

Application:

The following is an example of a TF-CBT treatment plan and goals (Child Trauma Treatment Training Program, 2011).

Goal 1: The child and caregiver will gain accurate knowledge about IPV, common responses to trauma, and the treatment process. Objectives: 1. The child and caregiver will learn facts about IPV. 2. The child and caregiver will learn facts about trauma-related symptoms, such as anxiety, depression, and stress by receiving information about trauma exposure and recovery. 3. The child and caregiver will learn about the TF-CBT approach to treatment. Intervention: Trauma-focused cognitive behavioral therapy Method for evaluating progress: The child and caregiver will demonstrate knowledge in session. The child and caregiver will take [standardized measures] at baseline, 3 months, 6 months, and 1 year.

Goal 2: The caregiver will develop skills for parenting a traumatized child. Objectives: 1. The caregiver will learn the PRIDE skills for providing positive reinforcement for desired and appropriate child behaviors. 2. The caregiver will learn to implement planned ignoring to manage undesirable behaviors. 3. The parent will learn methods for providing developmentally appropriate parenting commands. 4. The parent will learn how to provide developmentally appropriate consequences to shape the child’s behavior. Intervention: Trauma-focused cognitive behavioral therapy

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Method for evaluating progress: The child and caregiver will demonstrate knowledge in session. The child and caregiver will take [standardized measures] at baseline, 3 months, 6 months, and 1 year.

Goal 3: The child will engage in healthy expression of emotions related to traumatic experiences and be able to regulate distressing emotions. Objectives: 1. The child will learn to identify and rate feelings. 2. The child will demonstrate skills for healthy expression of emotions. 3. The caregiver will encourage and praise the child’s healthy expression of emotions. Intervention: Trauma-focused cognitive behavioral therapy Method for evaluating progress: The child and caregiver will demonstrate knowledge in session. The child and caregiver will take [standardized measures] at baseline, 3 months, 6 months, and 1 year.

Goal 4: The child will decrease physical and psychological distress related to traumatic experiences. Objectives: 1. The child will participate in gradual exposure to reduce anxious arousal related to traumatic memories. 2. The caregiver will learn skills and participate in therapeutic activities designed to support the child through gradual exposure processes. Intervention: Trauma-focused cognitive behavioral therapy Method for evaluating progress: The child and caregiver will demonstrate knowledge in session. The child and caregiver will take [standardized measures] at baseline, 3 months, 6 months, and 1 year.

There are two valuable on-line resources that provide templates for clinicians to use TF-CBT with their child clients:

Hendricks, A., Cohen, J., Mannarino, A., & Deblinger, E. (2014). Your very own TF-CBT workbook. Available at https://tfcbt.org/wp-content/uploads/2014/07/Your-Very-Own-TF- CBT-Workbook-Final.pdf

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Hendricks, A., Kliethermes, M., Cohen, J., Mannarino, A., & Deblinger, E. (2019). Dealing with Trauma: A TF-CBT workbook for teens. Available at https://tfcbt.org/wp- content/uploads/2019/02/Revised-Dealing-with-Trauma-TF-CBTWorkbook-for-Teens-.pdf

Concurrent Treatment of Post-Traumatic Stress Disorder and Substance Use with Prolonged Exposure (COPE)

Many survivors who experience post-traumatic stress disorder from IPV often have co- morbid substance use disorders (Flanagan, Korte, Killeen, & Back, 2016; Mills, et al., 2016). The clinical profile of survivors who also have substance use disorders include low education and occupational functioning, histories of polydrug use, poor physical health, poor mental health, and higher rates of overdose and attempted suicide (Mills, et al., 2016).

Concurrent Treatment of PTSD and Substance Use Disorders with Prolonged Exposure (COPE) is a model that incorporates cognitive-behavioral treatment and prolonged exposure (Mills, et al., 2016). Integrated treatments, such as those for co-morbid substance dependence and PTSD, address the cognitive distortions that can arise as the result of trauma as well as ineffective coping strategies, such as use of substances and alcohol. The core features of this treatment model integrate techniques that introduce a survivor to prolonged and repeated exposure to memories and physical sensations.

PERPETRATORS OF IPV

Victim-offender overlap is a phenomenon where perpetrators of IPV also report IPV victimization (Abajobir, Kisely, Williams, Clavarino, & Najman, 2017; Richards, Tomsich,

Gover, & Jennings, 2016). The theoretical model of the “cycle of violence” refers to how exposure to or socialization of violence during childhood affects later violent behavior in intimate relationships. Offenders who report histories of abuse in childhood are more likely to be exposed to continued abuse later in life or become perpetrators of violence themselves. A

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com child growing up in a family where violence is tolerated or condoned can learn that use of violence or submission to violence is a way to cope with interpersonal problems. In this way, violence can be multi-generational and be perpetuated among family members through generations.

The cycle of violence is a common term in current research and directly links childhood maltreatment with an increased risk in violence in adulthood (Abajobir, et al., 2017; Richards,

Tomsich, Gover, & Jennings, 2016). This victim-offender overlap includes childhood sexual violence as well as physical violence. In addition, childhood exposure, such as witnessing violence between parents or caregivers, is also associated with the use of violence in the community and later perpetration and/or victimization.

Social learning theory is commonly used to better understand the cycle of violence.

Bandura’s theory (1961, 1977) posits that individuals who are socialized into violence as children have learned to feel favorably or have some familiarity about the use of violence, thus increasing the likelihood of using violence in their own interpersonal relationship (Richards,

Tomsich, Gover, & Jennings, 2016). Similarly, children who have witnessed adult partner violence or experienced maltreatment themselves may have failed to learn alternative ways to resolving conflict without using violence. Children whose parents used violence on them often learn that this approach is an appropriate way to relieve frustration, anger, and conflict, especially related to a family member’s behavior. In addition, internalization of these values can affect the partners one chooses in adulthood, thereby increasing the chance of choosing a partner who uses or accepts violent behavior in the relationship. This phenomenon of learning violence early in childhood from parents, then later becoming either abusers or victims or both

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com as a result is called transmission of intergenerational violence. Patterns of behavior in IPV can be passed down through multiple generations as a result of these learned behaviors.

Children who are exposed to or witness violence often have trouble with adjustment and frequently have behavioral problems (Abajobir, et al., 2017; Fredland, et al., 2017). The early childhood problems with behavior and overall behavioral functioning have a strong impact on behavior in adulthood. Intimate partner violence has an impact on parental mental health, especially PTSD, depression, anxiety, and somatization, which in turn, can impact the parent’s ability to care for their children and attend to the children’s needs for recovery from episodes of violence. Children whose mothers have higher IPV-related mental health problems also have problems, such as depression and anxiety. In addition, children whose mothers had IPV-related mental health problems also displayed more external behaviors, such as hostility and aggression. These childhood experiences may lead to being a victim, a perpetrator, or both later in life (Abajobir, et al., 2017).

Factors that influence intergenerational transmission of violence include, biological sex, urbanicity, a history of other forms of violence, age, relationship stability, poor communication, verbal aggression, jealousy, and controlling behaviors (Abajobir, et al., 2017; Knight, et al.,

2016). Socioeconomic disadvantages, such as poverty and family instability, are associated with both child maltreatment and IPV perpetration (Abajobir, et al., 2017). Though the perpetuation of violence is related to childhood exposure, the degree of IPV perpetration over time seems to decrease over the course of time (i.e., a downward trajectory of violence over time) (Knight, et al., 2016).

Certain types of abuse in childhood have a greater likelihood for subsequent victimization. Child sexual abuse is associated with a two-fold likelihood of subsequent overall

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com IPV (Abajobir, et al., 2017). Childhood physical abuse and sexual abuse is associated with a seven-fold increase in risk of both physical and sexual IPV over the course of a lifetime.

Those who are exposed to early physical and sexual abuse, kidnapping or stalking, and having a family member murdered or die from suicide are likely to be victimized by violent partners later in life (Abajobir, et al., 2017). Childhood sexual abuse is associated with a higher risk of sexual violence victimization and/or perpetration later in life. Children who are emotionally abused and neglected also have higher rates of IPV, including physical and sexual abuse (Abajobir, et al., 2017).

The difference between corporal punishment and physical abuse in childhood can be viewed differently depending upon parenting style. A parent’s own childhood experiences with discipline and corporal punishment can influence how one disciplines a child (Burke, 2019).

Negative and harsh punishment as a child can be a risk factor for using physical means of discipline approach as a parent. Beliefs about these types of discipline practices are also transmitted intergenerationally. When children become parents themselves, they are more likely to use the practices their parents used with them as children.

Personality traits, such as impulsivity, aggression, dominance, and hostility are associated with individuals who perpetuate abuse (Dowgwillo, Menard, Krueger, & Pincus,

2016). Research suggests that both men and women who use violence in their relationships are more likely to have personality disorders, such as borderline, narcissistic, antisocial, passive dependent, and compulsive (Simmons, Knight, & Menard, 2015). In addition, perpetrators of abuse tend to have an increased use of alcohol and substances and higher levels of depression.

Along the same lines, a parent who has these types of personality traits, mental health problems, and substance use may likely approach discipline in harsh or abusive ways (Burke, 2019).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com The level of physical discipline a parent uses with a child is related to how angry the parent is about the child’s behavior (Burke, 2019). In addition, low parental involvement and warmth, alienation, dissatisfaction and hostility are also associated with the type of discipline that is used with a child. In turn, children often exhibit aggressive behavior towards others as result of exposure to angry and hostile parenting approaches (Burke, 2019).

Adolescents who experience violence during earlier childhood often enact aggressive or violent behaviors in their own relationships with peers (Liu, Mumford, & Taylor, 2018).

This type of intergenerational learning is not restricted to physical violence. Children who witness psychological or verbal abuse between parents are likely to use psychological or verbal abuse in their relationships as well. Parents who have verbal and physical abuse in their relationships are more likely to have children who report victimization and perpetration of the abuse later in life (Liu et al., 2018). Similarly, children who witness violence or psychological abuse in between their parents may also be more likely to accept abuse in their own relationships (i.e., normalization of abuse into family norms). Patterns of relating to one another are passed down from parents to children and so on. Thus, abusive or maladaptive interactions among family members, especially if accepted and normalized, have a higher likelihood of intergenerational transmission.

Intimate partner violence often involves bi-directional violence; a large percent IPV is bi-directional. Approximately 58% of IPV in large population samples is bi-directional, meaning that partners can be victimized by violence, but also perpetuate it as well (Hamel,

2016). Approximately 72% of survivors reporting IPV in legal or female-focused clinical treatment not associated with the military report bi-directional violence. Within military and male treatment survivors, approximately 39% is bi-directional. Both males and females who

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com perpetuate IPV report similar motives for violence in their relationships. Both report that primary reasons for the violence are to: a) retaliate against a partner for emotionally hurting them, b) stress or jealousy, c) to express anger and other feelings, and d) to get attention from their partner (Hamel, 2016). Women often report self-defense as a motive for the perpetuation of violence against their male partners (Hamel, 2016; VAWnet, 2019).

There are a number of factors associated with the perpetration of IPV. Demographic factors among IPV perpetrators include: young age, low income, unemployment, and minority group membership (Hamel, 2016). Stress, anxiety, and particular personality traits, attitudes, and beliefs as well as personality disorders, such as conduct disorder and antisocial personality disorder, are also associated with increased IPV perpetration (Hamel, 2016; Niolon, et al.,

2017). Additional factors, such as rigid beliefs in gender roles, a history of hostility and conflict in previous relationships, peer violence, a history of substance abuse, and hostile communication styles also play a part in whether an individual engages in violence against a partner (Niolon, et al., 2017). Exposure to or witnessing violence in childhood is also a predictive factor in the perpetuation of IPV (Hamel, 2016).

Substance use is associated with IPV perpetration (Hamel, 2016). Alcohol use is associated more with female-perpetrated violence than male perpetration. Overall, drug use is a stronger factor with IPV perpetuation than alcohol use. When severe physical violence, such as punching, kicking, and using a weapon, is perpetrated, rates of injury are higher among female victims than male victims (Hamel, 2016). These injuries are more likely to be life-threatening and require medical intervention at either an emergency room or hospital. When physical violence is moderate, such as shoving, pushing, and slapping, men and women report similar rates of injury.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com In general, the primary aim of perpetrators of IPV is to dominate and control their partners (NCADV, 2019). Perpetrators use a vary of tactics in an effort to obtain and maintain control over their partners. Violence in relationships is often not consistent and in equal measures. Rather, there may be periods of peaceful times in which partners experience good and happy moments. However, the cycle of violence will repeat and usually becomes more intense over time. Patterns of violence are not static across couples with IPV in their relationships. Some cycles of abuse progress rapidly while others develop more slowly over longer periods of time. Abusive tactics include behaviors, such as isolation, degradation, micromanagement, manipulation, stalking, physical abuse, sexual coercion, threats, and punishment (NCADV, 2019). There is no one-size-fits-all pattern of perpetration. Abusers will vary techniques and when used over time, will effectively establish dominance and control over their victims.

Perpetrators are often not violent from the first meeting of a partner (NCADV, 2019). A perpetrator may initially seem loving, attentive, and gentle. They may be successful, well-liked, and charismatic. They may seem charming and friendly with family and friends. Gradually the behaviors will change as the perpetrator begins to isolate and control the partner. An abuser may demand more time together or less time with others. Over time, a partner may feel increasingly trapped and unable to stand up to the abuser. The following are common tactics that abusers use to control their victims (NCADV, 2019):

• Expressing jealousy and/or possessiveness

• Blaming the victim for causing the abuse

• Being unpredictable

• Embarrassing or humiliating the victim

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • Exhibiting cruelty to animals

• Convincing others that the abuser is really the victim in the relationship

• Controlling all aspects of the relationship

• Using physical, verbal, emotional, sexual, or psychological control

• Endorsing rigid beliefs about gender roles

• Being hypervigilant of the partner’s behavior

• Exhibiting anger or a temper

• Sabotaging birth control methods or refusing to use birth control

• Sabotaging or preventing the partner from attending work or school

• Sabotaging the victim’s sobriety or recovery from substance use

• Controlling the household finances

• Abusing other family members, children, or pets

Abusers use tactics to first gain the trust of partners, friends, and family. Methodically they manipulate their partners and isolate them, thus reducing the likelihood that the violence will be revealed or the partner will leave the relationship. Many of those who are abused fear retaliation and feel unable to leave the relationship. Some may feel that the abuser may eventually kill them as a last effort to prevent them from leaving.

IPV-Related Homicide and Murder-Suicide

Most often women are the homicide victims of IPV-related violence (United Nations

Office on Drugs and Crime [UNODC], 2018). Roughly 82% of IPV-related homicides have

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com female victims compared to 18% of male victims (UNODC, 2018). IPV-related homicide is generally a result of an accumulation of prior IPV.

According to a national survey of IPV-related homicides, young women, especially women of color, are disproportionately the victims of homicide by an intimate partner as compared to Caucasian women (Petrosky et al., 2017). Non-Hispanic black and American

Indian and Alaska Native women comprise the two groups with the highest rates of IPV-related homicide. Over half of all homicides reported were IPV-related. In all racial groups (i.e., white, non-Hispanic; black, non-Hispanic, American Indian and Alaska Native; Asian/Pacific

Islander; Hispanic) more than three-quarters of women who were victims of IPV-related homicide were killed by their current partners as opposed to past partners. About 15% of female homicide victims between the ages of 18-44 were pregnant or postpartum. Many of those victims (11.2%) experienced some form of violence in the month preceding their deaths.

Jealousy and conflict were the common circumstances that precipitated the homicides.

According to the National Coalition Against Domestic Violence (NCADV; 2019), approximately 20% of homicide victims were not the IPV victims themselves. Rather, family members, friends, neighbors, responders, such as law enforcement, and bystanders were sometimes killed. Nearly three-quarters of all murder-suicides involve intimate partners.

Nearly 95% of the victims in these situations are women. That is, more often women are killed by their male partners and then the males kill themselves (NCADV, 2019; VAWnet, 2019).

According to VAWnet project (2019) of the National Resource Center on Domestic

Violence, nearly 20% of all murder victims were killed by their intimate partners. Women are more likely to be killed by an intimate partner than by anyone else. Nearly 40 - 50% of female murder victims are killed by an intimate partner as compared to about 5% of male murder

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com victims (Petrosky et al., 2017; VAWnet, 2019). Among those who knew their murderers prior to their deaths, 62% were either married, divorced, or girlfriends of the perpetrator.

Sometimes homicides are committed against family members other than the partner in a violent relationship (UNODC, 2018). Family homicides, also called domestic homicides, includes killings that are perpetrated by intimate partners against siblings, parents, children, and other relatives. Because IPV involves coercion, manipulation, and control, victims may not only fear for their own lives, but also the lives of their loved ones.

In Harlem, police investigate a double murder-suicide in which a man killed his wife and five- year old daughter before taking his own life. The couple was going through a divorce. There was no documented domestic history against his wife or the child, although police say that the husband had made prior threats of violence against his wife. In 2016, she sought and received a temporary restraining order against her husband for threatening behavior and harassment.

The order had since expired. A neighbor reported that they seemed like a loving family and did not know about the divorce. The couple was due in court, but did not show up. The woman’s brother-in-law called police to request a welfare check. What puzzles neighbors and friends is that there did not appear to be any sign of trouble (ABC7, 2019).

Perpetrator Treatment

Treatment programs for domestic violence perpetrators deliver services using group therapy, individual therapy, and couples therapy. Intervention programs generally aim to provide a range of skills and coping strategies. Topics for treatment include: identifying power and control tactics, developing communication skills, understanding the impact of abuse on victims, identifying and managing emotions, teaching conflict resolution skills, changing

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com violent and irrational thoughts, raising consciousness about gender roles, and developing coping skills (Cannon, Hamel, Buttell, & Ferreira, 2016). Programs for perpetrators of IPV also include training designed to help develop self-awareness, anger management and impulse control skills, an understanding of childhood experiences, life skills, and, meditation and relaxation practices.

Treatment programs also include information about trauma, how to heal from past trauma, and grief.

Common techniques in perpetrator treatment include using handouts, group exercises, and discussions (Cannon et al., 2016). Treatment approaches incorporate lectures, role-play, goal-setting, and journal-writing. Visual, audio, and digital sources of information can also be included. Common treatment models for perpetrators of IPV include: the Duluth Model,

Cognitive-Behavioral Therapy, and Acceptance and Commitment Therapy (Cannon et al.,

2016). Generally, treatment programs last approximately 30 weeks and can range from eight weeks to 78 weeks. Sessions can last approximately two hours. Treatment is generally provided in outpatient settings as opposed to inpatient settings or prisons.

Treatment begins with an initial intake assessment, usually face-to-face interviews

(Cannon et al., 2016). Clinicians can also review documents from referrals, police reports, court documents, and previous treatment progress notes. Often during the intake, clinicians will ask about past incidents of violence, substance use, family history of violence, lethality of risk, and motivation for treatment. An initial biopsychosocial assessment incorporates information about a perpetrator’s medical and psychiatric history as well as psychological functioning. It includes an assessment of family and social influences and supports. A thorough assessment is important in order to ensure that the treatment approach is appropriate for the individual.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Perpetrator treatment is often delivered according to a written curriculum (Cannon et al.,

2016). Clinicians can adapt treatment interventions for the particular needs of the clients or particular agency contexts. However, sometimes interventions can be guided by agency’s philosophy of treatment.

Clinicians may want to meet with perpetrators who are lesbian, gay, bisexual, or transgendered (LGBT) individually rather than in a group setting with heterosexual batterers

(Cannon et al., 2016). There may be unique issues and needs of LGBT abusers in their relationships that can be better addressed in individual sessions. Similarly, there may be some clients whose racial and ethnic backgrounds would be better addressed in individual sessions.

For example, a perpetrator who is American Indian or Alaska Native may want to incorporate spiritual and cultural healing practices that are unique to particular tribal beliefs.

Treatment often incorporates additional types of services. These services can include case management, parenting classes, substance abuse counseling, educational resources, and community advocacy (Cannon et al., 2016). Supportive services can include mentoring programs as well as access to food, transportation, career services, housing, and job training.

Sometimes clinicians in perpetrator treatment programs will contact victims prior to beginning treatment with an offender (Cannon et al., 2016). They then may also contact victims during and after treatment. Often clinicians will collaborate with victim treatment professionals in order to ensure comprehensive and thorough care. Many programs may offer other supportive services, such as mental health treatment, peer support groups, social service assistance, legal assistance, shelter beds, and transitional housing.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Most perpetrators will be referred for treatment primarily through court orders (Cannon et al., 2016). Sometimes they may present for treatment voluntarily, by family or friends, or through professional referrals. Clinicians may often be required to communicate treatment progress to representatives of the court system. They may also need to report to social services personnel. Often practitioners will need to coordinate care with other clinicians, such as behavioral health providers, substance abuse counselors, shelter staff, or law enforcement.

The Duluth Model

The Duluth Model is one of the most common treatment approaches for perpetrators of

IPV (Cannon et al., 2016). It focuses on both male and female perpetrators of IPV. This approach shifts responsibility for safety from survivors themselves to communities and states through policies and procedures designed to protect them (Domestic Abuse Intervention

Programs [DAIP], 2019). This strategy for intervention draws upon collective understandings and strategies so that offenders are held accountable for their abuse. This approach emphasizes core philosophical agreements, such as (DAIP, 2019):

• a shared understanding about how interventions are to be accountable for victim safety

and offender accountability;

• a shared understanding of how practitioners’ actions either support or undermine the

collective goals and strategies for intervention;

• shared definitions of safety, battering, danger and risk, and accountability;

• prioritizing the voices and experiences of survivors who undergo abuse in the creation of

policies and procedures.

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The Duluth Model includes coordinated community responses as part of its approach to treatment of offenders (DAIP, 2019). Community responses include written policies that practitioners and agency personnel utilize to put victim safety and offender accountability at the forefront. This helps to create an interagency intervention strategy. These shared protocols and procedures connect staff from different agencies and across different disciplines.

The coordinated community response component of the Duluth Model encourages an agency, preferably separate from the court system, to track and monitor cases of IPV (DAIP,

2019). This response component is an interagency, collaborative process to encourage dialogue and problem-solving by focusing efforts on systemic problems in an organization rather than on individual members in criminal and civil justice agencies, communities, and survivors. This is designed to improve the community’s response to the social problem of battering. Advocates and survivors in this model help to define and evaluate the interagency intervention strategies.

The Duluth Model incorporates a broad, multi-systemic approach to IPV. Its emphasis on connections between agency personnel across multiple domains is designed to attack the problem at multiple levels. This integrative model incorporates social systems, such as 9-1-1, law enforcement, individual advocacy and shelters, jails and prisons, prosecution attorneys, court systems, probation officers, restorative justice sentencing guidelines and restorative circles, and men’s non-violence programs (DAIP, 2019).

The Duluth Model uses the “power and control wheel” as a tool to better understand patterns of abusive and violent behavior (CrimeSolutions.gov, 2019). The power and control

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com wheel includes eight patterns that enable and perpetuate IPV. These eight behavior patterns are

(CrimeSolutions.gov, 2019):

1. Intimidation 2. Emotional abuse 3. Isolation 4. Economic Abuse 5. Male privilege 6. Coercion and threats 7. Using Children 8. Minimizing, denying, and blaming

These eight behavior patterns are designed to help offenders understand the different ways in which their behaviors are abusive, dominating, and controlling.

The “equality wheel” is a tool that introduces nonviolent strategies into offender interventions (CrimeSolutions.gov, 2019). This wheel includes eight patterns of behavior that are healthy and help to eliminate abuse. These eight patterns are (CrimeSolutions.gov, 2019):

1. Negotiation and fairness

2. Economic partnership

3. Shared responsibility

4. Responsible parenting

5. Honesty and accountability

6. Trust and support

7. Respect

8. Non-threatening behavior.

These healthy and adaptive behaviors work toward strengthening and maintaining healthy relationships that are not abusive.

Cognitive Behavioral Therapy

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Cognitive Behavioral Therapy (CBT) is another common approach to the treatment of

IPV perpetrators (Cannon et al., 2016; CrimeSolutions.gov, 2019). This intervention approach addresses violence as a learned behavior that is often internalized at an early age. The CBT model of IPV treatment emphasizes that since violence is a learned behavior, it can also be unlearned. In this approach, abusers learn to identify their underlying thoughts about violence, its triggers, and ways of changing their understanding and behaviors. Offenders receiving CBT treatment learn to examine the circumstances that lead to violence and disrupt their cognitive processes.

Once offenders understand their cognitive processes and how they affect behaviors, they can learn to replace maladaptive strategies with ones that are healthy. They learn that they use violence as a way to express anger, obtain compliance from their victims, and empower themselves with a sense of control.

A CBT approach incorporates techniques for communication, nonviolent assertiveness, social skills, and anger management (CrimeSolutions.gov, 2019). Its target population is IPV abusers, both male and female. It can be used across different treatment settings and offender types. CBT approaches incorporate six phases of treatment (CrimeSolutions.gov, 2019):

1. Assessment

2. Reconceptualization

3. Skills acquisition

4. Skills consolidation and application

5. Generalization and maintenance

6. Follow-up treatment

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com While the specific structure of CBT programs may differ, they all work with offenders’ cognitive distortions to replace them with healthy ones. In between sessions, perpetrators are given homework assignments to continue their therapeutic work. When offenders learn new skills and practice applying them, the new skills can become healthier patterns of behavior that does not include violence.

The content of CBT approaches to IPV treatment generally include weekly counseling sessions (CrimeSolutions.gov, 2019). They use a number of therapeutic techniques, such as imagery, affirmations, motivational self-talk, coping techniques for negative thoughts, relaxation, and exposure to triggering situations as part of gradually undoing the automatic thought responses and replacing it with a positive response.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) is an evidenced-based practice for perpetrators who engage in violence against their partners (CrimeSolutions.gov, 2019). The goals of this type of treatment are to increase psychological flexibility and decrease experiential avoidance. Psychological flexibility is the ability to work through psychological barriers, such as anger, fear, or shame, to act in ways that are healthy and appropriate. Experiential avoidance is the attempt to change the frequency, form, or situational discomfort of unwanted thoughts, feelings, and bodily sensations. When an individual is unwilling to examine or has difficulty dealing with internal emotions, thoughts, or urges, he may engage in behaviors that will affect

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com those negative emotions. Violent behavior can serve as an avoidance technique that is used to distract oneself from feeling negative emotions.

The ACT approach is designed to reduce experiential avoidance (i.e., avoidance of unwanted feelings and thoughts) by helping individuals to cope with distressing emotions.

There are six core processes of ACT treatment (CrimeSolutions.gov, 2019):

1. Being aware in the present moment 2. Accepting difficult emotions or thoughts 3. Decreasing the attachment to thoughts 4. Taking perspective of the situation 5. Identifying values 6. Committing one’s actions to be in line with values

The ACT model for IPV treatment of perpetrators is typically used in a group format.

This behavioral and emotional skills program is targeted to enhance positive skills among perpetrators and to let go of psychological emotions, thought, and behaviors that lead to violence against partners (CrimeSolutions.gov, 2019). The focus is on improving tolerance for emotional distress, increasing empathy for the victims, and helping to identify emotions. The

ACT model generally consists of 12 weekly, two-hour group sessions. These sessions include

(CrimeSolutions.gov, 2019):

Session 1: Introduction

This session lays the foundation for the group sessions. In this session clinicians

help perpetrators identify and clarify the kinds of relationships they would like to

have and the behaviors that prevent them from attaining them.

Session 2: Mindfulness

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com This session introduces clients to exercises in mindfulness. The goal is to promote

ongoing nonjudgmental experiences with psychological and environmental events in

their lives.

Sessions 3-4: Emotional Intelligence

These sessions focus on promoting emotional awareness and clarity. Clients learn to

identify and discern differences between emotional states and responses to particular

emotions.

Sessions 5-6: Acceptance

These sessions focus on helping clients to develop emotional acceptance and to

recognize the benefits of regulating emotions and the challenges of avoiding

negative feelings. These sessions include psychoeducational material on long-term

consequences of emotional acceptance and potential benefits in their lives.

Sessions 7-8: Defusion

These sessions focus on understanding how the mind works, emphasizing language

and cognition. The goals of these sessions are to reduce clients’ entanglement with

verbal processes and help to change their interactions.

Sessions 9-10: Behavioral Change and Commitment

These sessions focus on behavioral change, value clarification, and barriers to

behavioral change. Clinicians emphasize staying present in everyday living and

becoming aware of the many choices clients make in moment-to-moment living.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Sessions 11-12: Practice, Review, and Wrap-up

These final sessions include continued practice of skills learned, review of the

material from the previous sessions, and debriefing with group members.

In addition to weekly group sessions, client monitor and track their progress on written forms and through weekly homework assignments (CrimeSolutions.gov, 2019). This structured approach helps clients identify times when they act out on emotions rather than acknowledge and deal with them. They learn to identify and understand patterns of behavior that lead them problematic interactions, including violence towards their partners.

LEGAL ISSUES

Survivors of domestic violence can file criminal charges against their abusers for assault, battery, sexual assault, and/or rape. In addition to criminal charges, if an abuser is found guilty, other types of penalties can occur. The abuser may be ordered to pay money to cover financial losses. A survivor can request that a judge grant a restraining order. An offender can be ordered to receive treatment, such as mental health therapy and anger management. If found guilty, an offender can lose rights to child custody and visitation, especially if children experience and/or witness abuse between the partners. Similarly, a

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com survivor of IPV may need help with filing criminal charges, getting a protective order, or filing for child custody.

The Violence Against Women Act (VAWA) is a federal law that was enacted in 1996 and identifies domestic violence as a federal crime (Violence Against Women Reauthorization

Act of 2019, 2019). This federal law has 15 Titles that broadly address domestic violence:

• Title I: Enhancing legal tools to combat violence, dating violence, sexual assault and stalking • Title II: Improving services for victims • Title III: Services, protection, justice for young victims of violence • Title IV: Violence reduction practices • Title V: Strengthening the health care system’s response to domestic violence, dating violence, sexual assault, and stalking • Title VI: Safe homes for victims • Title VII: Economic security for victims • Title VIII: Homicide reduction initiatives • Title IX: Safety for Indian women • Title X: Office on Violence Against Women • Title XI: Improving conditions for women in federal custody • Title XII: Law enforcement tools to enhance public safety • Title XIII: Closing the law enforcement consent loophole • Title XIV: Other matters (includes sections among others, such as national stalker and domestic violence reductions, sex offender management, rape kit backlog, interagency working group to study federal efforts to collect data on sexual violence, and a national domestic violence hotline) • Title XV: Cybercrime enforcement

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com The VAWA designates that crimes of IPV are felonies. It is designed to guide state laws for victims of domestic violence and manage cases of interstate acts of violence. Other relevant laws that pertain to intimate partner violence are (Pace Law School Library, 2019):

• Firearms: Unlawful Acts Relating to Domestic Violence

• Full Faith and Credit Given to Protection Orders

• Interstate Domestic Violence

• Interstate Stalking

• Interstate Violation of Protection Order

• Self-petitioning for Battered Immigrant Women and Children

• Violence Against Women and Department of Justice Reauthorization Act of 2005

• Violence Against Women Reauthorization Act of 2013

• Violence Against Women Reauthorization Act of 2013: Implementation in HUD

Housing Programs

In addition, there are several federal agencies that provide resources about domestic violence:

• Family and Youth Services Bureau, Department of Health and Human Services

• Centers for Disease Control National Center for Injury Prevention and Control

• National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint

• Center for Mental Health Services and Substance Abuse and Mental Health

Administration

• Office of Violence Against Women

• Office on Women’s Health, Department of Health and Human Services

• Office for Victims of Crime, Department of Justice

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All 50 states have laws that prohibit domestic violence. These laws amend periodically and vary from state-to-state. The American Bar Association (2019) website includes links to specific states for their laws. These resources include information about: civil protection orders, animal cruelty, domestic and sexual violence criminal law, sign language interpreters, forensic evaluators, confidentiality, custody, housing, mediation, and gun laws.

Most states have mandatory reporting laws that require reporting specific injuries that may be related to suspected domestic violence (Durborow, Lizda, O’Flaherty, & Marjavi,

2010). These reporting requirements are separate from child abuse and vulnerable adult reporting laws. Generally, states that have reporting requirements fall within three categories:

1) injuries caused by weapons, 2) injuries caused as a result of violence through non-accidental means and in violation of criminal laws, 3) and domestic violence cases.

As of 2010, three states do not require mandatory reporting for domestic violence:

Alabama, New Mexico, and Wyoming (Durborow et al., 2010). Historically, some insurance companies have denied coverage for injuries related to domestic violence. Discriminatory practices by insurance companies against victims of domestic violence include, cancellation of insurance, claims denials, exclusions of coverage for intentional acts for co-insureds, rate surcharges, adverse actions against third-parties associated with survivors of domestic violence, and disclosures that place victims at risk. As a result of several cases of discrimination by insurance companies, the National Association of Insurance Commissioners developed a model legislation to prohibit these practices.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com There are laws that protect the confidentiality rights of survivors of IPV. The Family

Violence Prevention and Services Act and the Violence Against Women Act require that any shelter, rape crisis center, and domestic violence program that receives federal funds must protect client information about any survivor receiving services (Women’s Legal Defense and

Education Fund, 2019). In addition, many states also protect survivor confidentiality between domestic violence and sexual assault service providers and their clients.

Disclosure of confidential information from domestic violence service providers can occur in certain circumstances, such as: if a judge finds that the value of the information outweighs its harm, reports of child abuse or neglect, criminal, mental health, or perjury proceedings against the victim, court actions against the practitioner, or information in the records is exculpatory evidence about the abuser (Women’s Legal Defense and Education Fund,

2019). The Women’s Legal Defense and Education Fund (2019) provides a state-by-state list of confidentiality statutes and what are considered to be privileged relationships.

Restraining Order Process

States vary in terms of the requirements needed by survivors to file restraining or protective orders against their abusers. Restraining orders are legal orders issued by a state court which requires on person to stop harming another person (WomensLaw.org, 2019). All protective orders are court orders and typically instruct abusers to stay away from the victim, from the victim’s home, workplace, or school. Some state laws require the abuser to pay temporary child support or continue to make housing or car payments. Sometimes judges will require that abusers relinquish weapons, such as guns. Often judges will include decisions about the care and safety of children.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com A restraining order is an order issued by the court in either family (probate) or criminal (district) court that requires the abusive partner to do certain things (NASW, 2019). This judge’s order can order the abuser to:

• stop abusing the partner; • remain a particular distance away from the survivor; • vacate and/or remain away from the survivor’s home or work; • turn over any weapons and/or rights to carry a weapon; • relinquish custody of minor children; and, • pay child support.

A restraining order can be obtained at any time, 24-hours a day, 7 days per week either at a court house or at a police station (NASW, 2019). State regulations about restraining orders differ from state-to-state, but all have procedures for obtaining them in order to stop a perpetrator from abuse (WomensLaw.org, 2019). Generally, if an abuser fails to follow a court order, a survivor can ask the police and/or court to enforce the order. Sometimes failure to follow a court order can result in a criminal conviction and punishment.

MANDATORY REPORTING

Mandatory reporting requirements are established by U.S. federal and state laws and require certain professionals to report violence, abuse, and suspected abuse to a legal or governmental agency (Lippy, Jumarali, Nnawulezi, Williams & Burk, 2019). There are four types of reporting laws:

1) crime-related injuries caused by the use of weapons,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 2) child abuse, neglect, or exploitation,

3) elder/vulnerable adult abuse, neglect or exploitation, and

4) domestic violence or sexual assault.

The purpose of mandatory reporting laws is to protect individuals who may have difficulty protecting themselves. Survivors of IPV often do not willingly disclose abuse or seek treatment. Mandatory reporting is a clinician-initiated intervention that can be used when the safety of the victim and/or children are at risk. Specialized practitioners who respond to the reports of violence from mandated reporters, such as clinicians, medical personnel, or neighbors, can assess the risk of harm and safety of a victim and/or children and provided needed services.

Mandatory reporting laws for domestic violence differ from state to state (Lippy, et al., 2019). Most states require reporting from health care professionals if injuries are crime-related. All states have mandatory reporting regulations for a various of professionals, including teachers, child care workers, clergy, and others, to report actual or suspected child abuse and neglect. In some states, there are mandatory requirements for all adults to report suspected child abuse or neglect. Though a majority of states have mandatory reporting laws that require health care professionals to report IPV-related injuries, four states allow survivors to refuse the report (Lippy, et al., 2019). Some states require domestic violence paraprofessional advocates, including IPV shelter personnel, to report the abuse, especially if there are children in the home. Survivors who receive medical attention for injuries caused by the use of weapons can be reported by health care professionals because of “crime-related” injuries. Most states have expanded their mandatory reporting laws of child abuse and neglect to include child exposure to domestic violence. In 18 states and Puerto Rico, mandatory reporting laws apply to all adult members in society.

While these laws have a protective function for survivors of abuse and children who experience or witness abuse, they can also have unintended consequences. IPV survivors who want help may be reluctant to seek help from formal support sources (Lippy, et al., 2019). They may avoid obtaining medical care for fear that the health care professional may report them to

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com authorities. They may fear that disclosure of IPV may involve law enforcement, the court system, and potential removal of their children.

The fear of child removal is especially relevant. Child welfare cases that are associated with domestic violence are more likely to result in removal of the child and placement in another environment (Lippy, et al., 2019). Some survivors who have called the police because of domestic battery have also experienced unwanted removal of the children as well. Survivors of color are also more likely to be referred to child protection agencies for IPV-related issues compared with Caucasian individuals (Lippy, et al., 2019).

The needs of IPV survivors vary greatly and include such things as safety, informal support networks, individual recovery from the effects of suffering IPV or other mental health issues, and long-term planning. There are many factors that affect survivors’ lives and influence the degree to which mandatory reporting laws, criminal and justice systems, housing programs, health care, and other systems are effective. If survivors fear the potential consequences, they may likely refrain from disclosure especially to a mandated reporter. Survivors may fear that disclosure to a mandated reporter would result in the arrest of their partner and involvement in the criminal justice system (Lippy, et al., 2019). The partner’s arrest or even the threat of their arrest could result in retaliation by the abuser (e.g. “outing” the victim in same gender partnerships, stalking, threatening violence towards family members or pets), loss of family income, homelessness, and/or loss of the relationship. Female survivors with children likely will fear that their children will be removed by child protection agencies (Lippy, et al., 2019). Removal of the abuser commonly results in income and housing instability. For immigrant survivors, fears of deportation of their abuser or themselves can also be a real obstacle to disclosing abuse to a mandated reporter.

One way in which clinicians can help their clients who are survivors of abuse is to warn them about the legal responsibility to report, thereby giving them a choice about whether disclosing will help them or further hurt them (Lippy, et al., 2019). This warning can affect whether or not the survivor shares the information and the type of information shared. Survivors may decide to misrepresent their experiences in order to avoid reporting obligations required by their providers. Survivors who report their abuse to mandatory reporters may experience increased violence in their relationships. Sometimes a survivor will make a report

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com and experience later consequences that are even more difficult to manage than before the report was made. For example, if a provider reports IPV to the police and a protective order is issued, but not enforced, this can put the survivor in a potentially much more harmful situation that if she had not reported at all. Even if an abuser is incarcerated, but released shortly thereafter, the survivor may have to deal with increased anger and violence or go into “hiding”.

Clinicians can help their clients by understanding all of the potential outcomes that reporting can have. Warning their clients of their reporting obligations can allow survivors to decide what and when to disclose. Clinicians can be prepared for potential consequences and have a plan of support in place. This can include involvement of an informal support system, formal program services, and strategies for dealing with potential consequences. Clinicians can work with state policy makers to consider the consequences of particular reporting laws and help to develop alternative strategies to protect and support those in need (Lippy, et al., 2019).

Who Makes the Report?

State and local laws determine who is considered a mandatory reporter for domestic violence (Durborow, Lizdas, O’Flaherty & Marjavi, 2010). Clinicians should check their state and local laws regarding mandatory reporting to keep abreast of new legislative changes. Three states do not have mandatory reporting laws: 1) New Hampshire “…excuses a person from reporting if the victim is over 18, has been the victim of a sexual assault offense or abuse (defined in RSA 173-B:1), and objects to the release of any information to law enforcement” (Durborow, et al., 2010, p. 4), 2) Oklahoma “…does not require reporting domestic abuse if the victim is over age 18 and is not incapacitated, unless the victim requests that the report be made orally or in writing” (Durborow, et al., 2010., p. 4), and 3) Pennsylvania’s law states “…that failure to report such injuries when the act caused by bodily injury (defined in § 2301) is not an offense if the victim is an adult; the injury was inflicted by an individual who is the current or former spouse or sexual or intimate partner; has been living as a spouse or who shares biological parenthood; the victim has been informed of the physician’s duty to report and that report cannot be made without the victim’s consent; the victim does not consent to the report; and the victim has been provided with a referral to the appropriate victim service agency” (Duborow, et al., 2010, p. 4). In some states, health care professionals are required to make reports to law enforcement; in other states, they are not required to do so (FindLaw, 2020).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Some states require both health care professionals and managers of health care facilities to report specific types of abuse (FindLaw, 2020). For states that have mandatory reporting laws, practitioners report cases of domestic physical and sexual abuse to law enforcement agencies (Futures Without Violence, 2020).

What Types of Reports?

State laws vary about the types of abuse that must be reported. Most states have mandatory reporting laws that require reporting of specific injuries and wounds, and suspected abuse or domestic violence for individuals being treated by health care professionals (Duborow, et al., 2010). Reporting laws generally fall within four categories: 1) states that require reporting of injuries caused by weapons, 2) states that mandate reporting for injuries caused in violation of criminal laws as a result of violence or through non-accidental means, 3) states that specifically address reporting in domestic violence cases, and 4) states that have no general mandatory reporting laws (Duborow, et al., 2010; FindLaw, 2020; Futures Without Violence, 2020).

What Do Reports Include?

Reports of domestic violence typically include: the name of the patient, the patient’s location, a description of the patient’s injuries, and the name or identity of the abuser (if known) (FindLaw, 2020). Additional details may be helpful for law enforcement. Some states do not require that the health care provider tell the patient about the report. However, some federal laws require disclosures to law enforcement for certain purposes, such as to comply with a court order, court-ordered warrant, subpoena, or summons, to identify or locate a suspect, fugitive or material witness, or to respond to an administrative request (U.S. Department of Health and Human Services, 2020).

After the Report, What Happens?

Practitioners should be aware that a report to local law enforcement about domestic abuse may create additional problems (Duborow, et al., 2020; FindLaw, 2020). The risk of violence can escalate as a result of a report and create a potentially lethal environment for a

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com client. Mandatory reporting can potentially enhance patient safety, improve professional responses, and serve as an intervention in an abusive situation (Duborow, et al., 2020). Practitioners can help their clients by discussing the need for a report to law enforcement and strategies for managing potential fallout from the report. Safety planning, identifying resources, and making appropriate referrals can be helpful for clients.

CULTURAL CONSIDERATIONS IN TREATMENT

The way in which a survivor will experience and interpret IPV is affected by the survivor’s cultural values, norms, and traditions. The cultural context of trauma and its meaning and inferences is embedded in social context. Similarly, healing also takes place within a survivor’s particular cultural and social context (Ferencik & Ramirez-Hammond, 2019).

One way a clinician can be sensitive to an individual’s cultural context is to discuss and explore the meaning of violence within the client’s own family and culture (Ferencik & Ramirez-Hammond, 2019). Clinicians can gain a cultural frame of references by asking questions and encouraging survivors to discuss their cultural beliefs and mores in general and specific beliefs and practices as they relate to family and social relationships. Sometimes past experiences in a survivor’s culture of origin affect the way she experiences and interprets violence. If a survivor is from a region or country with violent political unrest, she may have been exposed to different types of violent acts. There can be a connection between a survivor’s experiences of violence in another region and the way she approaches her own healing process.

Survivors from marginalized groups, such as people of color, LGBTQ individuals, and individuals with disabilities may face additional challenges (Ferencik & Ramirez-Hammond, 2019; Gill, 2018). In addition to the stigma and marginalization of being in a unique group, a survivor must also address issues raised by violence in their intimate partnerships. In addition to trauma-related issues, survivors can continue to face challenges with racism, heterosexism, and ableism, which can add another dimension to treatment and recovery.

Psychopathology is more likely to arise after domestic violence in particular (McLaughlin, et al., 2019). Chronic and repeated exposure to violence in relationships often results in a

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com higher likelihood of psychopathology. Particular racial and ethnic groups have higher occurrences of domestic violence (McLaughlin, et al., 2019; Vann, 2019). African Americans and Latinos have higher rates of exposure to violence, especially child abuse and witnessing domestic violence (McLaughlin, et al., 2019). However, Caucasians are more likely than African Americans and Latinos to exhibit diagnosed mental disorders. One possible reason for this is that many members of racial and ethnic minority groups routinely experience discrimination, stigma, and structural oppression in the United States, and thus, have developed more resilience skills (McLaughlin, et al., 2019).

Asians in the United States report the lowest prevalence of exposure to overall violence (McLaughlin, et al., 2019). African Americans experience more violence, especially sexual violence, relative to Caucasians and Latinos. Latinos have the highest rates of physical violence compared to Caucasians and African Americans. Asians and African Americans have significantly lower trauma-related mental disorders than Caucasians (McLaughlin, et al., 2019). Latinos have lower rates of trauma-related depression, anxiety, and social phobias than Caucasians. Asians and Latinos have lower rates of lifetime PTSD compared to Caucasians (McLaughlin, et al., 2019). African Americans and Caucasians have similar rates of PTSD symptoms. African Americans, Latinos, and Asians are less likely to develop trauma-related depression, anxiety, and substance disorders compared to Caucasians.

Lesbian women, gay men, bisexual, and transgender individuals (LGBT) experience IPV in rates that are similar to heterosexual couples (Gill, 2018; Longobardi & Badenes-Ribera, 2017; Vann, 2019). Lifetime prevalence of rape, physical violence, and/or stalking is approximately 44% for lesbian women, 61% for bisexual women, 35% for heterosexual women, 26% for gay men, 37% for bisexual men, and 29% for heterosexual men. Though rates of IPV are similar, LGBT individuals face additional issues that are related to being part of marginalized sexual minority.

Individuals who are part of marginalized and oppressed groups often deal with “minority stress.” Minority stress presents additional stressors. Minority stress is related to stigmatization, prejudice, and oppression associated from social processes, institutions, and structures that go beyond individual conditions of events (Longobardi & Badenes-Ribera, 2017; Vann, 2019). Discrimination, experiences of violence, and harassment in daily life can lead to internalized

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com homophobia, and negative beliefs, behaviors and assumptions. Support from family and friends can be strained if they do not accept the sexual identity and orientation of a survivor. If an individual has not disclosed her gender identity or orientation, this can cause additional distress in addition to the effects of IPV. Negative social experiences make help-seeking for IPV treatment even more difficult (Gill, 2018).

Internalized homophobia is related to IPV in same-sex relationships (Longobardi & Badenes-Ribera, 2017). It can also lead to a greater likelihood of IPV perpetration among male same-sex partners. Psychological IPV among same-sex partners is more often reported than physical IPV. Bi-directional violence, that is when victimization and perpetration occur between both partners, is a common IPV pattern among LGBT individuals in same-sex partnerships (Longobardi & Badenes-Ribera, 2017).

“Taking my first step into the field of violence prevention, I had a personal question about the meaning of ‘gender-based violence.’ Surely, it must include folks that identify outside the gender binary? When I started my position as Health Program Assistant at FUTURES, I was so excited to see resources specifically created for trans/gender non-conforming (Trans/GNC) communities, for my community. This week weighs heavily, and while the important of remembrance cannot be understated leading up to Transgender Day of Remembrance conversation within my own community continues as we ask the question, ‘What can we do to stop the violence?’ FUTURES has posted before about standing with people of all gender identities, and the National health Resource Center on Domestic Violence (HRC) hopes to do just that by creating LGBQ and Trans/GNC specific resources, and offering technical assistance to advocates and health providers who are looking to make their programs and practices more inclusive of people who identify as Trans or GNC” (Olguin, 2019).

Individuals with disabilities are at a much higher risk of IPV compared to individuals without disabilities (National Coalition Against Domestic Violence (NCADV), 2019). As much as 80% of women with disabilities have experienced sexual assault. Women with developmental disabilities have among the highest rates of physical, sexual, and psychological abuse perpetrated by intimate partners and family members.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Individuals with disabilities are at greater risk for severe physical and sexual violence (NCADV, 2019). Survivors with disabilities are more often dependent upon their partners for their care. They are more likely to not report their abuse. Many programs that serve individuals with disabilities do not have professionals who are trained to provide services to this population.

Additional complexities arise when factors such as race, ethnicity, ability, and sexual identity and orientation are connected to IPV. Individuals who have experiences of oppression, prejudice, racism, and discrimination have additional burdens when trying to access treatment service professionals who are culturally competent (Longobardi & Badenes-Ribera, 2017; Vann, 2019). The intersectionality between different identities impacts service availability, provisions, and treatment protocols (Gill, 2018). Often treatment providers are from groups who have had historical and privileged access to institutional power and resources. There are relatively few resources and skilled professionals who are trained to work with survivors from diverse groups.

People with disabilities often face barriers to access for services (NCADV, 2019). Some survivors lack the abilities or skills to seek help or sometimes to even disclose their abuse. People with disabilities who depend on their partners are not likely to report the abuse because of losing their caretaker. Survivors may fear being institutionalized or losing their decision- making abilities if they are unable to care for themselves without their partners. In addition, survivors with disabilities may be at increased risk of losing custody of their children because they are likely to be viewed as unable to care for their children independently.

Culturally competent clinicians recognize that individuals from diverse groups have different cultural beliefs and practices; there is no one-size-fits-all approach that will work with every member from a culturally diverse background (Vann, 2019). They recognize that life context and meaning is based upon unique experiences. In some cultures, intergenerational patterns of violence can be continued by family members. These generational cycles of abuse can normalize IPV. When life context is not examined, clinicians can miss important information that can contribute to effective treatment.

Many treatment programs lack comprehensive services that address the needs of culturally diverse survivors (Vann, 2019). Help-seeking and disclosure of abuse is related to cultural context. When clinicians know this, they can help survivors feel accepted and recognized even

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com if their experiences and needs are tied to their own cultural contexts. Many individuals from diverse racial and ethnic groups incorporate religious approaches in their lives (Vann, 2019). Many traditional programs do not include or even exclude religious references, which can affect the level of a survivor’s engagement with treatment.

Practitioners who want to enhance services for survivors from diverse backgrounds must do so with conscious intention. They can assess community and agency readiness from culturally competent service provision by reaching out to members of diverse communities directly (Vann, 2019). Examples of questions to consider when developing culturally competent services Community & Agency Who are you developing services for? Are you considered a trusted resource by the target community? Readiness Who is providing input on the design of the service? What services do you plan to provide for the community? What will be the benefits to the community? What do you expect from community members in return? Identify Allies Who are potential friends and allies who can help with developing services? Who is willing to work with you? Who is willing to “vouch” for you if you are not a member of the target community? Are you connected to community organizations associated with your target population? Community Involvement Do members of the target community comprise the majority of stakeholders? Who will be involved (criminal justice representatives, mental health providers, school representatives, child welfare agencies)? What are the opportunities and challenges with providing specific services? Long-term planning What are the intra-agency processes that have played a role in excluding members of diverse groups? How does the target population view the agency? How does the agency view the target population? What agency policies and procedures need to be adjusted to (Vann, 2019) increase participation by target members?

Providers who offer services for survivors from diverse groups should make sure that the agency staff reflects those whom they serve (Vann, 2019). Organizational leaders need to consciously and actively recruit staff and board members who represent the realities of their clients and their needs. Clinicians can help their clients by demonstrating and conveying

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com respectful messages and aspirations to provide culturally inclusive services as an important part of building relationships with diverse communities.

“[Survivors] talk of the lack of professionals with appropriate training, the lack of understanding of abuse and the lack of consistency in treatment. Most commonly, [survivors] relate how, given the lack of awareness of such trauma, professionals would ask totally inappropriate questions in part because they might assume that abuse experiences fit into neat boxes or that there might be a beginning, middle, and end with answers. It is not so much that the impact and effects of the trauma falls on deaf ears, but ears that do not seem to hear because, the GP, the counselor, the therapist, perhaps even a consultant or mental health nurse simply does not seem to have the appropriate training and nuanced understanding for the depth of experience that comes from living through abuse” (Survivors Voices, 2019).

Culturally competent professionals understand that individuals have different ways of seeking treatment for IPV (Vann, 2019). Survivors will express their thoughts, feelings, and behaviors according to their own cultural contexts, which may differ significantly from other individuals outside their cultures. Help-seeking has a lot to do with trust, which for many survivors is difficult. Sometimes it is difficult for survivors to trust family and friends as well as professionals offering treatment.

This integrative treatment is a modified version that is an evidence-based, manualized, CBT intervention (Mills, et al., 2016). The intervention consists of 13 weekly, individual sessions that last 90 minutes each. Often the treatment is delivered by a mental health clinician in inpatient and outpatient sessions. Components of this treatment include:

Sessions Focus Sessions 1-4 Motivational enhancement and CBT for substance use disorders and psychoeducation Sessions 5-12 In vivo exposure, a systematic engagement and interaction to trauma reminders in the environment with the goal of working toward coping

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com with higher levels of distress and difficulty Sessions 6-12 Imaginal exposure, a systematic approach that includes repeated and prolonged engagement with processing trauma memory Sessions 8-12 Cognitive therapy to challenge and replace maladaptive cognitions with healthy, adaptive ones Session 13 Review treatment progress, develop an aftercare plan, and end the treatment

Integrated treatments, such as COPE, work well because they combine treatments to address symptoms as well as addictions (Korte, et al., 2017). Combined symptomology is often seen among survivors of IPV. Integrated approaches are better designed to deal with individuals who present complex symptoms rather than treatments that deal with substance use-only or PTSD-only symptoms. Often dealing with PTSD symptoms changes substance use behaviors when treated with combined approaches. Individuals who experience abuse in their relationships often use alcohol and drugs to alleviate symptoms of PTSD (Korte, et al., 2017). Substances can reduce unwanted trauma symptoms and use them to self-medicate. Survivors may also use substances to deal with PTSD symptoms, such as depression and anxiety.

CULTURE AND TRAUMA

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Domestic violence is prevalent in society across all groups, but members of some minority populations are at an increased risk for victimization. For example, Gomez and Freyd

(2018) and Schubert (2018) identify the following:

• Racial and ethnic groups, such as African Americans, Latino/a Americans, and

Native Americans, are at a disproportionately higher risk for domestic violence.

• Individuals of diverse sexual orientations and gender identities, such as lesbian,

gay, bisexual, transgender, and queer (LGBTQ) people, are at higher risk of IPV.

• People with physical and/or mental disabilities are at high risk for victimization.

• Sociocultural contexts of violence, such as historical trauma, societal inequities,

contextual factors, social status, and cultural values, affect the outcomes

associated with IPV.

• Immigrants and refugees often experience extreme trauma, such as torture and

extreme violence, that can cause serious physical and mental health

consequences.

An individual’s culture refers to a social group membership that includes shared values, mores, morals, religion, history, language, sexual or gender identities, political and/or lifestyle preferences (Schubert, 2018). It is the unique environment and shared collective of social routines, rituals, common beliefs, symbolic content, and rules for social conduct that is passed from generation to generation. Cultures vary in terms of social practices, geographical location or origin, economic systems, and social hierarchy. Individuals learn and internalize cultural nuances and meanings through interactions with other individuals within the social collective.

There is no one prototype for a cultural group. Rather, individuals within specific cultural contexts are heterogeneous.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Culture shapes the meanings that individuals attribute to experiences (Lopez et al., 2017;

Schubert, 2018). Beliefs and perceptions about violence, trauma, mental health, and healing are all shaped by an individual’s culture. An individual’s beliefs and subsequent reactions, and interactions are embedded within cultural communities and relationships with others in the community (Lopez et al., 2017; Schnyder et al., 2016). In addition, minority group survivors may face higher risks of additional victimization, such as multiple experiences of interpersonal, intimate partner, and community violence (i.e., poly-victimization) (Gomez & Freyd, 2018;

Lopez et al., 2017). These factors may help to explain the racial and ethnic disparities in trauma- related outcomes, such as depression and PTSD.

Violence is a cultural construct. How violence is defined, used, and normalized within a given culture affects how experiences are interpreted. Culture determines how the meanings of behaviors are transmitted in their communities from one generation to the other (Pacheco,

Medeiros, & Guilhem, 2017). Cultural influences on an individual’s perspective about gender roles, social status, and power affect the use and perpetuation of violence by members of communities. Gender roles and power assigned to these roles are elements of cultural beliefs about how men and women should behave in relation to one another (Pacheco, Medeiros, &

Guilhem, 2017). Social and cultural constructions of gender and inequalities are co-created and maintained by community members.

Culture influences an individual’s identifications and experiences of trauma – meaning that, it is common for individuals to understand and create meanings about trauma that align with their cultural values (Schubert, 2018). The Diagnostic and Statistical Manual of Mental

Disorders Symptoms (DSM) outlines symptoms of post-traumatic stress disorder (PTSD), but does not include sociocultural context and cultural particularities in the manifestation of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com symptoms (APA, 2013; Schubert, 2018). Individuals from diverse cultural and ethnic groups who experience trauma can exhibit symptoms that practitioners may find difficult to categorize in terms of traditional western mental health diagnostic assessment. Reactions to trauma among diverse individuals may not conform to western expectations (Schubert, 2018). Cultural constructs frame IPV in relation to deeply rooted beliefs about illness, trauma, and recovery. In other words, cultures establish the parameters for their respective societies about what is to be understood as illness and what is considered normal behavior (Schubert, 2018).

Within a cultural context, members of minority groups often develop feelings of attachment and trust with other individuals from the same group (Gomez & Freyd, 2018). This bond can serve as a protective factor against the effects of discrimination, marginalization, and oppression. However, when violence is committed against one member by another of the same minority group, disclosure of abuse can lead to within-group violence called cultural betrayal trauma (Gomez & Freyd, 2018). This betrayal can cause additional strain and pressure on survivors because disclosure of the abuse and help seeking may be seen as cultural disloyalty.

Members of diverse cultural groups express their perspectives of trauma and its effects on individuals in ways that are unique (Lopez et al., 2017; Schubert, 2018). Culture affects community perceptions of how the environment, social network, and chain of events leading to traumatic experiences affects survivors. Similarly, these factors affect survivors’ recovery processes, including the types of community and social supports available to survivors and choices survivors may make about engaging with these supports.

The biological reactions to violence in the form of PTSD are universal even when considering different cultural contexts (Schubert, 2018). Activation of particular endocrine and neurotransmitter interactions and brain regions occur in trauma survivors. However,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com interpretation of the associated feelings, thoughts, and behaviors are nuanced within cultures.

Individuals’ interpretations of the meaning of symptoms, social acceptance and support of distress, and effects to functioning all occur within a cultural framework.

Individuals from cultural minorities are at higher risk for additional traumatization exacerbated by social inequities (Gomez, 2018; Gomez & Freyd, 2018). Societal trauma contributes to internalized prejudice, fractured minority identification, and within-group pressure by other minority group members. Within-group pressure is when there is an expectation that a survivor of the minority group will “protect” a perpetrator of the same group because to expose the individual would bring further prejudice to the minority group as a whole or expose the perpetrator to other systemic violence (e.g. racism within the judicial system).

This dynamic is a form of group protection caused by societal trauma. Social factors, such as cultural and gender norms, poor regulatory laws and enforcement, unemployment, and inequality also contribute to the dynamics of violence within a culture (Schnyder et al., 2016).

Societal inequities and prejudices exacerbate the effects of traumatic experiences on cultural minority members by contributing to negative perceptions, such as distrust, shame, self-blame, anger, body image, sexuality, and coping strategies (Gomez, 2018). Perceived cultural betrayal by other group members adds pressure to survivors to protect perpetrators from outside scrutiny for fear of creating further societal problems for the group.

Cultural beliefs not only influence the personal meaning attributed to violence, but also reflect a particular culture’s values and appraisals about violence (Park, Currier, Harris, &

Slattery, 2017; Schnyder et al., 2016). The beliefs, values, and norms held by members of minority groups can influence the reactions of significant others and community members.

These reactions and beliefs can either support or impede survivors’ recovery efforts. Cultural

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com factors also influence how survivors and community members attempt to explain and recover from violence.

Cultural affiliations direct the understanding, interpretation, and manifestations of trauma; and, whether survivors should seek help and, if so, what type. Some cultural values lead individuals to seek help in traditional ways, while other cultural values support psycho- pharmaceutical remedies and combinations of treatment. Because interpretations of illness and health are culturally-driven, these same influences promote individuals’ unique practice of help- seeking (Park et al., 2017; Schubert, 2018). For example, in cultures that believe mental illness is caused by supernatural spirits, misdeeds, or offenses to divine powers, healing practices will align with these cultural constructs. In addition, individuals may trust only their own cultural and traditional approaches towards healing.

Unfamiliarity with behavioral health care systems and treatment approaches may discourage some survivors from seeking help (Schubert, 2018). Practitioners who are unfamiliar with the cultural values of a particular client may unwittingly ignore important cultural nuances. Practitioner-client language difficulties, cultural misunderstandings, and implicit and explicit biases can prevent the therapeutic relationship from fully developing. In addition, some survivors may have previous negative experiences with health care and mental health providers that further strengthen distrust and skepticism.

Social and familial influences are important parts of help-seeking (Schubert, 2018).

Many individuals first seek help from others in their close social circles. Social relationships are an important component of support, especially among cultures with collectivist values

(Schubert, 2018). Traditional healing ceremonies, healers, or remedies may be used as first-line

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com treatment for symptoms. Social stigma of help-seeking for approaches outside cultural context can inhibit survivors from exploring other treatment approaches.

There are disparities in rates of trauma, trauma-related symptoms, and treatment among members of ethnically and culturally diverse groups. For example, indigenous cultures, such as the Yup’ik Eskimos, Navajo and Athabaskan Indians, and Hawaiian Natives experience similar rates of trauma symptomologies (Salzman, 2018). Members of these groups experience higher rates of suicide, alcohol abuse, and accidental deaths. The similarities in behavioral and psychological indicators of trauma do not indicate deficiency of character or the presence of higher disease. Rather these symptomatic indicators can be related to historical trauma imposed on a cultural group. For example, consider how indigenous cultures have been traumatically disrupted as a result of contact with Europeans. Salzman (2018) offers some key points about culture:

• Culture infuses the world with meaning and supports individuals in their endeavors for

meaning in their lives.

• Cultures contribute to the construction of self-esteem of its members.

• Cultural norms, values, and beliefs serve as psychological defenses against anxiety,

depression, and other symptoms of existential crisis.

• Cultural norms and values are sources of meaning and self-esteem.

Salzman (2018) then furthers the key points about disruptions to entire cultural communities as a result of European colonization:

• Individuals use maladaptive attempts to manage the anxiety when cultural solutions are

removed, lost, or changed.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com • When traditional cultural solutions are removed and oppressed, grief ensues, resulting in

multi-generational transmission of trauma.

• Indigenous cultures engage in cultural recovery movements to restore ceremonies,

narratives, and rituals that address problems in their lives.

The disruption of cultural processes can create feelings of trauma and anxiety that are collective and deep-rooted. Cultural healing rituals are designed to help members heal from maladies and re-establish homeostasis in daily functioning. They promote a sense of continuity of community and an individual’s place within it (Salzman, 2018). Cultural road maps help members to identify “right ways” of being and behaving.

When a culture is disrupted or damaged, members can collectively develop symptoms of cultural trauma. Inter-generational transmission of trauma can result from cultural disruptions, marginalization, and oppression, such slavery (e.g., African Americans), colonization (e.g., indigenous peoples), homophobia and hate crimes (e.g., LGBTQ individuals), marginalization and exclusion (e.g., individuals with disabilities), ethnic hatred (e.g., immigrants and refugees), and exploitation of labor (e.g., Latinos).

Clients can be best served by understanding their stories and the contexts that surround them. Cultural trauma of significant and traumatic events is transmitted by family members through generations of stories, beliefs, and behaviors (Park et al., 2017; Salzman, 2018).

Historical narratives can help people see the world and their place in it. They can guide them through the difficult areas where people often struggle. Stories based on past experiences create human knowledge. New experiences are interpreted through old stories and serve as the basis for the individual and collective self.

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(Park et al., 2017; Salzman, 2018). Individuals act on the basis of interpretations of behaviors, situations, and events in their lives. Providers best help their clients when they pay close attention without judgment to the narratives of those who are in distress and conflict. In order to understand an individual’s culture, a clinician must also understand the cultural context and history of a particular culture.

Many cultures have underlying, fundamental narratives that help guide individuals to safety, security, and recovery (Salzman, 2018). These master narratives within a culture help individuals understand, interpret, and respond to trauma in their lives. Cultural members produce, tell, and repeat master narratives that have particular importance in a given situation.

Within these narratives, individuals reveal an interpretive reference point to understand their current experiences. Culture renders the human experience explicable and understandable through its stories of life experiences.

Cultural trauma, in comparison to individual trauma, attacks and damages the bonds that connect group members together and continue a sense of community (Caminero-Santangelo,

2016; Park et al., 2017). Cultural trauma includes not only sudden, acute acts of violence, but also the slow insidiousness of structural violence that is rooted in prejudice and discrimination based on gender, race, sex, class, abilities, and others (Caminero-Santangelo, 2016; Park et al.,

2017). Community-bound trauma works against its members, often slowly, resulting in a gradual accrual of trauma and range of symptoms, different from that of a single traumatic event.

Many individuals from diverse groups that are marginalized and oppressed are often traumatized by a range of experiences (Caminero-Santangelo, 2016). These negative

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The extent to which IPV is understood and interpreted depends on the event itself, but also on the worldviews held by the survivor and the survivor’s community. Traumatic experiences can sometimes destroy survivors’ worldviews about themselves, their partners, and their community members. When cognitive and emotional ways of understanding are destroyed or distorted by trauma, individuals try to create new meanings and understandings in order to recover (Park et al., 2017). A survivor may believe that her community is kind and benevolent, but after a traumatic incident, she may believe that she is unprotected, unsafe, and undeserving of kindness.

Culture is a multi-faceted and complex aspect of daily living. Violence within the context of culture is even more complicated. The identification, understanding, and interpretation of violence within a partnership exists within a cultural context that varies among individuals and cultural groups. Practitioners cannot know all things about all people, but rather need to understand that culture is embedded into every human being and, therefore, as a basic tenant of providing behavioral health and human services, practitioners cannot make assumptions about clients’ experiences or feelings. Culture expresses itself in client narratives about the events, circumstances, and interpretations of their lives. Practitioners need skilled, open, inquiring, and nonjudgmental approaches to their clinical work with clients.

CULTURAL AND SOCIAL NORMS THAT SUPPORT VIOLENCE

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com The WHO (2019) lists cultural and social norms that support different types of violence.

The purpose of understanding embedded cultural values about violence and control is for social workers, psychologists, marriage and family therapists, and mental health counselors to be better able work with survivors who adhere to these values. This does not mean that all members of these cultural groups use or condone violence against others. Rather, among those individuals who use violence, individual interpretation of the violence, family and friend support, and community resources often reflect cultural values.

Child Maltreatment • Child maltreatment correlates with IPV. • Female children are valued less in some societies than male children (e.g., Peruvian cultures); female children are considered to have less social and economic potential in some cultures. • Children have a low status in society and in the family (e.g., Guatemalan culture). • Physical punishment is an acceptable or normal part of child rearing (e.g., Turkish, Ethiopian cultures). • Communities adhere to harmful traditional cultural practices, such as genital mutilation or child marriage (e.g., Nigerian, Sudanese cultures). (WHO, 2019)

Community Violence

• Cultural intolerance, intense dislike, and stereotyping of “different” groups within

society can contribute to violent and aggressive behavior towards others (e.g. American

culture).

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• In some cultures, a man has the right to assert power over a woman and is socially superior (e.g., Indian, Nigerian, Chinese cultures). • A man has a right to “correct” or discipline female behaviors (e.g., Indian, Nigerian, Chinese cultures). • A woman’s freedom should be restricted (e.g., Pakistani culture). • Physical violence is an acceptable way to resolve conflicts within a relationship (e.g., South African, Chinese cultures). • Intimate partner violence is a taboo subject and reporting abuse is disrespectful (e.g., South African, Nigerian cultures). • Divorce is shameful (e.g., Pakistani culture). • When a dowry or bride wealth is an expected part of marriage, violence can occur either because financial demands are not met or because bride wealth becomes synonymous with purchasing and owning a wife (e.g., Nigerian, Indian cultures). • A man’s honor is linked to a woman’s sexual behavior. Any deviation from sexual norms disgraces the entire family, which then can lead to honor killings (e.g., Jordanian culture). • Mental health problems are embarrassing and shameful; individuals should refrain from seeking help (e.g., Australian culture). • Individuals in different social groups, such as LGBTQ individuals, within society are not tolerated (e.g., Japanese culture). • Sex is a man’s right in marriage (e.g., Pakistani culture). • Girls are responsible for controlling a man’s sexual urges (e.g., South African culture). • Sexual violence is an acceptable way of putting women in their places or punishing them (e.g., South African culture). • Sexual violence, such as rape, is shameful for the victim, which prevents disclosure (e.g., American culture). (WHO, 2019)

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According to UNICEF (2019), attitudes and social norms on violence permeate all aspects of a multi-cultural, global society:

• Adolescent girls are as likely to justify wife-beatings as boys (e.g., West and Central African, Sub-Saharan African, Middle Eastern and North African, Eastern and Southern African, and South Asian cultures). • Marriages of children under age 14 years are permissible in some societies (e.g., Western and Central African cultures). • Approximately 33% of girls aged 15 to 19 years have undergone female genital mutilation (e.g., Iraqi, Yemen, Indonesian, Somalian, Guinean, Djibouti cultures). • In nearly 75% of the countries with Unicef data, 20% of girls have experienced some form of IPV in the past year (e.g., Namibian, Guinean, Bolivian, Gabonese, Liberian cultures have the highest prevalence).

CULTURAL AND ETHNIC DIVERSITY AMONG IPV SURVIVORS

Minority stress theory posits that persons who belong to socially disadvantaged or otherwise marginalized populations experience unique stress experiences (LeBlanc, Frost, &

Wight, 2015; Tebbe & Moradi, 2016). Increased stress, especially among IPV victims from diverse cultural and ethnic backgrounds, and other types of special populations is associated with higher risks of IPV (Gilroy, McFarlane, Fredland, Cesario, & Nava, 2018). Experiences that cause stress can often lead to maladaptive responses that can causes psychological problems, such as depression, anxiety, fear, anger, or aggression (LeBlanc, Frost, & Wight,

2015). Chronic stress exacerbates problems and contributes to poorer physical and mental health outcomes.

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(LeBlanc, Frost, & Wight, 2015). These systems are often fraught with negative experiences for individuals from minority groups by perpetuating structural, systematic, and interpersonal disadvantages. LGBTQ individuals, racial and ethnic minorities, disabled persons, and individuals with low income, often face negative social attitudes and beliefs. They often experience discrimination, oppression, and marginalization by members of society. In addition, they can internalize these negative perceptions and beliefs.

Sociocultural prejudice and marginalization of individuals from minority populations can impact physical and mental health, and even leads to an increased risk of suicide (Tebbe &

Moradi, 2016). Inequitable laws, policies, and practices often marginalize and pathologize individuals and cause further oppression; and, these negative experiences can cause increased psychological distress and dysfunction, substance use, and mental health problems. Because of this, being a member of such marginalized ethnic/racial groups or special populations as lesbian, gay, bisexual, transgender, queer (LGBTQ) or persons with disabilities, can create a higher risk for IPV. More experiences of prejudice, marginalization, and oppression create higher levels of stress and dysfunction.

Different aspects of society can affect the degree to which individuals from minority groups experience stress (Sylaska & Edwards, 2015). These types of experiences and negative internalizations can increase the likelihood of IPV victimization and perpetration (Sylaska &

Edwards, 2015). It also affects the degree to which survivors will disclose abuse and seek treatment.

Significant barriers for IPV survivors from diverse groups include lack of social support from friends and family, discriminatory policies and practices, and social stigma by community

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com members (Sylaska & Edwards, 2015). Practitioners working with IPV survivors can work best when they understand the different psychological and social factors that affect their clients.

Factors such as immigrant and refugee status, race, ethnicity, sexual identity, age, disability, gender, geographic residence, and socioeconomic status have unique aspects that impact the way violence is viewed, accepted, disclosed, and treated.

Intimate partner violence is a complex and multi-faceted phenomenon that impacts individuals in a variety of ways. Clinicians who practice cultural humility and strive to understand the diverse experiences of IPV survivors can be in better positions to help their clients. The following sections describe unique groups and the effects that IPV can have on survivors and perpetrators.

Immigrants and Refugees

Refugees are involuntary immigrants who left their native countries due to stressful, difficult, or life-threatening circumstances (Schubert, 2018; Taggart, 2018). Both immigrants and refugees face difficult challenges in the host countries compared to native-born citizens.

Challenges, such as language acquisition, lack of financial resources, weakened social networks, and unfamiliar cultural processes, can create substantial burdens. Discrimination, bias, and prejudice add additional strain.

Traumatic experiences from extreme violence can impact generations of families

(Schubert, 2018). Attachment bonds can be disrupted because of the necessary adaptations and coping strategies developed by survivors to endure violence. Speech, behaviors, and emotions can be transmitted either directly or indirectly from parents to their children. Individuals who

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Refugees often present more symptoms of PTSD, depression, and anxiety than voluntary immigrants (Schubert, 2018). For those who have histories of torture, symptoms can be especially difficult and chronic. Acts of torture are often directed toward specific ethnic, religious, or sexual minority groups (Schubert, 2018). Physical torture, such as burning, suffocation, and asphyxiation, create extreme distress and subsequent severe PTSD symptoms.

Sexual violence can be used as a form of torture, especially against women and girls.

Psychological methods of torture, such as isolation, exposure to loud noises, and deprivation of clothing, may leave no physical scars, but lead to severe psychological distress and symptomology.

Many refugees suffer long-lasting mental health problems that are related to trauma

(Schubert, 2018). Tortured refugees may experience physical problems such as chronic pain in different parts of the body. While some somatic symptoms can be linked to damage to a particular body part or tissue, other sensory disturbances can emerge. The psychological effects of torture can be long-lasting and significantly disrupt functioning. These experiences of severe trauma are also associated with high levels of depression, anxiety, dissociative disorders, personality disorders, and adjustment problems (Schubert, 2018).

Immigration rates to the United States have been rising with recent immigrants coming from India, China, Mexico, the Philippines, and Canada (Taggart, 2018). Immigration populations are expected to increase and make up nearly a third of the American population by

2050. States with higher immigrant residents are: California, Florida, Hawaii, Illinois,

Michigan, New Jersey, New York, Ohio, Texas, and Washington (Taggart, 2018). The

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American-born citizens often have stereotypes and misconceptions about individuals who emigrate from other countries. In recent years, media outlets tend to portray immigrants in a negative light, including committing criminal offenses and excessively using alcohol and drugs (Taggart, 2018). This type of prejudice burdens immigrants who experience violence in their relationships because of the lack of community receptiveness and support.

The effects of immigration enforcement through raids, border deaths, disappearances, family separations, and fear of deportation often results in traumatic reactions (Amuedo-

Dorantes & Arenas-Arroyo, 2019; Caminero-Santangelo, 2016; Taggart, 2018). Police involvement in immigration enforcement causes fear and mistrust, which in turn, affects the willingness of immigrants to engage with police when they experience IPV (Amuedo-Dorantes

& Arenas-Arroyo, 2019).

Partners who use violence in their relationship may also use the survivor’s immigrant status as another vehicle for control (Amuedo-Dorantes & Arenas-Arroyo, 2019; Taggart,

2018). In particular, immigrant women sometimes depend upon their partners’ immigration status and are financially dependent upon their income. Even though federal laws (e.g., 1994

Violence Against Women Act) protect women from domestic violence, immigrant women may still be hesitant to report abuse and seek help. Spouses from foreign countries who are married to U.S. citizens can apply for lawful permanent residence in the United States. Remaining married is essential in order to transfer from a temporary status to a permanent status. Foreign spouses can be sponsored by their U.S. spouses as long as they are living together (Amuedo-

Dorantes & Arenas-Arroyo, 2019). This requirement can directly affect the foreign spouse’s

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U.S. citizenship independently, the steps required to self-petition in an abusive marriage can be burdensome and cause distress and fear of an unknown determination.

Immigrants may be less likely to seek medical assistance because they lack health insurance and/or authorization to be in the United States (Taggart, 2018). Some providers and medical personnel attempt to allay fears by posting signs and brochures explaining that immigration services will not be called if an undocumented immigrant needs medical assistance. However, uncertainty and mistrust may still influence help-seeking. The risks associated with a potential report to immigration services may outweigh the benefits of receiving care. Similar fears and mistrust may prevent an immigrant from calling the police.

Immigrant women may be more likely to seek help through informal processes without involving law enforcement (Taggart, 2018). Many undocumented immigrants fear deportation if they make a report to the police and may fear that their children will be removed.

Many immigrants face language barriers and a lack of education (Taggart, 2018). This can translate into barriers like having difficulty communicating experiences that are already difficult to disclose, such as sexual assault or physical abuse. It can also erode confidence in a survivor’s belief that help can be obtained. For survivors of abuse, this can present insurmountable obstacles in reporting abuse and seeking help.

Facing negative prejudice and stereotypes, many immigrant survivors are concerned with maintaining a good image for members of their culture (Taggart, 2018). Members of the cultural group may feel that a survivor will tarnish the group as a whole if she discloses

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Services and programs often do not address needs that are specific to the immigrant experience (Taggart, 2018). Many service providers do not know the process or procedures of obtaining a documented status. They may be unfamiliar with current immigration laws and survivors’ deep fears of immigration authorities and potential deportation of themselves, their abuser, or their children. Many service providers are not bilingual and may not understand the difficulties inherent in communicating in a language that is not native. Rights and privileges given to U.S. citizens are often not available to those who are undocumented. Thus, service providers may not fully understand the very real threat of negative consequences in disclosure.

Social isolation is a major issue for immigrant survivors (Taggart, 2018). Isolation from individuals in the host country is a common experience among immigrants. In an abusive relationship, survivors can also feel isolated from members of their own cultural group.

Isolation can occur from different influences. Within the culture, there are often beliefs about the dominant roles of men, religion, shame, fear, and disclosure that affect survivors’ willingness to seek help (Taggart, 2018). Combined with prejudice and mistrust by members of the host country, immigrant survivors often face a double-bind.

Resource: The National Network for Immigrant and Refugee Rights (NNIRR) works to defend all rights of all immigrants and refugees, regardless of immigration status. The organization has drawn membership from diverse immigrant communities, and actively builds alliances with social and economic justice partners around the country. NNIRR is committed to the vision of human rights as essential for a person’s security, health, safety, and peaceful life. Some of their key activities include: to strengthen role and participation in broader alliances and coalitions; to push back on the racist and xenophobic narrative of division, distrust, and hate; and, to advocate nationally and internationally for the human rights of all migrants and refugees. Website: http://www.nnirr.org/drupal/

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The group of Latino/a/x Americans is very diverse and includes individuals from countries in Central and South Americas. Central American countries include: Mexico, Belize,

Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (Migration Policy

Institute, 2019). South American countries include: Argentina, Bolivia, Brazil, Chile,

Colombia, Ecuador, Guyana, Peru, Uruguay, and Venezuela. Immigrants from Mexico comprise the largest immigration group in the United States (Migration Policy Institute, 2019).

This group comprises 25% of the total immigrant population.

The risks for IPV are increased by such common psychosociocultural factors as socioeconomic stress (e.g. poverty, low educational attainment, crime, and unemployment), childhood abuse, substance use, cognitive and mental health issues, and intergenerational transmission of violence; and, all these psychosociocultural factors disproportionately affect

Latino families in the United States (Simari, 2019). For example, Latinos are more likely to work in service jobs with lower pay and lower rates of promotion to higher-level managerial positions (Simari, 2019). Low educational attainment and legal status are contributing factors.

Financial stress, limited work opportunities, and (again) legal status may also impede a survivor’s decision to leave an abusive relationship. Undocumented Latinos may fear deportation if they report abuse or seek help for IPV.

Latinos who are recent immigrants have the additional challenges of navigating and adapting to American culture (Simari, 2019). They face challenges with learning a new language and social norms in addition to finding employment with wages that support independent living. Discrimination, stress from acculturation, separation or isolation from

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com family and friends, and living in areas of high poverty and crime create psychological distress on the individuals and families (Simari, 2019). Compared to Caucasian women in the United

States, Latinas are less likely to report IPV to law enforcement because of fears related to deportation, unfamiliarity with U.S. laws, and familial and cultural values and loyalties (Simari,

2019).

Latino IPV perpetrators have personality traits that may be reinforced by sociocultural factors, such as jealousy and machismo attitudes of batterers (Simari, 2019; Taggart, 2018).

Latino cultural beliefs affect how survivors perceive abuse and cope with its effects. At a young age, Latina women are taught cultural values of familismo, a strong emphasis on and loyalty to the family unit and its well-being (Simari, 2019; Taggart, 2018). These family values extend to members of their nuclear families as well as their extended families. Familismo emphasizes the importance of maintaining close family relationships as well as strong gender roles and family obligations.

Latino cultural values include collectivism and the importance of an intact family unit

(Simari, 2019; Taggart, 2018). Latina women are socialized from an early age to put familial priorities over individual needs. The decision-making process tends to be collective and involve nuclear and extended family members. For Latina survivors of IPV, they may stay in abusive relationships because of their strong cultural values in this regard. Disclosing abuse and/or leaving their abusers would likely be seen by family members as being disloyal (Simari, 2019).

Latino cultural values include a strong sense of gender roles. Males are seen as having control in the family, whereas females are the family’s caretakers (Simari, 2019). Latina women are given the responsibility for keeping the family unit together while allowing men to

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Machismo and marianismo are two aspects of Latino culture that may contribute to perpetration of IPV (Simari, 2019). Machismo is a set of values, roles, and beliefs about how

Latino males should behave. Positive machismo traits include honor, gentleman-like behavior, bravery, responsibility, and loyalty to the family. Negative traits, such as aggression, alcohol consumption, and sexuality, can contribute to IPV perpetration.

Marianismo is a cultural trait for Latina women to act submissively towards others, to be seen as a good wife and mother (Simari, 2019). Latina women follow this cultural norm when they conform to the ideal mother role and that their needs are secondary to those of their children. This can cause some Latina women to be less willing to leave abusive relationships.

By staying in the relationship, even if it is abusive, a victim may be carrying out her most important duty by keeping the family unit intact. In Latino families, the husband or father is considered the authority figure in the household (Simari, 2019). Children are taught at young ages to respect their elders, including parents and grandparents, but also older siblings, extended family members, and authority figures.

Sociocultural factors that affect many Latino-Americans include unemployment, discrimination, low-paying jobs, and lower education levels (Simari, 2019). All of these factors contribute to poverty, which contribute to higher stress and IPV. Latinos are more likely to work in service jobs compared to White individuals. They are less likely to hold higher paying positions, such as managers. Financial stress and lack of resources affect many Latino women making them less likely to leave abusive partners than women who have adequate finances and social support.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com In addition, language barriers may also inhibit Latino survivors from leaving their abusers (Simari, 2019). Latina women who are not legal residents in the United States also face the possibility of deportation. Undocumented survivors may fear deportation if they report abuse to authorities. Issues such as stress related to acculturation, separation from family and friends who may be in the country of origin, fear of living in an impoverished or unsafe neighborhood, discrimination, and marginalization can discourage victims from disclosing IPV and seeking help (Simari, 2019). Latina survivors may be unfamiliar with U.S. laws about abuse and protection from abuse. Many may not know what laws and protections are in place in the U.S. that are geared towards protecting victims of IPV.

The presence of children in the home may also making leaving an abusive relationship difficult (Simari, 2019). Loss of family support and the need for resources that are independent from the partner may make single parenting a daunting task. Survivors may choose instead to

“work” on improving in their relationships, despite the violence, in the hopes of creating a better relationship.

Cultural beliefs and practices among Latina women often contribute to the difficulty survivors have when contemplating departure from a relationship where there is violence

(Simari, 2019). Language barriers, legal status, level of acculturation, educational attainment, and income level can influence these decisions. Because the family is an integral part of Latino culture, leaving an abusive relationship could possibly mean leaving behind family and friends who may disapprove of IPV disclosure. Lack of independent financial resources is an extremely difficult obstacle to self-sufficiency for survivors who depend on their partners’ incomes.

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Resource:

Casa de Esperanza is a national resource center for organizations working with Latin@s* in the United States. This organization is based in St. Paul, Minnesota and began as an emergency shelter for women and their children. Since then, it has grown to become the largest Latina organization in the country that focuses on domestic violence. Casa de

Esperanza offers the National Latin@ Network for Healthy Families and Communities (NLN).

This network provides: 1) training and technical assistance to practitioners and activists throughout the United States and Latin America, 2) public policy initiatives that engage individuals and organizations to influence national policy, 3) research and evaluation that promotes social justice for Latin@s and those who work with Latin@s for domestic violence and sexual assault prevention, and 4) communications in various ways, including webinars, podcasts, and social media, to disseminate resources and information.

* Casa de Esperanza uses “@” in place of the masculine “o” when referring to people in gender-neutral terms. Their decision to use this reflects their commitment to gender inclusion and recognizes the important contributions that both men and women make in the

Latin@ communities. Website: https://casadeesperanza.org/

African Americans

African American women and men report a higher frequency of physical and sexual assault compared to White women and men (Williams & Jenkins, 2019). In a national survey, approximately 45% of African American women and 40% of men reported experiences of rape, stalking, or physical abuse during their lifetimes. In addition, over half of African

American/Black female homicide victims are killed by their intimate partners (Williams &

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Sociocultural factors, such as poverty, inadequate educational systems, and high unemployment, disproportionately affect communities of color (Valandra, Higgins, & Brown,

2016; West, DeKeseredy, Rennison, & Hall-Sanchez, 2018). These factors often result in high levels of stress and frustration which increases the likelihood that IPV can occur. Historical experiences continue to oppress and marginalize many African Americans in ways that inhibit equitable access to services and treatment. Some individuals may distrust law enforcement or service providers.

One sociocultural component in the African American community is the historical and cultural perspectives of African ancestors, which put a higher value on collective perspectives

(Valandra, Higgins, & Brown, 2016; West et al., 2018). These values include strong bonds between family and community members. This strong community and family connection can serve as a support network for African American survivors.

African American IPV survivors may face structural barriers to services that are rooted in historical societal prejudice (Valandra, Higgins, & Brown, 2016). This is especially relevant for help-seeking behavior. Some African Americans have negative experiences with law enforcement and receiving help in the legal system, which can impact their willingness to disclose abuse and seek treatment. Societal perceptions of domestic violence are embedded in patriarchal ideology that serve to create continued stereotypes and prejudice (Valandra, Higgins,

& Brown, 2016).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Intersections of multiple identities, such as race, gender, and class privilege influence social perceptions in the African American community (West et al., 2018). In particular, some media portrayals of African American/Black celebrities’ experiences with domestic violence are interpreted to be more entertainment than crimes (Valandra, Higgins, & Brown, 2016). In addition, White celebrities’ experiences with domestic violence are often not represented in equal numbers in the media. Thus, the stereotype of African American males as dangerous and violent abusers is perpetuated through mainstream avenues.

As in many collectivistic communities, African Americans may view domestic violence or marital discord as private matters (Valandra, Higgins, & Brown, 2016). Family members may prefer to keep their problems with their partners in the family, without outside involvement. Disclosure of abuse can bring social stigma, shame, and embarrassment to the family, causing further harm.

The intersection of race, gender, class, and socioeconomic status create a complex system for African American survivors of IPV. African American culture influences the meanings that survivors attribute or associate with domestic violence (Valandra, Higgins, &

Brown, 2016). It affects how victims think about IPV, how they respond to it, whether they disclose abuse, and how help is sought.

As a community, many African Americans have intergenerational historical trauma and structural violence from the effects of slavery and discriminatory segregation (i.e., Jim Crow laws) (West et al., 2018). Historical trauma, also referred to as post-traumatic slave syndrome, and segregation stress syndrome reflect the collective spiritual, psychological, emotional, and cognitive distress passed through generations of families as a result of their experiences with slavery and continuing patterns of present-day racism and discrimination. Historical and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com discriminatory experiences embedded in structural inequities reflect its source in higher rates of poverty, unemployment, residential segregation, and community and familial violence.

Inequitable policies and discriminatory practices further compound the effects of social factors, such as history, culture, ideology, and interactions that systematically ascribe privilege to White people and disadvantage to people of color (West et al., 2018).

Studies of African American couples point to high levels of bidirectional IPV (Valandra,

Higgins, & Brown, 2016; West et al., 2018). Among Black couples, the rate of bidirectional violence is two to six times more frequent than unidirectional violence (West et al., 2018).

West et al. (2018) suggests that although Black women use minor and moderate physical aggression against their partners, they often use physical aggression in the context of being victimized, in other words, in self-defense. In these situations, African American women are not the primary aggressors of violence against their partners.

African American women report more than twice the higher rates of reproductive coercion compared to White women (West et al., 2018). Some report pregnancy coercion by their partners to become pregnant (partners in these situations sabotage birth control efforts or try to pressure the victim to become pregnant). Many women in violent relationships report that their past pregnancy resulted directly from birth control sabotage and pregnancy pressure from their partners.

African American women report severe partner violence in the form of serious injury, including nonfatal strangulation (West et al., 2018). Compared to White and Latina women,

Black women are at higher risk for being victims of attempted, completed, or multiple nonfatal strangulations. Black women are more frequently the victims of gun violence and lethal IPV.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com They are more likely than White, American Indian, and Latina women to be killed by their partners.

Practitioners who work with African American victims can help best when they understand the confluence of multiple systemic factors affecting their clients. Multiple individual, family, and community interventions that address IPV are needed (Valandra,

Higgins, & Brown, 2016). Both victims and perpetrators can benefit from interventions that target healthy relationships, conflict resolution, and help-seeking before violence escalates.

Families and community members can benefit from providers and services that approach them with nonjudgmental support and resources. Children in families where there is violence between parents can benefit from age-appropriate interventions in order to disrupt the cycle of intergenerational transmission of violence perpetration and victimization.

At the community level, African American community leaders can raise awareness about domestic violence in order to reduce social stigma and stereotypes (Valandra, Higgins, &

Brown, 2016). Culturally-relevant settings, such as churches, barber shops, salons, sororities, and fraternities, can be used as places to educate and raise awareness to community members.

Institutions in the community can outwardly challenge cultural scripts that discourage public disclosure of private matters related to IPV (Valandra, Higgins, & Brown, 2016).

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Ujima is part of the National Center on Violence Against Women in the Black Community.

Ujima serves as a national, culturally-specific resource center to provide support services to, and be a voice for, the Black community in response to domestic, sexual, and community violence. Ujima was founded in response to a need for an active approach to ending domestic violence in the Black community. Ujima’s name was derived from the third principle of

Kwanzaa, meaning “collective work and responsibility.” As an organization, they understand the need to mobilize and heal communities. They use this principle to empower service providers, policy makers, advocates, and the community-at-large to address the unique challenges faced by the Black community as it relates to violence across a broad spectrum.

The Black community is comprised of a diverse set of people representing wide-ranging backgrounds and cultural expressions. It is with this understanding that they seek to be inclusive of all members of the African diaspora, including: African-Americans, Africans,

African immigrants, Afro-Caribbeans, and Afro-Latinos/as. Website: https://ujimacommunity.org/

Asian Americans

Immigrants from Asian countries come from vast and varied continental areas. Eastern

Asian countries include: mainland China, Hong Kong, and Taiwan, Japan, and Korea

(Migration Policy Institute, 2019). South Central Asian countries include: Afghanistan,

Bangladesh, India, Iran, Kazakhstan, Nepal, Pakistan, Sri Lanka, and Uzbekistan (Jordan &

Bhandari, 2016; Migration Policy Institute, 2019). South Eastern Asian countries include:

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Arabia, Syria, Yemen, Turkey, and Armenia; this group will be covered in a separate section.

Asian-Americans from India comprise the second largest immigrant group in the United States,

5.9% of the total population of immigrants, behind the number of immigrants from Mexico

(25% of the total immigrant population), and ahead of Chinese immigrants (5.5% of the total immigrant population)(Jordan & Bhandari, 2016; Migration Policy Institute, 2019).

Asian immigrants in the United States are diverse in terms of religion, geographic region of origin, and language (Jordan & Bhandari, 2016). Many share common cultural values, such as a strong belief in duty, acceptance of fate, family first, and collectivism. The collective nature of the Asian community can help individuals who immigrate to the U.S. by offering social and community support. These types of support can help to protect individuals from stress, depression, isolation, and anxiety.

Traditionally, South Asian cultural values include family-arranged marriages (Jordan &

Bhandari, 2016). South Asian men who immigrate to the U.S. may return to their home countries to marry. The brides’ families offer dowries to grooms’ families. Thus, masculinity and the role of men in the family is framed by the ability to control and dominate their wives

(Jordan & Bhandari, 2016). Male children are more highly valued than female children because sons preserve the family name, provide support for elderly parents, and are allowed to cremate the dead, which is especially important in the Hindu religion. Daughters leave the household once they are married and contribute towards the families of their husbands. Wives’ primary responsibilities include caring for their husbands, children, and in-laws. Thus, South Asian

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com women gain respect among their cultural members by fulfilling the roles of an ideal wife and mother.

Domestic violence among South Asian immigrant women is estimated at 40% for physical and sexual, double the lifetime prevalence rates for the general population in the

United States, and even as high as 50% for psychological abuse (Jordan & Bhandari, 2016).

Cultural factors, such as silence and shame, often prevent survivors from disclosing abuse. In

South Asian culture, physical “discipline” of the wife by the husband or family member is permissible and culturally sanctioned (Jordan & Bhandari, 2016). Perceptions by South Asian community members as well as those from native-born U.S. citizens serve as barriers that prevent South Asian immigrant women from seeking formal support services and legal intervention (Jordan & Bhandari, 2016).

When wives are brought to the U.S. by their husbands, they can face formidable social barriers. Violent husbands can exert psychological control by refusing to allow their wives to contact their families, prohibiting them from socialization, and refusing them decision-making power (Jordan & Bhandari, 2016). Male cultural roles, such as control over the household finances, are community-sanctioned and can also serve as continued abuse by preventing their wives from obtaining employment or accessing family resources.

Disparities in education between wives and their husbands contribute to continued financial restrictions. South Asian women may have a college education in their home countries, but their degrees are often not recognized in the United States (Jordan & Bhandari,

2016). This causes survivors to depend upon their partners’ income, which allows perpetrators to exert control.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Family and children are valued among Asian communities. However, abusive partners can manipulate this value as a means for exerting their control by threatening to harm or alienate the children (Jordan & Bhandari, 2016). Survivors without independent income may be concerned about what will happen to their children if they leave an abusive relationship and children may be a primary reason that survivors decide not to leave. In other circumstances when there is a danger to children, survivors may be motivated to leave the relationship in order to protect them from harm. In order to do this, they will need to have formal and informal networks in place to provide support during this stressful time.

In Asian culture, husbands’ families are involved in the lives of the couples (Jordan &

Bhandari, 2016). The families of abusive husbands may participate or contribute to the physical and psychological abuse. The husband’s mother may influence the opinions and actions of her son from what house to choose or how to “discipline” the wife (Jordan & Bhandari, 2016). The mother-in-law may shame the survivor by insulting or demeaning her role as a wife and mother, thus putting the blame for the abuse on the victim. Abusive husbands sometimes harass the wives’ families by demanding larger dowries, isolating the survivors from their families, or accusing the wives’ families of misrepresenting their daughters as ploys to obtain marriages.

Social isolation and lack of community support are significant factors in lives of survivors of IPV (Jordan & Bhandari, 2016). Many Asian-American survivors may be unfamiliar with the laws protecting women from abuse in the United States. This unfamiliarly can cause survivors to be reluctant to contact law enforcement or seek help from service providers. This isolation can also separate survivors from informal support systems.

Many Asian immigrant women report problems with lack of culturally-specific programs at service agencies (Jordan & Bhandari, 2016). Language barriers, lack of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com interpreters, and lack of understanding about cultural values and cultural perspectives on violence can present barriers for survivors. These barriers are often present in the legal system, such as reporting violence to police, filing protective orders, and participating in court proceedings.

The prevalence of lifetime IPV against Asian-American women is high, ranging upwards of 55% (Asian Pacific Institute on Gender-Based Violence (APIGBV), 2017).

Approximately 18% of Asian and Pacific Islander women report experiences of rape, physical violence, and or stalking by a partner, which is lower than other ethnic groups, such as

American Indians, Alaska Native women, African-American women, Latinas, and White women. The highest prevalence rates of IPV within the Asian-American community are among individuals who are Vietnamese (22.4%), Filipino (21.8%), Indian (19.5%), Korean (19.5%),

Japanese (9.7%), and Chinese (9.7%) (APIGBV, 2017).

Among Asian-American communities, one study reports that Vietnamese individuals blame their wives for the beatings (57%) compared to other Asian-American groups (APIGBV,

2017). Cambodian individuals (25%) and Chinese community members (23%) report beliefs that many wives “ask for beatings from their husbands.” The lowest rate for this type of belief is among Koreans. According to one study, 28% of Cambodians believe that “a husband is entitled to have sex with his wife whenever he wants it” (APIGBV, 2017). Other groups are lower among individuals who are Vietnamese (23%) followed by Chinese (10%) and Koreans

(3%).

Sociocultural factors that affect survivors of IPV in Asian-American communities include collectivist social values, a belief that protection of the family supersedes individual safety, and a male-dominated hierarchy of power in the family. Children are valued and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com protected in Asian cultures, which can make them a vehicle for manipulation of a survivor by a perpetrator. Physical discipline is a part of the upbringing of many Asian-American children and is a part of Asian culture with 70% of Cambodians, 61% of Chinese, 80% of Koreans, 79% of South Asians, and 72% of Vietnamese men and women reporting regular physical beatings as children (APIGBV, 2017).

Practitioners who work with Asian American victims of IPV can be effective when they understand the cultural and familial values of their clients and their clients’ families. Simply leaving an abusive relationship may be a huge challenge because the survivor may lose not only the family support of her husband, but also the support from her own family of origin. The husband’s family may rally around him and provide support to keep custody of the children and cut off financial support to his spouse. Culturally competent practitioners recognize the collectivistic values and social hierarchy of many Asian American communities and incorporate those values in their approaches with their clients.

Resource: The Asian Pacific Institute on Gender-Based Violence is a national resource center on domestic violence, sexual violence, trafficking, and other forms of gender-based violence in Asian and Pacific Islander communities. The organization: 1) analyzes critical issues affecting Asian and Pacific Islander survivors, 2) provides training, technical assistance, and policy analysis, and 3) maintains a clearinghouse of information on gender violence, current research, and culturally-specific models of intervention and community engagement. The Institute services a national network of advocates, community-based service programs, federal agencies, national and state organizations, legal, health, and mental health professionals, researchers, policy advocates, and activists from social justice organizations working to eliminate gender-based violence. It offers training, technical assistance, and materials in order to: a) increase awareness about the extent and depth of various forms of gender-based violence, b) make culturally- and linguistically-specific issues visible, c) strengthen models of prevention and intervention, d) identify and expand resources, e) inform and promote research and policy, and f) deepen understanding and analyses of the issues surrounding violence against women. Website: www.apiidv.org

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Hawaiian Natives and Pacific Islanders

Hawaiian Natives and Pacific Islanders include individuals from 14 sovereign states and

11 collectives (Asian Pacific Institute on Gender-Based Violence [APIGBV], 2017; Thomas,

2017). These states and ethnogeographies comprise three clusters: Melanesia, Micronesia, and

Polynesia located in areas such as Australasia, Oceania, or the South Pacific. Native Hawaiians and Other Pacific Islanders (NHOPI) ethnicities include: Carolinian, Chamorro, Chuukese,

Fijian, Guamanian, Hawaiian, Kosrean, Marshallese, Native Hawaiian, Niuean, Palauan, Papua

New Guinean, Pohnpeian, Samoan, Tokelauan, Tongan, and Yapese. In the United States, the

NHOPI population comprises 0.2% of total population or approximately 656,500 individuals

(APIGBV, 2017; U.S. Census Bureau, 2020). More than half of the NHOPI populations lives in

California and Hawaii.

NHOPI individuals are generally proficient in English with small proportions of individuals having limited English proficiency, though they often speak other languages at home (Ramakrishan & Ahmad, 2014; Thomas, 2017). This may be a protective factor for survivors who disclose and seek treatment. In areas where bilingual providers are limited, having at least some knowledge of English can help survivors feel more comfortable in reporting abuse and/or seeking professional help.

Rates of physical and sexual IPV among NHOPI women are high. Up to 68% of women report experiencing at least one act of physical or sexual violence by a partner (APIGBV, 2017;

Thomas, 2017). Many NHOPI communities are small, isolated, and close-knit. Many survivors

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However, there are some protective factors in small, close-knit communities. Families, clans, and community members help to maintain a stable environment by mediating disputes and other issues among members (APIGBV, 2017). NHOPI women are viewed as strong and resilient family figures whose responsibility is to maintain family peace. Shame can play a major role in disclosing abuse because it could bring shame onto the family. Family members often are encouraged to intervene in IPV situations. The husband and the husband’s family are collectively seen as accountable for all behaviors directed at the wife (APIGBV, 2017).

Because of the collective social structure of many NHOPI communities, many members see IPV as a community issue (APIGBV, 2017). In addition, Native Hawaiian and Pacific

Island communities have intergenerational experiences of historical trauma (Thomas, 2017).

Societal responses to historical trauma can include symptomology of physiological and genetic manifestations, psychosocial and sociocultural issues, as well as discrimination, marginalization, and oppression. Historical trauma is associated with public health disparities, including IPV (Thomas, 2017).

European colonization of Pacific Island territories beginning in the 16th century changed the sociocultural context of areas. Europeans constructed colonial governments in domination over indigenous rule of smaller cultures. Europeans brought their concepts of land ownership to the regions and, in combination with resource exploitation, were able to take control. An understanding of colonial legacy is important because it introduced a concept of “other” and ethnocultural superiority against NHOPI communities (Thomas, 2017). The sexualized

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Data on IPV among NHOPI individuals are lacking. The diversity of cultures, languages, countries, and territories is vast, which makes gathering data complex (Thomas,

2017). In the literature, IPV data is often aggregated with Asian-American communities, which makes it difficult to separate the phenomenon among individual NHOPI communities.

However, the rates of IPV among this population are high (Thomas, 2017; Wong, Wang, Li, &

Liu, 2017).

There are several sociocultural factors that contribute to the perpetration of IPV among

NHOPI individuals, particularly women. In Polynesian cultures, family is understood to include not only the immediate family, but also the extended family, the clan, the land, and the sea (Thomas, 2017). Experiences of IPV are often hidden under the cover of shame because revealing IPV is also exposes the entire family structure as part of the problem. Pressure from family members can inhibit survivors from reporting abuse for fear of bringing shame upon the family. Among many NHOPI families, men are seen as superior to the women; wife-beating can be viewed by officials as customary and legal (Thomas, 2017). Intimate partner violence is seen as a private matter that is to be handled within individuals’ families. Thus, many individuals do not ever seek help to deal with their abuse (Wong et al., 2017).

Among NHOPI communities, IPV may be associated with higher risk of suicide (Wong et al., 2017). Cultural meanings of negative life events, including IPV, can impact the possibility of suicidal ideation or behavior. In collectivistic cultures, individual life domains, such as finances, career, educational success, and family connectedness are linked to social

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Survivors may see suicide as one problem-solving approach without bringing that type of shame upon the family. NHOPI individuals who die by suicide often do not disclose their ideation to family members or professionals, even when exhibiting mental health problems

(Wong et al., 2017). However, one study found that intimate partner problems that precipitated suicide were more prevalent among White Americans than NHOPI Americans (Wong et al.,

2017). One reason for this may be the collective social structure of NHOPI communities providing more support and assistance when survivors decide to leave their relationships.

Intimate partner violence, sexual health, and intimate partner relationship dynamics are topics that are kept particularly private in NHOPI communities (Abbas, 2016). While protecting the family is a priority, for survivors of abuse, silence can increase risk of continued violence. In some communities, physical, sexual, and emotional abuse is perpetrated by in-laws

(Abbas, 2016; Yoshihama & Dabby, 2015). One study found that approximately six percent of

South Asian women were physically abused by in-laws (Yoshihama & Dabby, 2015). A higher proportion, approximately 15%, reported being emotionally abused by their in-laws. Being in a male-dominated culture, the husband’s family can pressure survivors to keep silent about the abuse and to resist seeking help outside the family.

Lifetime consequences to IPV affect the degree to which survivors can exert power over their relationships and keep themselves safe (Abbas, 2016). If a NHOPI partner is an immigrant, this can raise additional issues. Exploitation and threats about a spouse’s immigration status can cause further fear and intimidation. The roles of members in NHOPI communities can play parts of how abuse is recognized, addressed, and prevented.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com In NHOPI communities, friends and family can be protective factors for survivors of abuse (Yoshihama & Dabby, 2015). Domestic violence programs with professionals that are culturally competent can also provide support to survivors. Law enforcement professionals and criminal justice practitioners can help survivors if they are aware of the sociocultural factors that affect violence.

Resource:

The National Asian Pacific American Women’s Forum (NAPAWF) is an organization focused on building power with Asian American and Pacific Islander (AAPI) women and girls to influence critical decisions that affect their lives, families, and communities. Using a reproductive justice framework, they strive to elevate AAPI women and girls to impact policy and drive systemic change in the United States. They recognize the need for an organization that would amplify AAPI women’s stories and experiences. Being seen and heard in the public narrative gives their members the power to shape the policy and cultural change needed to gain agency over their lives, families, and communities. Their work focuses on: policy and structural change, civic engagement, legal advocacy and judicial strategy. In the reproductive justice framework, they seek to ensure equity in: reproductive rights and health, economic justice, and immigration and racial justice. Website: https://www.napawf.org/

American Indians and Alaska Natives

American Indians and Alaska Natives (AIAN) comprise 1.3%, or approximately 4.3 million people, of the total U.S. population (United States Census Bureau, 2020). AIAN individuals have the highest prevalence rates of domestic violence compared to other racial and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ethnic groups (Gurney, 2019; Hardy & Brown-Rice, 2016; Rosay, 2016). Approximately 84% and up to 91% of AIAN individuals have experienced violence in their lifetime (Gurney, 2019;

Hardy & Brown-Rice, 2016). Over half, 56.1% of AIAN have experienced sexual violence,

55.5% physical IPV, 48.8% stalking, and 66.4% psychological aggression by an intimate partner (Rosay, 2016). Overall, more than 730,000 AIAN women have experienced some type of IPV within the past year. There are also high rates of IPV among AIAN men. Approximately

82% of AIAN men reported violence in their lifetime, including 27.5% who have experienced sexual violence, 43.2% physical violence by a partner, 18.6% stalking, and 73% psychological aggression by an intimate partner (Rosay, 2016).

AIAN women are 1.2 times more likely to have experienced violence within the past year, including physical IPV and stalking (Rosay, 2016). AIAN men are 1.3 times more likely compared to non-Hispanic white-only men to have experienced violence in their lifetime; they are 1.4 times more likely to experience physical IPV and 1.4 times more likely to experience

IPV in the form of psychological aggression. AIAN female survivors are more likely than survivors of other racial groups to be physically injured, need services, and miss days at school or work (Rosay, 2016). Survivors in this group are more likely to need medical care, legal services, and advocacy services. However, services for AIAN populations are lacking with approximately 38% of female survivors and 17% of male survivors being unable to access them.

Historical trauma plays a role in the perpetration of IPV violence against AIAN women

(Gurney, 2019; National Native Children’s Trauma Center (NNCTC), 2016). European and

American colonization of AIAN communities make AIAN women particularly vulnerable to domestic violence. As Gurney (2019) reports, “[Federal policies of] removal, relocation, and

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Native women at greater risk of violence, disruption in family life and parenting, and loss of familiar and communal support systems” (p. 892). Other types of sociopolitical factors affect

AIAN survivors as well, such as insufficient funding for services, vague jurisdiction guidelines for law enforcement, and community distrust of police and criminal justice systems.

One of the leading causes of homelessness in AIAN communities is domestic violence

(Gurney, 2019). Survivors face homelessness more than five times the national average. Lack of services, specifically domestic violence shelters, exacerbate the problem. Only recently laws associated with the Tribal Law and Order Act of 2010, allow tribes to impose stricter sentences on criminal defendants (Gurney, 2019; Hardy & Brown-Rice, 2016). Prior to the passage of that law, non-Indian abusers received immunity when committing IPV on Indian tribal lands.

Then the Violence Against Women Act of 2013 recognized the power to exercise special criminal jurisdiction over all persons (Gurney, 2019). Even with the enactment of this legislation, the crime must be domestic or dating violence that occurs in the Indian country of participating tribes. A tribe can only exercise jurisdiction over non-Indian batterers with those who have “sufficient” ties to the tribe, such as a resident of the tribal territory, employed by the

Indian tribe, or is a spouse or intimate partner of a member of an Indian tribe.

Criminal justice guidelines for IPV continue to be complex matters (Gurney, 2019). The issue of constitutionality of law enforcement and court decisions on non-Indian/Indian battering continues to be complex. The interplay between federal authority and local authorities make criminal justice practices uncertain. For AIAN survivors of abuse, this can prove to be a formidable obstacle for reporting and charging a partner with violent crimes.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com American Indian women who live on tribal lands often have difficulty leaving violent relationships because of sociocultural values that encourage victims to protect their abusers

(Hardy & Brown-Rice, 2016). AIAN women report higher levels of recurrent victimization compared to women in other racial and ethnic groups. Because of this, symptoms of complex traumatic stress may be particularly prevalent.

Other social and economic factors affect the prevalence of IPV in AIAN communities.

Socioeconomic status is a significant factor for IPV among AIAN women living on tribal lands

(Hardy & Brown-Rice, 2016). Women living on tribal lands and who were receiving financial assistance from the government are 2.5 times more likely to report physical IPV.

Unemployment and poverty rates for AIAN individuals living on tribal lands is far above the national rates, sometimes reaching over 50% (Hardy & Brown-Rice, 2016). Substance use issues for AIAN individuals have higher prevalence rates than the national average and are associated with increased risk of IPV (Hardy & Brown-Rice, 2016). AIAN women reported that 62% of the perpetrators were heavy alcohol users compared to 42% of perpetrators from other backgrounds.

The Indian Health Services is the system primarily responsible for providing physical health and mental health care to AIAN on tribal lands (Hardy & Brown-Rice, 2016).

Underfunding and understaffing of this agency limits the amount of support available for those in need of IPV-related physical and mental health care needs. The result is that services are lacking in comparison to standards of physical and health care for other populations. In addition, many AIAN individuals do not have health insurance due to high cost and low income.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Mental health services in tribal lands are often geographically distant, making it difficult for survivors to access services (Hardy & Brown-Rice, 2016). For sexual assault survivors, there may be an extra burden of driving long distances in order to receive services by a sexual assault examiner. More than two-thirds of the tribal lands in the United States are not accessible to sexual assault response teams with almost half of tribal communities without any coverage (Hardy & Brown-Rice, 2016).

Sociocultural factors for AIAN individuals include culture-specific beliefs about health and healing that incorporate spirituality (Hardy & Brown-Rice, 2016). The Native American

Medicine Wheel includes four elements: mental (air, winter, warrior), physical (earth, autumn, healer), spiritual (fire, spring, visionary), and emotional (water, summer, teacher). Other aspects of Native American healing methods include: a) smudging, b) using Native American symbols, c) incorporating Native American languages, d) creating visual Native American art forms, e) talking circles, and f) consulting elders in tribal communities (Hardy & Brown-Rice,

2016). Professionals working with AIAN survivors may want to consider changes in the setting for services. They can have counseling sessions outside a traditional office setting in a natural environment, like a garden, to facilitate spiritual expression (Hardy & Brown-Rice, 2016).

Survivors may present symptoms of complex trauma given the high rates of physical violence and sexual assault, historical trauma, and other social factors, such as income, substance use, and unemployment. AIAN individuals have higher exposure to traumatic incidents in childhood, such as abuse and neglect (NNCTC, 2016). These experiences can result in a higher risk of negative outcomes, such as alcoholism, drug use, depression, suicide attempts, sexual violence, IPV, and various physical problems. AIAN populations experience more trauma compared to any other U.S. population (NNCTC, 2016). Clinicians working with

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com these individuals can better serve their AIAN clients by understanding the complex interplay of factors that affect this population. Skills in addressing multiple needs, complicated facets of abuse, and the consequences of complex trauma are needed in order to be effective practitioners.

Resource:

The National Indigenous Women’s Resource Center (NIWRC) is a Native-led non-profit organization dedicated to ending violence against Native women and children. The NIWRC provides national leadership in ending gender-based violence in tribal communities by lifting up the collective voices of grassroots advocates and offering culturally-grounded resources, technical assistance and training, and policy development to strengthen tribal sovereignty.

NIWRC’s nationwide advocacy emphasizes that offenders can and will be held accountable and that Native women and their children are entitled to: a) safety from violence within their homes and in their community, b) justice both on and off tribal lands, and c) access to culturally-grounded services designed by and for Native women. The mission of NIWRC is to provide national leadership to end violence against American Indian, Alaska Native, and

Native Hawaiian women by supporting culturally-grounded, grassroots advocacy.

Website: https://www.niwrc.org

Middle Eastern Americans (Western Asian Americans)

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Middle Eastern women who experience IPV may be unwilling or unable to seek services for violence because of the cultural stigma surrounding mental health and treatment (Balice et al.,

2019). Women who experience violence face significant social and cultural stigma if they want to address problems associated with partner violence. Many may fear continued violence, loss of familial and social support, concern for the safety of their children, loss of immigration status, disruption to their family life and cultural network, and involvement of U.S. agencies, such as police, protective services, and criminal justice systems (Balice et al., 2019).

The prevalence of violence against women in the Middle East and Mediterranean regions is approximately 37%, second highest behind Southeast Asian, among other global regions (WHO, 2017; WHO, 2013). Some Middle Eastern countries have a higher prevalence of IPV than others. For example, rates of IPV are reported as high as 47% in Egypt (Niaz,

Hassan, & Tariq, 2017). Approximately 41% of partner murder, the majority of which were related to suspicion of illegitimate relationships, were perpetrated by husbands (Niaz, Hassan, &

Tariq, 2017). Risk factors for IPV include: lower education levels, histories of childhood abuse, witnessing family violence, substance abuse, attitudes that condone violence against women, community norms that value male hierarchy over women, and low levels of employed women

(WHO, 2017). Sociocultural factors that affect IPV include: beliefs about family honor and sexual purity, ideologies about male sexual entitlement, and weak legal consequences for violence against women (WHO, 2017).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Among Middle Eastern communities, there are different factors that are related to a higher risk of IPV (Balice et al., 2019). The use of corporal punishment and lower socioeconomic status are associated with a higher risk of physical violence, in particular with

Egyptian women. Among Arab-American women, patriarchal attitudes about marital and family roles are related to IPV. Among Pakistani women, early age at marriage and unemployment is related to IPV. There is a low acceptance of IPV among Jordanian men and women compared to other Arab nations; however, there are differences among those who are unemployed and living in rural geographical areas.

Some individuals in Middle Eastern communities do not view IPV as a social issue, but rather a personal one (Balice et al., 2019). This emphasis on personal privacy comes from concerns about family reputation, cultural expectations, religious values, and interdependence among community members. In addition, the degree of acculturation and social support among

Middle Eastern Americans affects the likelihood that a survivor of abuse will seek help for violence.

Many Middle Eastern cultures value patriarchy as part of the social and cultural norms

(Balice et al., 2019). Many patriarchal societies encourage male dominance, which in turn, legitimizes the use of violence against women. The view that IPV is a private and personal matter can significantly hinder survivors from seeking medical assistance and professional services, or even support from family and friends. Failing to follow such marital rules as a wife obeying her husband, and/or damaging the family’s reputation in their community, and/or neglecting household or child-rearing duties can lead to acceptance of violence against a wife in the family’s particular community (Balice et al., 2019).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Cultural acceptance of violence as a tool to deal with marital discord encourages women to refrain from disclosure or seeking help. In countries, such as Egypt, Turkey, and Palestine, perpetrators of IPV are often insulated from legal punishment because of the cultural norms and patriarchal social attitudes for female and male behavior (Niaz, Hassan, & Tariq, 2017).

Perpetrators of IPV against Tunisian and Saudi Arabian women may legitimize violent actions on the basis of husbands’ rights to control the behavior of their wives.

Intimate partner violence among Middle Eastern women is related to a host of psychological symptoms, including depression, anxiety, and shame. Cultural attitudes about mental health issues and seeking psychological help, especially in the form of Western psychotherapy, negatively affect the likelihood that survivors will seek help for their problems

(Balice et al., 2019). Many Muslim immigrant women may avoid seeking psychological help because it could impact the potential for marriage proposal prospects (Balice et al., 2019).

Shame and stigma around seeking professional help are significant barriers to obtaining support.

Western psychotherapy is sometimes seen by Middle Eastern individuals as culturally incompatible and contrary to cultural beliefs (Balice et al., 2019). Particular factors, such as a survivor’s level of acculturation to American culture, the political context in which the survivor grew up, the personal beliefs about Americans and American culture, and the level of trust, influence the degree to which a survivor may seek help. For example, Muslim leaders in the

Middle East often rely on the principles of Islamic religion for direction about family well-being and spiritual direction (Balice et al., 2019). Information and support for Middle Eastern survivors may need to be targeted towards culturally relevant institutions, such as places of worship.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Intimate partner violence against Middle Eastern women can result from the culmination of individual, familial, social, and cultural factors. At an individual level, psychological risk factors include childhood neglect, abuse, maladaptive parenting styles, and parental substance abuse (Niaz, Hassan, & Tariq, 2017). Family risk factors include lower socioeconomic statuses, less female decision-making power, poor communication, and lack of effective conflict management skills. Community risk factors include neighborhood and workplace locations and safety, and levels of community support. Finally, social risk factors include cultural norms that reinforce inequities in gender roles and promote male dominance and attitudes (Niaz, Hassan, &

Tariq, 2017).

For example, IPV in Pakistan is related to low education levels, lower empowerment among women, poverty, unjust dowry systems, and misconceptions about Islamic teachings and traditional norms (e.g., honor killings) (Niaz, Hassan, & Tariq, 2017). Marital conflicts about finances, child-rearing, failure to meet household responsibilities, relationships with other family members, disputes with in-laws, and husbands’ sexual complaints against their wives are factors that contribute to the risk of IPV (Niaz, Hassan, & Tariq, 2017). Perpetrators of IPV in

Middle Eastern countries often escape punishment because of discriminatory laws against women.

Families that immigrate from Middle Eastern countries bring their cultural and social worldviews and experiences to the United States. Practitioners who work with Middle Eastern survivors and perpetrators can better work with their clients when they understand the cultural and social norms that are embedded into the lives of their clients. Complex issues, such as privacy, patriarchy, religion, gender roles, involvement of in-laws, laws, and beliefs about disclosure and help affect the way in which clients bring their issues to treatment and the way

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com practitioners can effectively address needs. Cultural understanding and humility are needed in order to create an environment in which Middle Eastern survivors feel safe and supported through the treatment process. Culturally sensitive practitioners understand that survivors and perpetrators face many obstacles, such as potential loss of social status and family pressure, and discrimination from the dominant culture leads to minority stress. Minority stress increases risk for violence, especially for new immigrants who may be unaccustomed to managing further feelings of disempowerment and degradation. Further, survivors risk the potential for increased violence when they request services; and, social isolation and marginalization in their communities.

Resource:

The Asian Pacific Institute on Gender-Based Violence provides advocacy for Muslim women and those from Arab, Middle Eastern, and West Asian descent. They offer a report on

“Islamic marriage contracts: A resource guide for legal professionals, advocates, Imams, and communities” that provides information for legal professionals and advocates working with

Muslims. They offer other resource guides including several bibliographies on three key topics: gender, domestic violence and women; Muslim women and domestic violence. They also provide a factsheet (dated 2011) about domestic violence in Muslim communities.

Website: https://www.api-gbv.org/culturally-specific-advocacy/community-and-systems- engagment/muslim-women/

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SPECIAL POPULATIONS

Intimate partner violence is a complex issue that affects all life domains of survivors.

There are physical, behavioral, emotional, spiritual, and social consequences of violence.

Individuals who are also members of special populations face even greater challenges as they deal not only with the commonly known consequences of IPV, but also with special circumstances of their particular situation. Understanding the intersectionality of IPV with individuals from other types of special populations can help practitioners conduct assessments and provide treatments that are designed for unique needs.

Rates of IPV are higher among members of special populations than the general population. Similar to experiences of survivors from ethnic/racial minorities, people from special populations have unique needs and circumstances that make many of them vulnerable to

IPV. Many individuals from these groups experience such negative social influences as stereotyping, prejudice, marginalization, and oppression. In addition to dealing with IPV- related issues, such as PTSD, depression, anxiety, physical, and sexual injuries, there are unique circumstances that require the assistance of skilled professionals. The following sections address IPV survivors in the following special populations: LGBTQ, teenagers

(adolescents/young adults), elders, people with disabilities, men, individuals living in geographically isolated areas, and economically disadvantaged individuals.

Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Individuals

According to the Centers for Disease Control (CDC) National Intimate Partner and

Sexual Violence Survey (NISVS), bisexual women experience higher rates of IPV compared to

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com heterosexual women (Brown & Herman, 2015). Bisexual women are 1.8 times more likely to report IPV than heterosexual women. Lifetime prevalence rates of IPV among lesbians is higher than heterosexual women. Approximately 90% of bisexual women report only male perpetrators of IPV; almost a third of lesbian women experienced IPV by male perpetrators.

According to the NISVS, bisexual men are more likely to report IPV than heterosexual men (Brown & Herman, 2015). A little over a quarter of gay men reported IPV in their lifetimes and 12.1% experienced IPV within the past year. The studies of transgender individuals are fewer than those of gay, lesbian, and bisexual individuals. However, lifetime

IPV among transgender people range from 31.1% to 50% (Brown & Herman, 2015).

Rates of IPV in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community are higher than those in cisgender, heterosexual populations (Woulfe & Goodman, 2020).

Persons who are LGBTQ face unique challenges with access to social support and formal services that are designed to address their needs. LGBTQ survivors of IPV also face additional inequities and marginalization caused by societal prejudice and discrimination, such as heterosexism and homophobia. In IPV-related experiences, this can mean threatening to disclose (i.e., “out”) an individual’s gender identity or sexual orientation to families, employers, or others. In large part, society continues to perpetuate heterosexism and denigrate people who are lesbian, gay, bisexual, and transgender (Woulfe & Goodman, 2018). These types of societal negativity increase psychological distress and places LGBTQ individuals at higher risk for IPV.

“Outing” an individual is a psychological abuse tactic that an abusive partner uses to instill fear that their sexual orientation or gender identity will be disclosed without consent

(Woulfe & Goodman, 2018). If an abuser outs an individual, the result can be harassment, shame, and loss of employment, housing, family relationships, friendships, and access to

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com activities and services. A mirror tactic of this type of abuse involves undermining, attacking, or denying a partner’s identity as an LGBTQ person. Abusers can question or challenge their victims’ identities by accusing the individual of being straight or questioning their authenticity

(Woulfe & Goodman, 2018). Intimate partner violence perpetrators can make their transgender partner feel ashamed, “not good enough”, or prevent them from expressing their identity. An abuser can employ identity abuse tactics such as preventing the survivor from using their preferred pronouns or name, or drawing attention to the parts of the survivor’s body that are the sources of distress, dysphoria, or discomfort. Identity abuse includes psychological tactics intended to isolate, demean, and control LGBTQ partners. As many as 40% of LGBTQ persons report experiencing identity abuse at some point in their lives (Woulfe & Goodman, 2018). Of those, individuals who identify as transgender or gender non-conforming report the highest rates of identity abuse. In terms of sexual orientation, queer individuals reported the highest rates of identity abuse (48.6%) followed by bisexual participants (48%).

Another psychologically abusive tactic includes using homophobic or transphobic language (Woulfe & Goodman, 2018). This tactic involves use of derogatory language that targets the survivor’s sexual orientation or identity. Terms such as “tranny,” “fag,” and “dyke” among others can be used to demean and diminish an individual’s well-being and self-esteem.

LGBTQ survivors may experience social isolation because much of society remains prejudiced and discriminatory about other sexual orientations and gender identities. Abusive partners can discourage or forbid their partners to socialize with others in their LGBTQ communities.

Members of the LGBTQ community have intersecting identities that shape their experiences and the degrees of abuse (Woulfe & Goodman, 2018). Identity abuse is different across gender identities and sexual orientations. LGBTQ women experience significantly more

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com exposure to abuse in adulthood compared to men. Transgender/non-conforming individuals report higher rates of identity abuse in adulthood compared to cisgender individuals.

In addition to the negative mental health outcomes created by IPV, such as depression, anxiety, and PTSD, LGBTQ individuals have additional strain caused by societal negativity.

Exposure to issues related to homophobia and heterosexism increase the likelihood of depression and PTSD symptoms (Woulfe & Goodman, 2020). LGBTQ survivors can experience increased psychological distress from the additional burdens of discrimination, stigma, rejection, and hate crimes. Negative social experiences can trigger negative self- concepts and erode self-confidence, efficacy, and self-esteem, making recovery from traumatic experiences even more difficult.

There are several barriers for LGBTQ survivors to receive assistance due to their unique needs related to sexual orientation and gender identity. Some legal definitions of domestic violence exclude language for same-sex couples (Brown & Herman, 2015). Some survivors may not know about LGBTQ-specific resources. Non-LGBTQ providers may hold homophobia stereotypes or prejudices that inhibit survivors from seeking help. LGBTQ individuals may be reluctant to involve law enforcement or criminal justice personnel because of biases and stereotypes.

Protective factors that can help LGBTQ survivors include having a positive identity as a member of an oppressed group (Woulfe & Goodman, 2020). A stronger social network, supportive familial relationships, and positive self-concept can help survivors recover from the effects of IPV. Those with a positive self-concept and strong membership identity are better able to avoid internalizing stigma and effectively heal from their experiences. Practitioners who work with LGBTQ survivors understand the complexities involved in gender identity and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com sexual orientation. They understand the social context that can place burdens on LGBTQ survivors from seeking help. They can work effectively with their clients by offering assistance in a nonjudgmental and open fashion that is designed to allow LGBTQ clients to feel comfortable.

Resource: The National LGBTQ Institute on IPV aims to improve access to meaningful domestic violence advocacy for LGBTQ survivors of abuse. The project is a collaboration of The Northwest Network of Bi, Trans, Lesbian, and Gay Survivors of Abuse and NCAVP. The institute is a member of the Domestic Violence Resource Network and is funded by the Family Violence and Prevention Services Program (FVPSA). The Institute plans to bring culturally specific training to advocates working in LGBTQ specific and mainstream domestic violence programs through in-person trainings, webinars, and online tools. It plans to expand research about LGBTQ domestic violence and the programs that LGBTQ communities have created to both prevent and intervene in domestic violence. A goal of the Institute is to support and build the capacity of LGBTQ advocates in LGBTQ organizations through resources, education, best practices, and program to program support. Website: https://avp.org/ncavp/national-lgbtq- institute-ipv/ Adolescents and Young Adults

Approximately seven percent of women and four percent of men experiencing IPV report childhood experiences of physical and/or sexual abuse and behaviors (e.g., stalking) before the age of 18 (Niolon et al., 2017). Estimates of IPV among teenagers are approximately

10% (Kaufman-Parks, DeMaris, Giordano, Manning, & Longmore, 2018). Approximately 21% of girls and 10% of boys report some form of teen dating violence (TDV) (Niolon et al., 2017).

Because IPV victimization and perpetration is related to early experiences of violence, understanding the experiences of adolescents is important. Exposure to family violence and child maltreatment are strong predictors of IPV victimization and perpetration later as adults.

Familial experiences play a role in the development of violent reactions in partnerships.

Relationships between children and their family members play a vital role in the psychosocial development of children. Intergenerational transmission of violence often occurs

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com when children are exposed to violence in their families, including between their parents

(Kaufman-Parks et al., 2018). Specifically, children who experience or witness family violence in their families may develop the expectation for violence in their intimate partnerships. They learn that violence is a vehicle for control and power in their relationships. However, not all children who witness and experience violence in their families become perpetrators or victims of IPV. In fact, most do not (Kaufman-Parks et al., 2018).

Physical aggression and violence in general typically peak between the ages of 16 and

19 years old, but then tapers off. Similarly, families change over time and sometimes become more stable as adolescents transition into adulthood. Parent-child relationships change as well as overall family functioning.

Parental physical abuse towards youth in later adolescence has negative life effects in later life and is a predictor to adolescent and young adult outcomes (Cadely et al., 2018;

Kaufman-Parks et al., 2018: NIJ, 2018). Repeated physical abuse has stronger negative effects over the individual’s lifespan, than does one incident of violence. Parent-child physical aggression and the parent-child relationship quality contributes to IPV over the course of adolescence and young adulthood (Cadely et al., 2018; Kaufman-Parks et al., 2018; NIJ, 2018).

There is an increased risk of IPV among young adults when partners witnessed physical aggression between their parents as children (Cadely et al., 2018). One possible reason for this is that children learn from their parents about ways of behaving socially. They learn to ascribe meaning and biases towards particular behaviors and internalize those meanings. As late adolescents or young adults, these processes of early learning can lead to the enactment of aggressive behaviors (Cadely et al., 2018; NIJ, 2018). Intergenerational transmission of aggression and physical IPV during adolescence may continue into young adulthood. In

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com adolescent and young adult relationships, insecurities about the relationship also contribute towards aggressive patterns.

The CDC (2020a) reports that approximately nine percent of females and seven percent of male high school students experienced physical dating violence within the past year.

Approximately 11% of females and three percent of male high school students experienced sexual dating violence in the past year. Over one-quarter of adult women and 15% of adult men who were victims of physical or sexual violence, or stalking report that their first experiences happened before 18 years old.

Youth who experience TDV are more likely to experience symptoms of depression, anxiety, unhealthy behaviors, such as smoking, drug use, and alcohol consumption. They are more likely to exhibit antisocial behaviors, such as lying, theft, bullying, or hitting, and think about suicide (CDC, 2020a). Early experiences of IPV and sexual violence perpetration and/or victimization contribute towards IPV perpetration or victimization later in life. A child whose parents or caregivers exposed them to illegal activities, such as drugs, or other antisocial activities, such as theft and aggression, is at a higher risk for becoming victims of dating violence later in life (NIJ, 2018). These children often were less attached to their caregivers in mid-adolescence.

A child who experiences multiple childhood traumas is also at a higher risk for perpetration or victimization of dating violence (NIJ, 2018; Niolon et al., 2017). Trauma symptoms, substance use, and dating violence are related to negative psychological outcomes.

Perpetration and victimization patterns of relationship abuse are evident by the end of young adulthood, around 25 to 28 years old (NIJ, 2018). Both perpetration and victimization of dating violence peak around 20 years old. Individuals who experience more episodes of relationship

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com violence in adolescence tend to report higher levels of relationship violence later in life (NIJ,

2018).

Interpersonal conflict and difficulty managing conflict are associated with higher physical and psychological aggression among adolescents and young adults (NIJ, 2019).

Maladaptive interaction patterns during teen dating are associated with higher levels of dating violence. Young adults who had parents who lacked effective and nurturing parenting skills are at a higher risk of exhibiting antisocial behavior as a teenager. This increases the risk of experiencing IPV in their young adult relationships.

Extreme adolescent and teen violence can result in homicide. Of all U.S. adolescent homicides from 2003 to 2016, approximately seven percent were intimate partner homicides

(Adhia, Kernic, & Hemenway, 2019). The majority of perpetrators, approximately 78%, were on average about 21 years old and current partners of the victims. Handguns were the most common weapon used to injury and/or kill partners. Young adult victims of intimate partner homicide were between the ages of 19 and 24 years old (Adhia, Kernic, & Hemenway, 2019).

The most common reasons for intimate partner homicide were: broken relationships, jealousy, an altercation followed by reckless firearm behavior, and pregnancy.

Because rates of IPV are higher in late adolescence/early adulthood and lessen over the course of the lifespan, early intervention efforts may be particularly helpful (Niolon et al.,

2017). Strategies for early intervention include:

- Teaching safe and healthy relationship skills

- Engaging influential adults and peers

- Disrupting the developmental pathways toward partner violence

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com - Creating protective environments

- Strengthening economic supports for families

- Supporting survivors to increase safety and lessen harms (Niolon et al., 2017).

The goal for intervening in TDV early is to emphasize the importance of creating safe, stable, nurturing, and healthy relationships. Social and emotional learning even as early as preschool and engaging parents in family and skill development can help to address the behaviors that are associated with IPV over the lifespan (Niolon et al., 2017). Practitioners can emphasize healthy and nurturing social gender norms among parents and children. They can teach appropriate relationship skills and change unhealthy attitudes that foster violence in relationships. They can explain the connections between IPV and substance use, attitudes about violence, and weapon use.

Family-based programs may be successful in reducing TDV behavior and high-risk behaviors (Niolon et al., 2017). Practitioners can teach conflict resolution skills and improve knowledge about how violence is transmitted from early childhood to adulthood. By addressing maladaptive factors in the family, practitioners can intervene to decrease the likelihood that

TDV will progress to IPV.

Resource:

Loveisrespect is an organization whose purpose is to engage, educate, and empower young people to prevent and end abusive relationships. Trained advocates offer support, information, and advocacy to young people who have questions or concerns about their dating relationships. They provide information and support to concerned friends and family members, teachers, counselors, service providers, and members of law enforcement.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Loveisrespect strives to be a safe, inclusive space for young people to access information and get help in an environment that is designed specifically for them. Website: https://www.loveisrespect.org/

Elders

There are varying rates of IPV among elders ranging from 10% to 27% (Brossoie &

Roberto, 2015; Gerino, Caldarerea, Curti, Brustia, & Rolle, 2018). IPV among older adults negatively influences their well-being and mental health. Among older adults, there are increased feelings of worthlessness and identity loss over the course of the lifespan. The nature of a violent intimate relationship can change over time; physical violence can transition to psychological violence as the abuser ages. The longevity of abuse can continue to accumulate over time even when physical violence shifts to more psychological abuse over time (Gerino et al., 2018).

Gerino and colleagues (2018) cite the following protective factors for IPV among elders, including:

o community connections,

o friendships,

o social support and networks,

o help-seeking behaviors,

o protective interventions during childhood,

o self-esteem, and

o coping strategies and life skills.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Across age ranges, the biggest protective factor against IPV is social support, including friends, community connections, and social services. These elements can support survivors’ coping strategies and provide resources. There are several strategies that can promote healthy intimate relationships for elders, including: legal programs, medical approaches, social services, psychoeducation about IPV, and skill enhancement.

Similar to other age groups, risk factors for IPV among elders include:

o gender,

o age (e.g., IPV declines as perpetrators get older),

o parental violence,

o intergenerational transmission of violence,

o low social support,

o social isolation,

o cognitive impairments (such as dementia and Alzheimer’s disease),

o physical impairment,

o cultural values,

o depressive symptoms,

o ethnic differences,

o immigration status,

o unemployment/low income,

o personal factors (e.g., stress),

o relationship factors,

o environmental factors (e.g., little privacy),

o verbal abuse,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com o substance abuse, and

o caregiver stress.

(Brossoie & Roberto, 2015; Gerino et al., 2018; Pathak, Dhairyawan, & Tariq, 2019).

Because risk factors for IPV overlap, it is difficult to separate factors that are specific to individuals who are older. For example, depression in older individuals may be related to health status, but also compounded by a history of IPV. Older women are more often abused by their partners than older men (Gerino et al., 2018).

The younger group of elders (55 to 69 years old) have a higher risk of psychological and physical IPV than those who are older than 69 years (Gerino et al., 2018). The lower risk among the group of older individuals can be due to the declining health or death of the abusive partner. Also, IPV declines as the age of the perpetrator increases. Older women from ethnic minorities have a higher risk of IPV, which is similar to younger ethnic minority women

(Gerino et al., 2018). Lower support from family members and social isolation are also associated with poor mental health outcomes. There is a strong association between cognitive impairments, such as Alzheimer’s disease, neurological and psychiatric age-related diseases, physical impairments, and IPV in old age (Gerino et al., 2018). Verbal and psychological abuse are associated with IPV. The rates of psychological IPV may be higher than physical or sexual

IPV later in life (Pathak, Dhairyawan, & Tariq, 2019). In addition, substance use, especially alcohol, is associated with IPV in older couples (Gerino et al., 2018).

Cultural factors include values, norms, and beliefs. IPV is more prevalent among ethnic minorities at all ages compared to white couples (Brossoie & Roberto, 2015; Gerino et al.,

2018). Such factors as immigration status, gender inequality, and patriarchal values, can amplify the negative effects of IPV. Older individuals may have been socialized to gender roles

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com and had other life experiences that pre-date feminist trends. Thus, psychologically embedded gender norms and hierarchal values may continue to reinforce IPV even later in life.

Intergenerational transmission of violence, historical racism and sexism, and gender inequality continue to be factors associated with IPV in later life (Gerino et al., 2018). These factors are also associated with IPV in younger years and continue to impact relationships later in life. The combination of these factors in addition to others associated with old age (e.g., physical and mental health) can make risks higher for IPV in later life.

Social factors involved in the lives of elders can influence professionals’ beliefs about

IPV (Brossoie & Roberto, 2015). Professionals who reside in communities that recognize the prevalence of elder IPV are likely to be aware that abuse often continues among older couples.

Several issues, such as age-related factors (e.g., physical and mental health and self- sufficiency), social (e.g., social structure, hierarchy, and values), and geographical (e.g., service availability and economic hardship) can interact and overlap to create a host of potential risk factors for IPV and barriers for reducing it (Brossoie & Roberto, 2015; Pathak, Dhairyawan, &

Tariq, 2019).

There are increased physical symptoms among women who experience IPV (Pathak,

Dhairyawan, & Tariq, 2019). These symptoms include gastrointestinal problems, respiratory problems, and pelvic and genitourinary symptoms. They may experience chronic pain, fatigue, and exacerbation of symptoms for other conditions, such as arthritis and hypertension.

Behavioral health professionals may not be as aware of IPV among elders as they are with other groups. Most professionals are familiar with IPV-related issues among younger and middle-aged individuals, but may not recognize violence in relationships between elders

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com (Brossoie & Roberto, 2015). IPV in older populations is less prevalent in the professional literature. So, many practitioners may be unfamiliar with IPV-related issues. Some clinicians may believe that IPV eventually ends as individuals become older and less able to maintain high levels of violence. They may believe that IPV occurs primarily among older couples when one is inflicted with a disease-related cognitive impairment. In these circumstances, providers may understand better why partners will stay with their abusers rather than leave them.

Certain professionals may come into contact with older survivors of abuse. In particular, emergency health care professionals, police, and victim advocates may have more exposure to older survivors and the effects of IPV (Brossoie & Roberto, 2015). Yet, as with survivors of other age groups, there are many psychosocial factors that affect survivors. Many older individuals associate aging with loss: loss of self-sufficiency, children leaving home, regrets of past decisions, loss of time for future endeavors (Brossoie & Roberto, 2015; Pathak,

Dhairyawan, & Tariq, 2019). An older survivor may feel that it is easier to stay with a partner who abuses her rather than leave. If aging already involves losses that are expected, she may be reluctant to add more. In older age, income is likely to be fixed and resources limited (Brossoie

& Roberto, 2015). Employment is often no longer a possibility. Cultural and familial values may discourage older survivors from seeking help.

Many family members and/or survivors may not believe that separation or divorce at an older age is a viable option (Brossoie & Roberto, 2015). Shame may prevent older survivors from leaving or seeking help. Resources that address IPV-related issues may not include specific resources for older survivors. Some resources, such as mental health therapy, may have a social stigma for some older survivors. Limited finances to pay for services may further

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com discourage older survivors from seeking help. Older survivors may be reluctant to discuss their problems with younger practitioners, especially with an opposite-sexed provider.

Professionals may inadvertently see symptoms as being attributed to age-related illnesses rather than consequences of IPV (Pathak, Dhairyawan, & Tariq, 2019). Practitioners may interpret mental health symptoms, such as depression and anxiety, as part of a normal trajectory of age-related development. Older survivors may experience even more difficult feelings related to normal transition, such as children leaving the home. In an abusive relationship, this developmentally appropriate life stage may trigger feelings of deep isolation and hopelessness. The aging process and the decline of physical strength and ability may lead to increased dependence on their abusive partners. Practitioners can be most effective when they continue to screen for IPV, even among older individuals, and consider other age-related factors as part of a thorough and comprehensive assessment.

Resource:

The National Clearinghouse on Abuse in Later Life (NCALL) is a national project committed to creating a world that respects the dignity of older adults and enhances the safety and quality of life of older victims and survivors of abuse. NCALL promotes victim-defined advocacy and services for older survivors, fosters coordinated community response teams by offering training and technical assistance on building and enhancing coordinated community response teams, and advocates for elder justice by providing information on legal remedies and resources that enhance victim safety and holds offenders accountable. NCALL raises

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com awareness of abuse in later life and elder abuse by creating effective outreach materials and engaging in diverse methods to heighten the visibility of older survivors and their needs. It engages in policy development by working on a range of issues that affect survivors of abuse in later life. NCALL partners with organizations that address domestic violence, sexual assault, abuse later in life, and elder abuse to promote respect and dignity across the lifespan and to confront ageist social norms. Website: https://www.ncall.us/

Persons with Disabilities

At its essence, IPV in special populations is an examination of intersectionality. Issues related to race, ethnicity, age, sexual orientation, and gender are familiar to many practitioners who work with survivors. Survivors who have disabilities also incorporate beliefs, attitudes, and perceptions as members of their own diverse groups (Cramer, Choi & Ross, 2017; Crowe,

2017; Stern, van der Heijden, & Dunkle, 2020). Each cultural group has its own views and beliefs surrounding disability and ability that commonly result in prejudice and discrimination for those who are disabled.

People with disabilities experience disproportionately more IPV compared to those without disabilities (Breiding & Armour, 2015; CDC, 2020b; Crowe, 2017). Children with disabilities are also at higher risk for physical and sexual abuse. This is especially relevant given the likelihood of intergenerational transmission of violence in families. Individuals with disabilities can face challenges with some major life activities, such as self-care, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com reading, concentrating, thinking, communicating, and working. It is important to recognize that the label “disabled” represents a group of heterogeneous individuals with varied abilities and disabilities who commonly experience marginalization, discrimination and oppression because of their disability (Brown, 2017).

Individuals with disabilities are often embattled with prevailing misconceptions and presumptions of incompetence (Brown, 2017). This incompetence is applied to their ability to think, feel, remember, or make decisions. Often individuals with disabilities are de-sexualized or deemed unable to have sexual agency and autonomy. Once disabled individuals are seen as incompetent, they become subjected to the control of other people and institutions who are ascribed roles of protector (Brown, 2017). If an individual has a caregiver or guardian, the caregiver, guardian, or even partner is presumed to be benevolent. This is an especially dangerous presumption and offers a form of protection for an IPV perpetrator.

The relationship between a disabled survivor and an abusive partner can be complex. A survivor may be trapped in a long-term relationship because to end the relationship may result in loss of care for which he or she may be unable to pay for on his or her own (Brown, 2017).

Marginalization and oppression of disabled individuals from people with able-ist attitudes serves as a structural form of discrimination that inhibits survivors from addressing their needs in a fair way. Because IPV includes patterns of violence in a framework of control and dominance, for many survivors who are disabled, this control can manifest as withdrawal of or threats to withdraw life-sustaining care, medications, necessary adaptive equipment or accommodations, or services.

Individuals with disabilities have nearly double the lifetime risk of IPV victimization compared to those without disabilities (Breiding & Armour, 2015). Women with disabilities are

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2015; CDC, 2020b). Men with disabilities are also at greater risk for experiencing sexual violence other than rape compared to men without disabilities. For both men and women with disabilities, there is a higher risk of sexual coercion and unwanted sexual contact. Similarly, both men and women with disabilities are more likely to report IPV of all types compared to those without disabilities.

There are several factors that could make individuals with disabilities more vulnerable to

IPV. Dependence upon a caregiver, higher levels of poverty, social isolation, and perceived vulnerability may contribute to IPV (Breiding & Armour, 2015; Stern, van der Heijden, &

Dunkle, 2020). Survivors may have greater difficulty leaving a relationship because of the need for care and financial support from the abusive partner (Breiding & Armour, 2015).

Individuals with disabilities often face social prejudice, discrimination, and stigma in a society that reinforces the idea that able-bodied individuals are more important than those who are not (Stern, van der Heijden, & Dunkle, 2020). Services may not be accessible to individuals with disabilities in terms of communication (e.g., American Sign Language for deaf individuals) or physical accessibility (e.g., elevators or bathrooms accessible for individuals in wheelchairs).

Some practitioners may not screen for IPV among people with disabilities, which can prevent survivors from disclosure. Though men with disabilities are at higher risk of IPV, practitioners may not routinely screen them.

Social perceptions include beliefs that people with disabilities are weak or unable to care for themselves (Stern, van der Heijden, & Dunkle, 2020). Disability can sometimes compound an already unsafe environment because perpetrators believe that the individual would be unable to run away (e.g., individual in a wheelchair), disclose the abuse (e.g., deaf individual), identify

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com the abuser (e.g., blind individual), or understand the abuse (e.g., individual with an intellectual disability). Disabled survivors can find themselves without community support because of beliefs that exclude them from involvement, inaccessibility, and internalized stigma (Stern, van der Heijden, & Dunkle, 2020).

In addition to the forms of IPV that survivors who are not disabled experience, there are some unique forms of abuse that can occur with people with disabilities. These factors can exacerbate the situation and create additional burden and complications for survivors. Below is a list of forms of abuse that can occur with survivors with disabilities (American Psychological

Association, 2020; Crowe, 2017):

- Removing or destroying a person’s disability device (e.g., wheelchair, hearing

aid, cane)

- Denying access to prescribed medications

- Forcing the individual to take medication against his or her will

- Forcing someone to lie in soiled undergarments

- Removing communication devices (e.g. videophone, communication board)

- Preventing access to food or water

- Inappropriate touching a person while assisting with bathing or dressing

- Denying access to disability-related resources in the community, including health

care appointments

- Prohibiting contact with friends and family

- Preventing physical escape or departure from the environment.

Survivors with disabilities face a number of barriers that are associated not only with

IPV, but also with having a disability. Some survivors with disabilities describe a sense of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com failure when compared to other able-bodied individuals (Stern, van der Heijden, & Dunkle,

2020). Gender norms and ideals about social responsibilities can isolate, discriminate, and stigmatize survivors. Male survivors can experience severe social stigmatization because of social concepts of men as strong and protective providers for the family. Disability is often associated with being dependent and helpless, which demasculinizes male survivors. Female survivors with disabilities may be seen as less attractive marital partners, which also perpetuates blame.

IPV survivors often experience social and community isolation. Both male and female survivors with disabilities experience additional isolation that compounds the situation (Stern, van der Heijden, & Dunkle, 2020). In addition, IPV has significant health effects not only on non-disabled survivors, but especially on survivors with disabilities (Ballan & Freyer, 2017).

Survivors with disabilities are more likely to experience abuse for longer periods of time compared to those without disabilities. Thus, it is no surprise that trauma symptomology among survivors with disabilities is significantly higher than those without disabilities.

The long-term physical and mental health difficulties associated with IPV for disabled survivors include injuries, mental health problems, physical difficulties, substance abuse, and death (Ballan & Freyer, 2017). Mental health issues include depression, PTSD, anxiety, self- harm, and sleep disorders. Survivors who have chronic mental illnesses are more likely to attempt suicide as a result of IPV and are less likely to seek help from informal social networks.

Practitioners who work with survivors who have disabilities recognize the additional barriers to accessing support services for IPV (Ballan & Freyer, 2017). These barriers can be due to social isolation, physical barriers to mobility caused by their disability and a service provider’s lack of required accommodations, and fear of retribution by the perpetrator. Trauma-

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com informed practitioners understand the impact of violence on all aspects of an individual’s life and development. They understand that disability is only one intersection of identity, but plays an important role in seeking and receiving help. Clinicians understand that multiple systems, such as medical, social, political, and personal factors, play roles in the survivor’s life (Ballan &

Freyer, 2017). Trauma with disabled survivors includes many factors, but especially disability- related risk factors and consequences.

Health-related factors, such as physical dependence on abusers for activities of daily living, can influence whether a survivor reports abuse and seeks help (Ballan & Freyer, 2017).

Lack of employment, restricted financial resources, and fears of losing custody will impact a survivor with a disability. Accessible and affordable health care is especially difficult for individuals with disabilities. A lack of accessible and affordable housing may prevent a survivor from leaving an abusive relationship.

Practitioners who work with survivors with disabilities must take into account the varied and complex personal, social, and structural systems that either impede or promote recovery from IPV. They must understand that there are complicated and complex social systems that affect a survivor’s willingness to disclose abuse and leave a relationship. Many survivors with disabilities rely on their partners for daily living, services which they may not be able to afford on their own. Survivors with disabilities want providers to understand, respect, inform, and connect with them around disability-related issues. Safety planning, for example, may need special considerations (Ballan & Freyer, 2017). The following are recommendations for working with survivors with disabilities (Ballan & Freyer, 2017):

- Avoid treating survivors with disabilities as a homogeneous group

- Consider the type and severity of disability and one’s adaptation to it

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com - Consider the immediate environment and if referrals are made, the environments

of the referral agencies

- Express an understanding of disability-related needs and considerations

- Recognize the survivor’s strengths

- Screen individuals with disabilities for IPV

- Provide choices that empower survivors to make their own decisions.

Because individuals with disabilities are disproportionately affected by IPV, practitioners should strive to understand the context of each individual’s particular situation. They understand that survivors are part of a larger intersectional identity process that is complex and unique to the individual. Accessible services are vital in meeting the needs of survivors with disabilities.

Resource: The Deaf Abused Women’s Network (DAWN) is a trauma-informed, culturally responsive and transformative justice-based agency that provides multi-faceted services to deaf and hard of hearing IPV survivors and the community. The staff strive to understand and address power-based violence by providing direct services and education. Their mission is to promote healthy relationships and reduce abuse in the deaf community in the Washington, DC area. They emphasize that all forms of violence are intersectional. The staff works with survivors who have many identities and recognize that these identities may decrease safety and autonomy. They are committed to working toward promoting healthy relationships and reducing violence in the deaf community by recognizing the power, control, and violences caused by all forms of oppression. Website: https://deafdawn.org/

Men

Many men can be victims of violence by their partners. In the United States, approximately 11% of men are victims of severe physical IPV (SAMHSA, 2020). Nearly half of all men report psychological aggression, such as humiliation and verbal abuse. The 2015

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com National Intimate Partner and Sexual Violence Survey indicated that 33.6%, nearly 37.3 million

American men experienced physical, sexual, and/or stalking in their lifetimes (CDC, 2020b;

Smith et al., 2018). Most of these men experienced physical violence (31%) with nearly 15% experiencing severe physical violence. Over 34.2% or 38.1 million men experienced psychological aggression by an intimate partner during their lifetimes. Approximately 11% reported sexual violence, physical violence, and/or stalking by an intimate partner. Over half of men who are victims of IPV report that they first experienced violence before the age of 25

(CDC, 2020b). Most perpetrators of completed or attempted rape against men are male partners

(CDC, 2020b). Other forms of sexual IPV, such as being made to penetrate or sexual coercion, are most often female perpetrators. Both men and women are perpetrators of stalking against men.

Gender identity and gender roles often impact a male survivor’s willingness to disclose abuse and seek treatment (Stiles, 2017). The behaviors that are considered to be IPV among women may be labeled or interpreted differently when they are against men. Men who experience IPV often display symptoms similar to women, such as PTSD, anxiety, and depression, but these may be not seen as IPV-related. Traditional gender roles expect men to be able to protect themselves and their families. Because of biased views about IPV, the abuse of men may not be awarded any conceptual significance by social supports (e.g. friends and family members) or professionals who would otherwise be in a position to offer assistance. This is especially true when the perpetrators are women and IPV may be misconstrued as simple marital discord (Stiles, 2017).

Male survivors may feel shame or guilt about their violent partners (Stiles, 2017). They may fear that disclosure of abuse will lessen their masculinity and diminish self-worth. Social

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com prejudice and stereotypes may minimize the violence because men are seen as strong, superior, and in control. Though male survivors, as well as female survivors, risk extreme injury or death, many, including male survivors themselves, may minimize the potential for harm.

Because many male survivors face problems associated with stigmatization, they may be reluctant to share their experiences and report partner violence (Espinoza & Warner, 2016).

Stereotyping and prejudice about female perpetration of violence can even cause mere discussion of male victimization to be taboo. Males are often associated with being perpetrators of abuse against female partners so disclosure of victimization may be especially challenging.

Both men and women are less likely to hold female perpetrators accountable for violence than male perpetrators (Espinoza & Warner, 2016). In addition, injury to male victims is often not equal to female injury making female-perpetrated violence seem less important or significant.

Socially, both men and women are more permissive of female-perpetrated violence and often minimize its significance (Espinoza & Warner, 2016). Acts of violence by women are often seen as more socially acceptable with the use of violence substantiated under certain circumstances. Males who perform similar acts of violence receive greater blame and their acts are more often attributed to personal dispositions.

Male victims rarely report IPV (Espinoza & Warner, 2016). Female-perpetrated abuse is rarely prosecuted as a crime. Law enforcement and legal professionals reflect biases against male survivors by addressing female perpetrators with leniency. Male perpetrators are significantly more likely than females to be arrested, charged with a crime, and convicted

(Espinoza & Warner, 2016). Law enforcement is less likely to believe men when they assert self-defense. Male-perpetrated convictions are as much as three times higher than female- perpetrated offenses. Similarly, female perpetrators are less likely to have severe restrictions in

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com restraining orders compared to men. There is a significantly less proportion of men who are granted restraining orders for female-perpetrated IPV than women with male perpetrators

(Espinoza & Warner, 2016).

The first step to including male IPV victims is to take an inclusive, proactive approach to services, outreach, and educational materials (Espinoza & Warner, 2016; Stiles, 2017).

Practitioners, advocates, law enforcement, and others can be most helpful if they understand, through training, the diverse experiences of male victims. Often shelters for domestic violence victims are gender-specific for women only. Male victims are sometimes sheltered at other sites, like hotels, but this can exacerbate survivors’ feelings of isolation and limit access to other support services (Stiles, 2017).

Men in general and, male victims of IPV in particular, may be reluctant to seek mental health counseling services for the effects of their abuse (Espinoza & Warner, 2016; Stiles,

2017). Social norms and internalized gender roles often do not support the need for counseling because to seek help is to be less masculine. Men are viewed as chivalrous, invulnerable, and dominant. Victimization is seen as a deviation from masculine gender roles (Espinoza &

Warner, 2016). Male survivors internalize these attitudes and may be reluctant to even disclose abuse to friends and family. Behavioral health practitioners can be more effective by implementing unique counseling styles and approaches to male survivors. Support groups for men may be helpful in reducing feelings of isolation and invisibility. Male peer advocates can help to build support and identify a network of community support.

Unlike male perpetrators, violent acts by women against their male partners is viewed less as a function of disposition than as a reaction to other factors, such as infidelity, finances, and conflict (Espinoza & Warner, 2016). Male victims suffer significant psychological and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com physiological effects of IPV, especially high levels of PTSD, depression, suicidal ideation, psychosomatic symptoms, high blood pressure, and general psychological distress (Machado,

Santos, Graham-Kevan, N., & Matos, 2017). However, men are less likely to disclose abuse and seek help. Fear of not being believed, victim-blaming, internalized gender stereotypes, masculinity norms, ambivalence combined with a lack of male-specific resources make disclosure and help-seeking unlikely (Machado et al., 2017). Men who seek help for IPV- related symptoms often report being turned away, experiencing ridicule, and being accused of perpetrating the violence themselves (Machado et al., 2017). In combination with social stereotypes and departure from socially perceived gender norms, male survivors are likely to try to manage symptoms themselves, sometimes in ways that may not be healthy, such as substance use.

Male survivors report red flags in their intimate partnerships that signal IPV (Machado et al., 2017). Relationship factors, such as jealously, problems with children, issues with previous partners, social isolation, family members’ negative reactions, and economic problems often provoke initial episodes of violence. The cycles of violence frequently seen in male- perpetrated IPV (i.e., tension-building, acute battering, remorseful, apologetic behavior) is also seen in female-perpetrated abuse. Relationship conflicts may start with psychological triggers, but can also escalate to physical violence. Often the psychological violence is more damaging than physical violence. Female perpetrators can make false police allegations, threaten to withhold children, and validation of physical violence, which are often believed by family, friends, and law enforcement (Machado et al., 2017). Similar to female victims of IPV, male victims of IPV are at the greatest risk for increased and severe violence when attempting to leave or end their relationship.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Research of male IPV victimization is lacking in comparison to male-perpetrated IPV

(Machado, et al., 2017). Help-seeking behaviors and the effectiveness of gender-specific interventions with men are also understudied. Practitioners who work with male victims can adopt a gender-informed approach that addresses not only couple-specific dynamics, but also socially-driven factors, such as gender norms and stereotypes. Awareness and prevention efforts should target both male and female survivors. Providers who work with male survivors can help build a social network of formal and informal resources that can address their needs.

Resource: MaleSurvivor is dedicated to providing personalized support for men at every stage of the healing process. They facilitate dialogue among survivors, as well as between survivors and professional therapists, on their online forums, discussion boards, online 24/7 chats, and in- person events. MaleSurvivor provides educational resources that help empower men to process their past and look forward to a healthier future. Because the damaging effects of sexual abuse transcend gender, race, religion, age, nationality, class, and sexual orientation, their services are also designed to help survivors’ loved ones, the media, and the general public better understand the men that the organization services. MaleSurvivor offers various methods of support, including: a) a special support group titled: Dialogue Among Thousands of Survivors, b) support groups, c) community events, and d) empowerment blogs, articles, and insights. Website: https://malesurvivor.org/about-malesurvivor/

Geographically Isolated Individuals

In general, rates of crime and property crimes are higher among individuals living in urban areas compared to rural areas (DuBois, Rennison, & DeKeseredy, 2019). However, the differences among IPV-related crimes in urban versus rural areas are less clear. Other factors,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com such as race and ethnicity, become relevant for raising the risk of IPV among individuals who live in rural areas. Poverty, isolation, and social conservatism are factors that are associated with an increased risk for IPV. Women residing in small towns have the greatest rates of IPV compared to dispersed geographical areas (i.e., dwellings separated by large parcels of land), urban areas, and suburbs (DuBois, Rennison, & DeKeseredy, 2019). Victims who live in rural areas are at higher risk of IPV-related homicide (Neill & Hammatt, 2015).

Patterns of IPV and its severity vary across types of rural populations (Schwab-Reese &

Renner, 2017). Social isolation and rural sociocultural context can also increase an individual’s vulnerability to IPV (Schwab-Reese & Renner, 2017; Shannon, Nash, & Jackson, 2015) and like all the special populations described in this learning material, individuals in this group come from other varied backgrounds and the concept of intersectionality is equally applicable here . Rural IPV victims may be less likely to disclose their abuse and seek help for symptoms associated with violence. Reluctance to disclose and seek help are likely related to embarrassment, concerns about confidentiality, fear of retaliation by the perpetrator, gender role stereotypes, and law enforcement biases (Schwab-Reese & Renner, 2017; Zorn, Wuerch, Faller,

& Hampton, 2017). In addition, social perceptions of violence and blame assignment by families and friends may also influence survivors’ decisions to disclose abuse.

Many IPV victims who reside in rural areas face challenges with accessing resources and services (Zorn et al., 2017). In addition to the factors that may influence disclosure of abuse listed above, contextual issues of rural living, such as animal care-taking and safekeeping, may also play a role. In rural geographical areas, domestic violence shelters that are close and easily accessible are few. There can be a lag in response time in getting to services because of the distance to services or transportation difficulties (Zorn et al., 2017; Shannon, Nash, &

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Jackson, 2015). Privacy and anonymity in small geographical areas are also primary concerns, especially when accessing services for IPV, which may be taboo among rural families and small communities. In small communities, individuals and their family members often know one another. Even making a report of a law enforcement officer may entail filing the report with someone they know.

Individuals in rural areas often experience lack of community services, such as public transportation, service providers, access to neighbors who live close by, and employment opportunities (Rural Health Information Hub (RHIH), 2020; Shannon, Nash, & Jackson, 2015).

For victims of IPV, these community services are especially important, but may provide insurmountable barriers for disclosure and help-seeking. Poverty, geographic isolation, and the combined effects of limited or no access to economic resources, health care services, and behavioral health services present real and significant challenges for IPV survivors (RHIH,

2020; Shannon, Nash, & Jackson, 2015).

Substance use among individuals who live in rural areas is an important consideration because substance use increases the likelihood of IPV. High substance use rates in rural areas highlight the need to incorporate substance use treatment approaches (Shannon, Nash, &

Jackson, 2015). Health-related problems may be exacerbated because of regional disparities in health care services, lack of services, and pervasive poverty. These factors also make mental health problems more likely.

IPV survivors who live in rural areas may find alternative ways in dealing with an abusive relationship (RHIH, 2020). Reporting IPV to the police may not be seen as an effective strategy, especially if they personally know the law officer or someone in his family or if the perpetrator is part of the law enforcement presence in the area. They may decide to deal with

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com problems privately, with family and friends. If access to health care or mental health care is limited in a particular area, survivors may decide to either not disclose the abuse or disclose it only to individuals in their closest circle. When community services are lacking, survivors may decide to not report the abuse, especially if there is a risk for retaliation or increased violence as a result.

The National Rural Health Association recommends several actions to improve support for victims of IPV (RHIH, 2020). These recommendations include:

o Increasing employment opportunities and vocational training,

o Providing behavioral health counseling,

o Establishing violence prevention programs in clinical settings,

o Creating awareness campaigns promoting prevention and intervention programs,

o Increasing awareness of IPV within the community through local media outlets,

o Expanding community resources centers by establishing funding partnerships,

o Implementing batterer intervention programs

o Providing advocacy and legal services

o Providing expertise on victim safety and emotional support

o Helping navigate financial systems to retain or regain assets and establish power

of attorney, guardianship/conservatorship, or custody

o Offering assistance with obtaining restraining orders

The circumstances involved with violent relationships are not necessarily caused by rurality. However, responding and providing services to victims are affected by challenges associated with living in remote geographical areas (Neill & Hammatt, 2015). The number of available service and service providers can be at far distances or limited in a particular area.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Clients who prefer services geared towards particular cultures (e.g., LGBTQ) or accessible services (e.g., deaf clients) may have insurmountable challenges in rural areas. Medical services and social services may be difficult to obtain because of distances, lack of transportation, or high costs associated with traveling to sites.

In order to be effective, service providers to individuals who live in rural areas must be familiar with the ways in which environmental circumstances and personal characteristics affect survivors of domestic violence and help-seeking strategies (Neill & Hammatt, 2015). They can partner with organizations to help reach victims in underserved areas. They can work as a collaborative partner with health care and social systems in order to build an effective response.

They can act as liaisons to help survivors connect with criminal justice, health, social, human services, and mental health services.

Practitioners who work with individuals from remote geographic locations understand that their clients may be struggling financially, lack formal education, and lack access to consistent or continual health and mental health care services (Neill & Hammatt, 2015). Social factors, such as unemployment, cultural, social, and gender norms, as well as gender inequalities affect how individuals disclose abuse, seek help, and respond to treatment. Many victims of IPV may not report abuse because of higher risk of escalation, lack of response by service providers, or other limitations as a result of living in a remote area. Their lives may be complicated by low socioeconomic status, family roles, and community ties (Neill & Hammatt,

2015). Sometimes residents of rural areas may not be aware of services that are available to victims of domestic violence. They may feel uncertain what will happen if the police are notified in instances of abuse.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Geographically isolated victims of IPV may be faced with the lack of shelters, delayed responses by law enforcement and criminal justice systems, the influence of religious community beliefs, and long-term familial ties to a particular region (Neill & Hammatt, 2015).

The willingness of a survivor to report abuse may be influenced more by community and family loyalties than by an individual’s own feelings. Some may believe that using violence is an acceptable, cultural norm in certain circumstances. Reporting abuse may cause the victim to experience stigma, and there may be community pressure to avoid shaming the family and the family’s reputation. Social rejection from family members, neighbors, and church members can influence the decision to disclose abuse (Neill & Hammatt, 2015). Often the perpetrator is known in the community. Issues surrounding confidentiality and privacy are likely to be an important social factor. Community individuals working in jobs, such as law enforcement, medical personnel, court officials, may be the perpetrators or victims or may be known by both the victim and the perpetrator.

Practitioners who are effective with survivors in rural areas understand that there are unique issues related to geographic location that can affect service provision and access. They can be supportive to help survivors connect with formal resources and informal networks to help decrease their isolation (Neill & Hammatt, 2015). They can assist with negotiating safety for the victim by working with professionals from other disciplines who can be a network of support. Clinicians can address the unique barriers that many survivors in rural areas face so that they can be safe and receive treatment.

Resource

The Rural Health Information Hub is a national website that provides a range of information

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com about a variety of topics that are related to rural health. It provides individual state information as well as publications, news and events, funding opportunities, and organizational information. It provides articles about interventions, prevalence, medical-legal partnerships, as well as other culturally-relevant information about violence and abuse in rural

America. Website: https://www.ruralhealthinfo.org/topics/violence-and-abuse/organizations

Economically Disadvantaged Individuals

As poverty increases, so does the risk of IPV (Gilroy et al., 2018). Victims of IPV often are also victims of poverty (Breiding, Basile, Klevens, & Smith, 2017; Gibbs, Jewkes, Willan,

& Washington, 2018; Gilroy et al., 2018; Satyanathan & Pollack, 2015; Simari, 2019). Physical

IPV is also a leading factor in homelessness. A host of factors, including lack of affordable housing and lack of accessibility to services, including legal services, contributes to the poverty of survivors of domestic violence, especially families. Other mechanisms of IPV, including manipulation and control, contribute to barriers in employment. Survivors may be prevented from seeking employment as a form of IPV. There may be psychological aspects of IPV, such as symptoms of PTSD, that present challenges to obtaining and maintaining employment.

Physical marks of IPV, such as bruises, may prevent a survivor from going to work for fear that coworkers may notice. Survivors of IPV may be late to work, have excessive absenteeism, or have lower work productivity as a result of IPV (Satyanathan & Pollack, 2015). IPV can present multiple barriers to getting a job and keeping it.

While many shelters provide emergency housing and services to survivors, they often cannot provide income that is needed to become financially self-sufficient (Satyanathan &

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Pollack, 2015). IPV services generally offer access to legal services, counseling, emergency shelter, and sometimes help with finding jobs. However, economic independence often takes a long time to build and sustain.

Poverty is multi-dimensional with varying effects on individuals. At the household level, poverty is related to issues that arise from housing and food insecurity. This economic stress can increase the risk for IPV (Gibbs et al., 2018; Gilroy et al., 2018; Simari, 2019). Though individuals with higher levels of income also experience IPV, the stress that is created by lack of resources adds additional strain to relationship and can exacerbate stress and conflict in the relationship. Lack of economic resources increases the dependency of one partner, particularly women, on the other partner causing barriers to survivors who want to leave their relationships.

Food and housing insecurity are both indicators of overall economic insecurity and distinct social determinants of physical and mental health (Breiding et al., 2017). Concern about lack of housing and food creates extreme stress than impacts individual and family functioning. Lack of financial resources to provide for food or shelter is associated with IPV victimization not only in the United States, but around the world. Economic insecurity can cause individuals to engage in such economic survival strategies as temporary and multiple unstable housing arrangements or living with acquaintances, which can lead to higher victimization (Breiding et al., 2017).

Poverty can impact a male’s sense of masculinity and respect, which can be a driving factor in the perpetration of IPV (Gibbs et al., 2018). Men who are unemployed or are unable to support their families may be stereotyped and judged, which can cause further need for control and dominance in their intimate partnerships. Not only can lack of economic security put strain on the relationship, it can contribute to community members’ negative views of a man’s

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com inability to provide financial stability and affect the man’s self-esteem, which can, again, lead to aggression as a psychological compensatory measure or protection against feeling unmasculine.

Poverty is also associated with poorer mental health and substance use (Gibbs et al.,

2018; Gilroy et al., 2018; Simari, 2019). Both of these factors are also associated with a higher risk of IPV. Symptoms of PTSD, such as depression and anxiety, are linked with substance abuse as both, survivors and perpetrators, use substances to manage feelings associated with problems in their lives. Childhood trauma is also related to poor mental health outcomes and substance use. In combination, all of these factors can increase the likelihood of relational conflict and IPV.

Childhood trauma is linked with low educational attainment, which is also linked to poverty (Gibbs et al., 2018). Components of childhood trauma, such as intergenerational transmission of violence, gender attitudes, and controlling behaviors, can result in disruptions in schooling. This can affect motivation and achievement, which can have an impact on whether one obtains a job that can ensure financial security.

The relationships between poverty and IPV are complex and compounded by multiple factors. Poverty reinforces gender identity (e.g., perceptions of masculinity), which shapes ideas about gender roles and gender equality (Gibbs et al., 2018; Gilroy et al., 2018; Simari,

2019). Gender inequality and rigid gender-defined expectations contribute to the perpetration and acceptance of IPV. Substance use, poor mental health outcomes, and food insecurity, all connected to poverty, are all related to IPV (Gibbs et al., 2018). In particular, poverty shapes individuals’ experiences of education, childhood trauma, and mental health. Income and food insecurity contribute to stress in the family, which is directly associated with IPV perpetration.

This also affects the ability of a partner to leave an abusive relationship.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Poverty exacerbates the consequences of IPV (Gilroy et al., 2018). Survivors may have limited access to health care or funds for transportation to attend visits. They may have more difficult challenges in obtaining the help that is needed to treat physical and psychological injuries.

There is some evidence that transfers of cash can reduce IPV (Gibbs et al., 2018; Gilroy et al., 2018; Roy, Hidrobo, Hoddinott, & Ahmed, 2017). Transfer programs are widely used to combat poverty worldwide. These types of programs, especially when targeted towards women, often reduce the prevalence of IPV (Roy et al., 2017). Direct cash transfers help women, in particular, because it elevates their bargaining power in the household and family. In households where a perpetrator’s power and control are derived from financial control, providing victims with their own money can help to balance power. By having their own financial resources, victims have greater independence and more choices for managing a violent relationship. When partners have financial resources, this can also relieve the burden of poverty, reduce stress, and therefore, potentially reduce the risk of IPV (Roy et al., 2017). One of the problems with transfer programs is that once the financial resources stop, the risks of poverty again increase (Roy et al., 2017). Transfer programs are not meant to be offered indefinitely and the IPV that existed before the cash transfer could potentially return once resources have ended.

Economic sufficiency, while providing resources in the form of money, also influences knowledge, attitudes, and life skills (Gilroy et al., 2018). These factors can be used to negotiate power in relationships, obtain educational opportunities, and increase employability. With increased economic self-sufficiency, survivors can develop, access, and use networks of supportive individuals that enhance well-being and care. This social support can be

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com psychological (e.g., having someone that cares about the survivor), tangible (e.g., providing a place to stay in emergencies), and informational (e.g., providing information about available resources) (Gilroy et al., 2018). Having access to personal funds and support can increase the decision-making power about finances one has in relationships (Gilroy et al., 2018). An individual who has the financial means necessary to meet the family’s needs is less dependent on others to provide for those needs.

Resource:

The National Legal Aid and Defender Association (NLADA) serves the legal needs of low- income communities. Homelessness, incarceration, illness, denial of disability and veterans’ benefits, unemployment, and abuse are often products of vulnerable populations’ access to justice. NLADA leads a broad social network of advocates to advance justice and expand opportunity for all by promoting excellence in the delivery of legal services for people who cannot afford counsel. NLADA is America’s oldest and largest nonprofit association devoted to the delivery of legal services in the form of: a) advocacy, b) guidance, c) information, and d) training and technical assistance. It serves as a collective voice for America’s civil legal aid and public defense providers. It also provides training events for the equal justice community.

Website: www.nlada.org

PROVIDER SELF-CARE

Working with individuals who have experienced trauma often affects the providers

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com offering treatment. Compassion fatigue, which is emotional strain of working with those suffering from the effects of traumatic events, is a symptom that can cause providers to burn out (SAMHSA-HRSA, 2019). Providers who work with survivors of trauma can experience physical, psychological, and emotional reactions as a result of their work. Providers may become apathetic or over-involved with the clients. They may develop cynical or apathetic attitudes towards their work. Providers can also experience vicarious trauma as a result of working with survivors.

Vicarious trauma is similar to compassion fatigue in that providers experience emotional difficulty directly as a result of working with survivors of trauma (National Sexual Violence Resource Center, 2019). Symptoms of compassion fatigue and vicarious trauma can lead to feelings of burnout and stress. Some signs of vicarious trauma include (NSVRC, 2019):

● Physical symptoms, such as changes in appetite, sleep, and chronic illness

● Use of substances, such as caffeine, nicotine, alcohol, or drugs as a means of coping with the stress at work

● Intrusive thoughts of client stories

● Withdrawal from others

● Anxiety or frustration with clients and coworkers

● Sense of helplessness

● Emotional distance from work

● Apathetic about the problems of friends of family members

● Avoidance of work or coworkers to prevent overwhelming feelings

Interestingly, many of the symptoms of provider vicarious trauma are those that many survivors of IPV face. As with survivors, these reactions can occur immediately during the work with a client or accumulate over time. The effects of vicarious trauma can lead to worker burnout and fatigue that not only affect the work they do with their clients, but also to

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com themselves and their personal relationships.

In order to combat the effects of vicarious trauma, there are several recommendations

for providers (NSVRC, 2019):

● Be aware of the feelings and stay present in the moment. Mindfulness is one technique

that can help cultivate an intentional awareness of the present moment. It can help providers

develop more creative and fulfilling ways of dealing with the effects of vicarious trauma.

● Decide when to become involved and when to distance. At times providers may need to

distance themselves from instances or situations where the toll on emotional well-being is too

much. A provider can choose to leave a training or a work event in order to refocus energy on

personal well-being.

● Incorporate personal creativity in the work space. Providers may need to reconnect with

their own identities and preferences to create an office space that fosters comfort, peace, and

focus. A provider may decide to decorate her office or change paint colors to bring about a

more restful and peaceful space. Another provider may choose works of art that bring about

a peaceful aura of calmness and reflection.

● Create an organizational culture that reduces vicarious trauma. Administrators at an

organization can create an intentional work environment that supports its employees. They

can incorporate trauma-specific supervision and trainings; they can include vicarious trauma

into staff orientation; they can provide resources for self-care and wellness to both employees

and clients.

Providers need to be aware of their own feelings and experiences in their work with

survivors of IPV. Clients bring intense and often traumatic experiences to their sessions with

clinicians. They face difficult and complex challenges that require a clinician who is not only

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com present and skills, but also who is individually healthy. Providers and their clients can benefit from a structured and intentional program of self-care.

SUMMARY In summary, practitioners can be most effective with individuals and families that experience domestic violence when they are aware of the complexity of the challenges survivors and children face. Clinicians can use a variety of techniques and approaches to address the varied needs of survivors and their families. A number of practice frameworks help guide clinicians in choosing their approaches with survivors and families.

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