Family Violence: Intimate Partner Violence (IPV)

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Family ViolenceIntimate Partner Violence (IPV)

• Ashley Owen, Ph.D.
• Emory University
• Department of Family and Preventive Medicine

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Understanding Intimate Partner Violence
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Understanding Intimate
Partner Violence
Learning Objectives 1.) Place knowledge
about the definition, epidemiology, and
demography of intimate partner violence into a
clinical context. 2.) Develop competence at
routine inquiry about intimate partner violence
using the ASSERT model. 3.) Formulate an action
plan with immediate support for an abused woman
returning to an unsafe environment. 4.)
Facilitate an abused woman's consideration of and
access to local community services and agencies.
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Key Elements of IPV

• Usually a pattern of assaultive and coercive
  behavior, not an isolated event includes
  physical, sexual, and psychological attacks, as
  well as economic coercion
• Perpetrator and victim are
• known to each other and
• have shared an
• intimate relationship.

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Key Elements of IPV (cont.)

• A combination of physical attacks and controlling
  tactics used by perpetrators that result in fear,
  as well as physical and psychological harm, to
  their partners and children.
• A pattern of purposeful behavior, directed at
  achieving compliance from or control over their
  partner.

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Prevalence of Intimate Partner Violence

• 22 of women report lifetime prevalence
• Gay and lesbian couples are at same, and possibly
  grater risk than heterosexuals for partner
  violence (30-40 of lesbians)
• More prevalent among women than diabetes, breast
  cancer, and cervical cancer
• 30 of murdered women are killed by their
  intimate male partners
• Findings of 45 of wives of alcoholic men have
  been beaten (alcohol drug most commonly
  associated with IPV)

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Family Dynamics of IPV and Alcohol Abuse

• both substances and violence are used to resolve
  conflict and cope with stress discharges
  tension, ends the argument, or asserts control.
• secrecy is
• maintained about
• both violence and substance abuse (shame, fear
  of unwanted intervention, and the feared career
  or social consequences of disclosure).

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Family Dynamics of IPV and Alcohol Abuse

• Particularly due to the increased risk of harm in
  a family that experiences both substance abuse
  and family violence, after treating injuries
• the provider must
• FIRST focus on
• immediate safety planning for the victim of
  violence and other family members.

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Patient Symptoms often associated with IPV

• Pain in any place in the body
• Vaginal discharge
• Constipation
• Diarrhea
• Shortness of breath
• Choking
• Difficulty sleeping
• Fatigue
• Nightmares
• Depression and/or anxiety
• Hx of substance abuse
• Suicidal Ideation

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Progression of Violence

• Phases build-up, explosion, honeymoon

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What keeps women in the relationship?

• fear of partners actions (Ill never be safe, I
  might as well live with him)
• effects of IPV (Cant face making decisions)
• roles the culture forces on women (guilt,
  economic)
• personal history (My father beat my mom it just
  goes along with being in a relationship)

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What keeps women in the relationship?

• isolation and lack of resources
• The most harmful tactic an abuser can use is
  isolating the victim from social contacts.
• The world the victim lives in becomes a reality
  from which it is difficult to escape. (He
  wouldnt let me see friends or family for so
  long, now I dont have anyone to stay with
  anymore)
• love and hope (I dont want to give up the good
  times I keep hoping hell change)

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• How to think about whats going on with your IPV
  patients
• and how to help them.

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STAGES OF CHANGE MODEL
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STAGES OF CHANGE MODEL

• Changing behavior is a dynamic and cyclical
  process and one progresses through stages in
  trying to modify their behavior
• Stages of change readiness to change
• Processes of change techniques or strategies to
  bring about change

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STAGES OF CHANGE MODEL

• Assist as your patient moves along the stages of
  change process
• (transtheoretical model of behavior change)
• precontemplation
• contemplation
• preparation
• action
• maintenance

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STAGES OF CHANGE MODEL

• Precontemplation
• typically referred by others
• do not intend to change
• relatively unaware of situation
• defensive
• feel helpless, and resourceless
• often accept batterers definition of the
  situation-that violence is her fault
• counseling thought-oriented

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STAGES OF CHANGE MODEL

• Contemplation
• intend to change but only thinking about it and
  not committed to changing
• may use this stage to build social and emotional
  support and explore options for financial
  independence
• stay in this stage for as long as weigh pros and
  cons of leaving the batterer
• counseling thought-oriented

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STAGES OF CHANGE MODEL

• Preparation
• actively plan to change and are ready for action
• develop a safety plan
• discuss with a friend of family member who may
  provide a safe house
• call an abuse hotline
• set aside emergency money
• contact an attorney or law enforcement
• leave the abuser briefly
• counseling thought and action-oriented

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STAGES OF CHANGE MODEL

• Action
• overtly make changes
• implement a safety plan
• leave abuser
• demand and receive a reduction in, or an end to,
  the violence

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STAGES OF CHANGE MODEL

• Action (cont.)
• tell others about the IPV and get support
• obtain community support and resources
• highest risk of relapse" (recycling) during this
  phase
• counseling thought and action-oriented

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STAGES OF CHANGE MODEL

• Maintenance
• solidify change and resist temptations to relapse
• continue to work to maintain a violence-free life
• counseling thought and action-oriented

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STAGES OF CHANGE MODEL

• Once the woman is safe and has progressed to the
  action or maintenance phase,
• she may choose to engage in interventions for
  her trauma (ex. PTSD).
• Its not that some people have willpower and
  some dont. Its that some people are ready to
  change and others are not.
• - James Gordan

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IPV ASSESSMENT Why is it so
important?

• Part of any complete interview
• (contribution to psychiatric/physical concerns)
• Potential harm of not asking
• (message to patient, help patient understand
  relations among abuse, health problems, and risk
  bx, unassessed risk)
• Therapeutic value of compassionate inquiry
• Inquiry and support really do bring value to
  patients lives.

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IPV ASSESSMENT Why is it so important?

• "Since I can't rescue victims, I realize all I
  need to do is be empathetic and supportive, and
  this simple intervention can really help empower
  someone"

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IPV ASSESSMENT Barriers for providers

• Lack of IPV education
• Lack of time
• Lack of effective interventions
• Powerlessness
• Fear of offending the patient
• Privacy concerns
• Personal history of abuse

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IPV ASSESSMENT Barriers for patients

• Not asked by the clinician
• Concerns about confidentiality
• Perception that clinicians are not interested
• Perception that clinicians have no time
• Fear of involving the police
• Embarrassment
• Fear of retaliation

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IPV ASSESSMENT HOW TO

• Ask
• Sympathize
• Safety
• Educate
• Record
• Treat (refer)
• It really is that simple!

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ASK (sample introduction questions )

• How would you describe
• your relationship?
• How do you and your
• partner work out problems?
• I ask many of my patients about
• their family life as it affects their health
  and safety. May I ask you a few questions?
• Sometimes when I see an injury like yours, it is
  because somebody got hit. How did you get this
  injury/bruise?

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ASK (sample introduction questions)

• What happens when there is a disagreement with
  your partner or others in your home?
• Have you ever been hurt or threatened by your
  partner?
• Do you ever feel afraid of (controlled or
  isolated by) your partner?

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ASK (sample follow-up questions)

• Has the violence gotten worse or scarier? Is it
  more frequent?
• Has your partner ever threatened to kill you,
  him/herself or your children?

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SYMPATHIZE (sample statements)

• You dont deserve this abuse and it is not your
  fault.
• Im afraid for your safety and that of your
  children.
• You are not alone and help is available.
• I will be here to help you.
• I am here to listen.
• I want to help you with this.

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SAFETY (review with patient)

• - Do you have an escape route?
• Doors, stairs, first floor windows, basement
  exits
• - Do you have a safe place to go to?
• Home of relative/friend with unconditional
• support, motel, shelter
• - Do you have a survival kit?
• (hide safely or leave with trusted person)
• Money, extra house and car keys and documents, ID
  documents (passports, birth certificates),
  insurance papers, checkbook and credit cards,
  legal documents (marriage/ separation agreements,
  protection orders, papers of joint ownerships),
  change of clothes, valuable jewelry

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SAFETY (review with patient)

• Know Domestic Violence hotline phones and
  research shelter info.
• Try to start individual savings account
• (and have statements sent to
• trusted person).

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EDUCATE (sample statements)

• - Violence tends to continue and often becomes
  more frequent and severe. (cycle of
  violence discussion)
• - Domestic violence is common and happens in all
  kinds of relationships.
• - Abuse can impact your health in many ways.

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REPORT

• Document patients statements within chief
  complaint, history of present illness or social
  history (based on what is most pertinent).
• Avoid judgmental documentation
• Use patient declines services at this time and
  patient states (or shares) that instead of
  patient refuses help or patient alleges
• Offer to report with the patient or provide
  documentation to help him or her report.

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TREAT

• Encourage patient to follow up
• with you (open-door policy).
• 2) Provide referrals
• Hotline number
• Legal referral
• Shelter number
• In-house referral

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IPV Assessment Things to Remember

• Offer nonjudgmental acceptance and validation of
  the battered woman and her experience
• Provide immediate support and form a working
  alliance
• Assume self-determination
• View coping strategies as strengths, not
  pathology

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IPV Assessment Things to Remember

• Not asking may negatively impact the physician
  patient relationship.
• Statements expressing sympathy, concern, and
  legitimacy enhance patient satisfaction with
  care.
• Most (74) women want their physicians to ask.

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IPV Assessment Things to Remember

• "By backing off from a rescuing role and instead
  respectfully appreciating someone's strengths...,
  my relationship with my patients becomes more
  important in their lives.

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CONCLUSION/QUESTIONS?

• Remember
• WE CAN MAKE A DIFFERENCE!!!