The%20Common%20Clinical%20Problem%20of%20Adult%20Intimate%20Partner%20Violence:

1

• The Common Clinical Problem of Adult Intimate
  Partner Violence
• Learning How to Incorporate Routine Assessments
• Into Your Practice
• Kathy McCloskey
• University of Hartford
• Graduate Institute of Professional Psychology
• 200 Bloomfield Avenue
• West Hartford, CT 06177
• 860.768.4442
• mccloskey_at_hartford.edu
• http//kathymccloskey.net/
• APA-Approved Pre-Conference Workshop (4 CEUs)
• 33rd Annual Conference of the Association for
  Women in Psychology (AWP)
• March 13, 2008
• San Diego, CA

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• The Need for Training in IPV

• Over a decade ago, Harway Hansen (1993) and
  Hansen, Harway, Cervantes (1991) showed that
  therapists were not effective in identifying
  intimate partner violence (IPV) issues using a
  clinical case vignette.
• The case vignette was modeled after a real-life
  scenario where the male partner in the couple
  ultimately raped and then killed his female
  partner (see below).
• In their findings, Harway and colleagues found
  that psychologists addressed conflict in the
  vignette only about half of the time, while other
  mental health therapists did so only about 38 of
  the time.
• Overall, 40 of all therapists in their sample
  failed to address conflict at all.
• Lethality was not once addressed by therapists in
  their sample.

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Case Vignette

• Carol and James have been married 10
  years. They have two children Dana, 9, and
  Tracy, 7. James is employed as a foreman in a
  concrete manufacturing plant. Carol is also
  employed. James is upset because on several
  occasions Carol did not return home from work
  until two or three in the morning and did not
  explain her whereabouts to him. He acknowledges
  privately to the therapist that the afternoon
  prior to the session, he had seen her in a bar
  with a man. Carol tells the therapist privately
  that she has made efforts to dissolve the
  marriage and to seek a protection order against
  her husband because he has repeatedly been
  physically violent with her and the kids and on
  the day prior, he grabbed her and threw her on
  the floor in a violent manner and then struck
  her. The family had made plans to go shopping,
  roller skating, and out to dinner after the
  session.
• Initial questions included the following
• What is going on in this family?
• Using the most recent version of the DSM, what
  diagnosis would you make?
• How would you intervene?
• What outcome would you expect from your
  intervention?
• What are the legal/ethical issues raised by this
  case?

4
The Need for Training (cont.)

• Since the studies by Harway and colleagues, IPV
  and domestic violence issues in general have
  become more visible within society as well as the
  mental health professions.
• For instance, child abuse and neglect and elder
  abuse have become important ethical issues,
  especially since the advent of mandatory
  reporting statutes.
• It is expected that, over a decade later, mental
  health service providers would be able to
  identify the issues surrounding IPV in a more
  effective manner.
• Indeed, this is what Raphael, McCloskey,
  Kustron (in press) found recently when they
  replicated Harway and colleagues study.

5
The Need for Training (cont.)

• Even though almost 85 of todays clinicians
  identified the conflict as the main focus of
  treatment, only one identified lethality as a
  possible outcome of the scenario.
• Only about half of todays clinicians suggested
  crisis intervention (including basic safety
  planning) of any sort as the intervention of
  choice.
• Because of this, it is important that clinicians
  become more aware of the issues surrounding IPV
  for all clients.
• Indeed, as will be shown below, clinicians should
  expect and plan to deal with clients that are
  presenting with IPV issues (either from the past,
  or in their lives now).

6
Background

• Prevalence and Severity Gender Asymmetry
• IPV victimization is primarily a genderized
  phenomenon that is, women are
  disproportionately victims of IPV and men are
  disproportionately the perpetrators, resulting in
  gender asymmetry.
• While there have been controversies over IPV
  gender asymmetry in the literature (see Malloy,
  McCloskey, Grigsby, Gardner (2003) for a recent
  review), research overwhelmingly supports the
  notion that women are more negatively impacted
  when it comes to the consequences of IPV.
• Regional surveys
• Washington State 23.6 of women reported
  experiencing IPV compared to 16.4 of men, and
  21.6 of women reported experiencing injury
  during IPV compared to 7.5 of men (Washington
  State Department of Health, 2000).

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Gender Asymmetry (cont.)

• South Carolina 25 of women reported a lifetime
  prevalence of IPV at the hands of a partner
  compared to 13 of men (South Carolina Department
  of Health and Environmental Control, 2000).
• U.S. national surveys
• National Survey of Families and Households
  (NSFH)
• of those injured as a result of IPV, 73 were
  women and 27 were men (Zlotnick, Kohn, Peterson,
  and Pearlstein, 1998).
• National Crime Victimization Survey (NCVS)
• rates of IPV victimization were 7.7 per 1,000 for
  women but only 1.5 per 1,000 for men, and that
  over 50 of female IPV victims were injured as a
  result of IPV (Bureau of Justice Statistics,
  1999 Rennison and Welchans, 2000).
• within this data set the proportion of male
  homicide victims due to IPV dropped significantly
  from 1976 to 1998, while the proportion of female
  homicide victims increased.

8
Gender Asymmetry (cont.)

• National Violence Against Women Survey (NVAWS)
• lifetime prevalence of physical assault and/or
  rape at the hands of an adult intimate was 25
  for women and 7.6 for men men reported
  virtually no sexual violence in this sample.
• 45 of women versus 20 of men reported fear of
  serious injury or death at the hands of an
  intimate partner.
• women sustained injury, required medical
  treatment, were hospitalized, sought mental
  health treatment, lost work time, reported IPV to
  the police, and obtained a protection order at
  greater rates than did men.
• women were 22.5 times more likely to be raped
  than men, 8.2 times more likely to be stalked,
  and 2.9 times more likely to be physically
  assaulted by an intimate partner than men.
• 11 of women co-habiting with women experienced
  IPV compared with 30.4 of women co-habiting with
  men, and 7.6 of men co-habiting with women
  experienced IPV compared with 15 of men
  co-habiting with men -- co-habiting with a male
  increased the risk of IPV for both men and women
  (Tjaden Thoennes, 2000a 2000b).

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Gender in the Therapy RoomClients Are Most
Likely Women and Women Are Most Likely Survivors
of IPV

• Because most recent research suggests that about
  one-quarter of all women in the U.S. have been
  victims of IPV at some time in their lives,
  service providers should not only expect but
  prepare for women presenting with problems
  directly related to IPV.
• This is especially important because women tend
  to access mental health services at greater rates
  than men (Addis Mahalik, 2003 Mahalik, Good,
  Englar-Carlson, 2003 Rhodes, Goering, To, and
  Williams, 2002).
• Possible reasons for this gender discrepancy?
• impact of male gender roles (the strong, stoic,
  silent type) on help-seeking behavior.
• the inhibition of emotional awareness needed to
  identify and own a personal problem (e.g.,
  Moeller-Leimkuehler, 2002).

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Contextualization Psychological Effects of IPV
Victimization

• Walker (1994) and Herman (1992) provided reviews
  of the literature showing that up to 60 of women
  seeking mental health services also had a history
  of physical abuse, although they tended not to be
  diagnosed or treated specifically for IPV.
• Walker (1994) suggests that the historical
  invisibility of victimization within the mental
  health field is because providers simply do not
  ask questions.
• If the context of IPV is absent, the
  psychological sequelae of IPV in women masquerade
  as mental health symptoms which can lead
  providers to misdiagnose.
• Thus, clinicians must put the CONTEXT back into
  IPV by providing a complete and thorough
  assessment.

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Contextual Factors and Possible Mental Health
Sequelae

• Fear
• In couples reporting IPV, women exhibit
  significantly more fear of their partners than
  did males.
• Both men and women report that, overall, men are
  not fearful of their female partners and tend to
  laugh or make fun of womens aggression.
• On the other hand, women report significant
  long-term levels of fear toward their male
  partners (Cantos, Neidig, OLeary, 1994
  Dasgupta, 1999).
• Mental Health Symptoms
• Traumatic brain injury due to repeated physical
  assaults may present as cognitive deficits (e.g.,
  Jackson, Philp, Nuttall, Diller, 2002).
• Elevated scores on standard personality
  assessment tools may be found (e.g., Morrell
  Rubin, 2001).
• The psychological sequelae of IPV in women can
  present as cognitive disturbances, high
  avoidance or depression behaviors, and high
  arousal or anxiety disturbances (Walker, 1994,
  pg. 70).

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Contextual Factors (cont.)

• Bloom Reichert (1999), Herman (1992), and
  Walker (1994) have documented the following
  symptoms that may arise as a result of IPV
  victimization
• cognitive attentional deficits that may bring
  about a dissociative state,
• a chronically pessimistic cognitive style
  sometimes linked to depressive presentations,
• neurological deficits as a result of repeated
  head beatings and head shaking,
• avoidance behaviors including seclusion/isolation,
  denial, minimization, and repression of
  traumatic memories,
• high arousal symptoms including anxiety, phobias,
  sleep disorders and nightmares, sexual
  dysfunctions, panic attacks, nervousness, heart
  palpations, hypervigilance, hypersensitive
  startle responses, and obsessive/compulsive
  behaviors, and
• somatic sequelae from chronic exposure to abuse
  that can result in a breakdown of the
  immunological system, stomach/intestinal disease,
  susceptibility to infection, chronic headaches,
  and other physical diseases.

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Contextual Factors (cont.)

• Common Misdiagnoses
• schizophrenia (particularly paranoia)
• clinical depression
• generalized anxiety disorder
• obsessive/compulsive disorder
• psychosexual disorders
• somatoform disorders
• dependent personality disorder
• borderline personality disorder
• all without regard to the context of abuse
  (Dienemann et al., 2000 Gleason, 1993 Rathus
  and Feindler, 2004 Walker, 1991 1994).
• Obviously, IPV victimization can lead to
  psychological symptoms that may be misdiagnosed
  if the context of victimization is neither
  recognized nor understood.

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Summary of Background Information

• Victims of IPV are overwhelmingly women, and thus
  are likely to suffer from psychological symptoms
  as a result of IPV victimization.
• Women constitute the majority of clients
  presenting for mental health services.
• Thus, chances are QUITE HIGH that victims of IPV
  will be on your caseload.
• There are clear, predictable psychological
  symptoms that result from IPV victimization which
  may be commonly misdiagnosed by a clinician who
  does not understand or assess the context of IPV.
• It is important that mental health clinicians
  understand this shortcoming and educate
  themselves about IPV so that effective
  assessment, diagnosis, and initial
  safety-planning strategies may be used.

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IPV Assessment Overview

• Below is presented a clinical assessment approach
  based on conceptual and theoretical issues that
  heavily emphasize safety, as well as years of
  clinical experience within the field of IPV.
• It should be noted here that this approach is
  designed specifically for use by non-forensic
  practitioners in the regular course of therapy
  and assessment.
• Use in forensic arenas may require a higher level
  of empirical support than currently available
  here.
• This approach would likely be most effective when
  used for all adult clients, not just female
  clients presenting for treatment.
• While it has been shown that women are the most
  common victims of IPV, men can also be victims --
  it is helpful to keep this in mind throughout the

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IPV Assessment Flowchart
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Initial Assessment Screening

• Clients presenting for services should be asked a
  series of basic questions related to IPV issues.
• As part of routine clinical practice, adults
  within couples or families should be separated
  and screened privately for the presence or
  absence of IPV issues.
• It cannot be overstated -- safety is the reason
  for separating adult partners during
  couple/family therapy for IPV assessment
  procedures (Rathus Feindler, 2004).
• For some clients, this may be the first
  disclosure to any official social agent, and can
  represent extreme danger to the victim (Bograd
  Mederos, 1999 Davies, 1994 McCloskey Fraser,
  1997).

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Initial Screening (cont.)

• It is not unusual that disclosure by the victim
  is followed by severe levels of violence from the
  perpetrator.
• This crucial safety issue must be kept in mind by
  the clinician during the initial contact, as well
  as throughout all future contacts with either the
  victim or perpetrator (Bograd Mederos, 1999
  Campbell, 2002 Davies, 1994).
• During the initial contact, if the individual
  adult denies that IPV is present in her/his life,
  stop the initial screening process for that
  session.
• However, since many victims (and especially
  perpetrators) do not initially admit to IPV when
  first asked due to numerous valid reasons such as
  fear, shame, and guilt (Campbell, 2000 2002),
  revisiting the screening process whenever
  appropriate throughout later sessions is very
  helpful.

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Initial Screening (cont.)

• Relationship content brought up by the client
  throughout later sessions presents an ideal
  opportunity for the clinician to once again
  complete an IPV screening.
• Should the client disclose IPV concerns later in
  therapy, the full-scale assessment can be
  completed at that time.
• The IPV screening is a series of questions that
  asks about arguments between partners that have
  occurred in a clients relationship, beginning in
  a general sense and becoming quite specific in
  terms of partner and client behavior.
• These questions can be converted into
  standardized interview questionnaires that the
  clinician follows during session, or can be
  memorized with practice by the clinician to
  eliminate the need for a written format.

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Initial Screening (cont.)

• To save time, some clinicians may be tempted to
  create a client IPV paper-and-pencil screening
  questionnaire to be filled out during standard
  paperwork intake procedures.
• However, it has been shown that clients tend to
  self-disclose painful and sometimes shameful IPV
  material at a greater rate during face-to-face
  interviews than on paper-and-pencil
  questionnaires (Campbell, 2000 Murphy OLeary,
  1993).
• Thus, the recommendation remains that the
  screening be completed interpersonally between
  therapist and client, perhaps supplemented with
  paper-and-pencil questionnaires.
• The IPV screening questions given below assume
  that clients are presently in an intimate
  relationship with an adult partner. If clients
  are not in a current relationship, therapists
  should still complete the screening because past
  victimization can influence current psychological
  symptom presentation and concerns.

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Screening Questions
22
Full-Scale Assessment

• Once the therapist has determined there is indeed
  the presence of IPV in a clients life, a
  full-scale IPV assessment can be completed. This
  assessment consists of three sections
• History taking
• Determination of the primary batterer and victim
• Degree of lethality
• These three areas help the clinician assess the
  frequency, duration, and intensity of IPV as well
  as possible avenues for effective intervention.

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History Taking

• History-Taking questions are further grouped into
  three content areas
• (a) IPV across time in context (including
  injuries)
• (b) Intervention by others (including the
  criminal justice system)
• (c) Co-occurrence of drug-use or other mental
  health issues

24
History Taking IPV Across Time
25
History Taking Intervention by Others
26
History Taking Mental Health/Substance Abuse
Issues
27
Determination of Primary Batterer and Victim

• Determining the primary perpetrator and the
  victim is sometimes very obvious from the results
  of the initial screening as well as the history
  obtained earlier from portions of the full-scale
  assessment.
• However, there may be controversy concerning the
  person responsible for the continuing abuse in
  the relationship, especially with same-sex
  intimate partners, or some opposite-sex partners.
• Sometimes, determining the pattern of control and
  intimidation becomes difficult.
• This section of the full-scale assessment is
  designed to specifically address this issue.

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Primary Batterer/Victim (cont.)

• Even though the victims identity may be obvious
  from earlier clinical data, it is still
  recommended that the following be completed.
• This is so the psychological effects of IPV can
  be more completely described for each client, and
  to aid in diagnosis.
• This section provides
• questions to elicit the way clients attribute
  meaning to the IPV incidents, and
• conceptual factors to help the clinician organize
  each clients viewpoints and IPV attributions so
  that the primary batterer and victim can more
  easily be determined.

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Primary Batterer/Victim (cont.)

• These conceptual factors are primarily the work
  of victim advocates from the Artemis Center for
  Alternatives to Domestic Violence (1992) and
  McCloskey and Fraser (1997) that represents a
  liberal adaptation, integration, and expansion of
  their original presentations.
• These factors are given so that the clinician may
  categorize client responses in a reasonable
  fashion.
• It should be noted that for both primary
  batterers and victims, there are important
  exceptions to the rule for every indicator.
• Thus, therapists may wish to use this information
  in a check-list format so that the preponderance
  of clinical evidence drives their determination.
• For example, if a particular client fits a
  majority of indicators in the victim list, then
  it bolsters clinician confidence that the client
  indeed is the primary victim in the relationship.

30
Meaning-Making and Victim/Perpetrator
Determination (adapted from Artemis Center for
Alternatives to Domestic Violence, 1992 and
McCloskey and Fraser, 1997)
31
Primary Victim
32
Primary Victim (cont.)
33
Primary Victim (cont.)
34
Primary Batterer
35
Primary Batterer (cont.)
36
Primary Batterer (cont.)
37
Lethality Assessment

• For safety reasons, the lethality assessment must
  be completed in every reported instance of IPV,
  and should be updated throughout the course of
  treatment (i.e., when new information comes to
  light due to periodic therapist inquiry and/or
  spontaneous client self-disclosure).
• Lethality is grouped into six content areas
• (a) severity of violence
• (b) obsessive/stalking behaviors
• (c) psychological risk factors
• (d) other criminal behaviors
• (e) failure of past interventions
• (f) other

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Lethality Assessment (cont.)

• A predominance of risk factors should help the
  therapist determine the severity of the situation
  and the urgency with which she or he must act.
• This lethality assessment is liberally adapted
  from victim advocacy work (Artemis Center for
  Alternatives to Domestic Violence, 1992), results
  of community collaboration within the state of
  Ohio (Montgomery County Criminal Justice Council,
  1996), and empirical research in the field (e.g.,
  Campbell, 2002).
• Besides the standard homicidal/suicidal risk
  assessment items such as intent, plan, time,
  place, and means (Bennett, 2003 Sanchez, 2001
  Shneidman, 2001), there are other lethality red
  flags unique to IPV.

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RED FLAGS

• The following batterer behaviors and beliefs
  should alert the clinician to the presence of
  extreme risk of lethal violence in order of
  importance (Campbell, 2002 Kropp Hart, 1997
  McFarlane, Campbell, Watson, 2002)
• batterer perception that relationship is
  threatened and/or ending (infidelity, separation,
  divorce, etc.)
• past/present threats by batterer to kill self or
  partner (including statements such as I cant
  live without you and If I cant have you, no
  one will)
• batterer unemployment (suggests that batterer has
  nothing to lose)
• past/present batterer violence, including
  attempted strangulation of victim
• batterer stalking and monitoring behavior
• batterer drug/alcohol use

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IMPORTANT!

• The presence of even one of these factors
  (especially separation or divorce) is a sign that
  the clinician needs to be highly wary of future
  lethal violence and provide safety plans to both
  the batterer and victim accordingly.
• The presence of all six of the above factors
  should alert the clinician that outside help for
  the batterer is warranted (hospitalization,
  contacting the police, etc).

41
Lethality Assessment Items
42
Lethality Assessment Items (cont.)
43
Therapist Knowledge of Barriers in the Environment

• Therapists should also know about the resources
  available in the community and firmly imbed
  client experiences within the surrounding
  environment (Davies, 1997 Dutton, 1992 Grigsby
  Hartman, 1997 McCloskey Fraser, 1997).
• First, therapists should educate themselves about
  the local criminal justice system response to
  IPV, most notably regulations and assumptions of
  county and state laws that impact their
  communities.
• Due to reasons of safety, therapists should be
  able to understand their crisis intervention
  options in the face of high risk (e.g., criteria
  for hospitalization of the batterer versus police
  intervention), and convey accurate information
  concerning legal options to victims.
• At the very least, therapists should have
  referral information on hand that direct clients
  to the appropriate resources (IPV court
  advocates, etc.).

44
Knowledge of Barriers

• Second, therapists should be cognizant of the
  effects that cultural and gender-based societal
  expectations can have on clients and how these
  expectations may present barriers to effective
  intervention.
• For example, negative interactions with
  socially-sanctioned officials in the past by
  members of minority populations may create
  barriers to accessing community services that
  could help reduce lethality.
• Third, therapists should examine their own
  psychological conceptualizations in order to
  recognize and honor not only the dangerousness
  inherent in IPV cases, but also the extreme
  impact that IPV can have on victims and children.
  
• This issue brings a therapist squarely into the
  reinterpretation of standard assessment
  techniques within an IPV context.
• In other words, clinicians must be able to embed
  and integrate standard psychological assessment
  and intervention strategies within the issues
  shown below.

45
Barriers in the Environment (adapted from
Grigsby and Hartman, 1997)
46
Barriers in the Environment (cont.)
47
Barriers in the Environment (cont.)
48
Barriers in the Environment (cont.)
49
Initial Safety Planning

• Once the IPV screening and full-scale assessment
  is completed, you will then have a good idea of
  the level of lethality inherent in the situation.
  
• Hopefully, you will also have embedded specific
  client information within the possible barriers
  to safety within the environment.
• For example, in the clinical vignette used by
  Harway and colleagues (Hansen, Harway,
  Cervantes, 1991 Harway Hansen, 1993) mentioned
  earlier concerning the male intimate partner who
  raped and then killed his female partner shortly
  after their family visit to a therapist, the
  partners would have been separated and the IPV
  screening would have commenced.
• You would then complete the full-scale assessment
  procedures with each partner, ending with a
  determination of the primary victim/batterer and
  completion of the lethality assessment.

50
Safety Planning (cont.)

• Once barriers to safety were identified for both
  the victim and perpetrator, safety planning could
  then be tailored to the unique characteristics of
  both the clients and the situation.
• There are two major issues that we should also
  consider for safety reasons
• First, we must have a profound understanding of
  the barriers in the environment that support
  on-going violence. If these barriers are not
  understood, safety planning may well be
  ineffective or put clients at greater risk.
• Second, it cannot be overstated that even when a
  safety plan is in place, there is no guarantee
  the victim will be safe.

51
Safety Planning (cont.)

• Furthermore, we may be drawn to first intervene
  with the victim of IPV since this individual
  usually is the most motivated for change
  (McCloskey Fraser, 1997), and may be the only
  presenting party in the therapy room.
• We should always intervene with the primary
  batterer when possible (such as in couples or
  family therapy), build compliance as much as
  possible, and be willing to bring in outside
  authorities if lethality is high (similar to
  managing homicidality/suicidality in other
  clinical situations Bennett, 2003 McFarlane,
  Campbell, Watson, 2002 Sanchez, 2001
  Shneidman, 2001).
• The engagement of resources by the therapist
  outside the therapy room (hospitalization,
  contacting the police, involving other adult
  family members, etc.) will be a judgment call
  based on the level of lethality.
• As discussed above, presence of the most lethal,
  high-risk factors may tell the clinician that
  outside authorities should be contacted in order
  to keep all parties safe.

52
Safety Planning (cont.)

• If the victim is the only individual presenting
  for services, safety plans can still be devised.
  By discussing with victims the safety plan shown
  below, we underscore the level of danger the
  batterer represents and sending the message that
  the therapist takes this risk very seriously.
• It is possible that we could copy this safety
  plan as a handout and give to victims after
  explanation in session has occurred and any
  possible barriers to implementing the plan are
  explored.
• However, the victim is usually not the family
  member who is in most danger of using lethal
  violence, although it is possible victims may use
  violence as a self-defense measure (Malloy et
  al., 2003).
• While an in-depth discussion of long-term
  intervention strategies is outside the scope of
  this presentation, the reader is referred to
  Campbell (2002), McCloskey and Fraser (1997), and
  Walker (1994) for further discussions of IPV
  safety planning, initial treatment plans, and
  long-term interventions, respectively.

53
Safety Planning With Clients Who Are IPV Victims
54
Safety Planning With Clients Who Are IPV Victims
(cont.)
55
SUMMARY

• Concrete intervention strategies were presented,
  beginning with initial screening procedures and
  ending with in-depth assessment approaches.
• The recommended assessment began with very
  specific, direct questions concerning IPV as part
  of screening and history taking which included
  examination of specific violent behaviors, the
  occurrence of IPV across time, intervention by
  others, and the co-morbid presence of substance
  abuse or other mental health issues.
• The assessment then moved to questions assessing
  the meaning that clients attribute to IPV as well
  as the effects of IPV, followed by a conceptual
  model with which the therapist can organize all
  the preceding information in order to determine
  the primary victim and batterer in the IPV
  situation.

56
Summary (cont.)

• Finally, all the information gleaned from the
  above was integrated into a lethality assessment
  as an aid for determining the seriousness of the
  violence and the urgency with which the therapist
  should intervene, all within the context of
  possible barriers to safety found in the
  environment.
• The assessment moved from the concrete to the
  abstract. Thus, this approach was designed
  specifically to incorporate both clinical data
  collection and conceptualization.
• It is hoped that this approach will help us all
  become more mindful of the ubiquitous presence of
  IPV in clients lives. It is also hoped that the
  presentation of concrete strategies for assessing
  dangerousness will increase the chances that
  therapists will assist clients in remaining safe
• WRAP-UP
• Questions? Answers?
• Comments?
• Suggestions for Improvement?