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Intimate Partner Violence in a Cultural Context: Implications for Mental Health Research and Treatme

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Title: Intimate Partner Violence in a Cultural Context: Implications for Mental Health Research and Treatme


1
Intimate Partner Violence in a Cultural Context
Implications for Mental Health Research and
Treatment
  • Findings of the
  • Trauma Recovery Project at the
  • Guadalupe Valley Family Violence Shelter
  • Speaker Jennifer Hill, LMSW
  • Trauma Recovery Project Director

2
Introduction Agency Community Context
  • GVFVS, housed in Seguin, TX, has been serving
    victims of domestic violence and sexual assault
    in Guadalupe, Gonzales, Karnes, and Wilson since
    1983.
  • Largely rural areas with isolated communities,
    most of which have few social services available
    to the working poor and indigent who make up
    large segments the population. The county
    population breakdowns according to the U.S.
    Census (2000) are as follows Guadalupe
    (population 89,000), Karnes (pop. 15,446),
    Gonzales (pop. 18,628), and Wilson Counties (pop.
    32,408). The agency serves 3,339 square miles.
  • Mission is to provide shelter, safety, and
    supporting services to victims of domestic
    violence and sexual assault and to assist
    victims in becoming self-sufficient through
    education, counseling, and legal advocacy.
  • Since 2002, executive staff has noticed an
    increase in survivors presenting with mental
    health symptoms and barriers to treatment in the
    rural areas covered by the shelter.
  • Determination made that the short-term crisis
    counseling offered by a part-time counselor was
    inadequate to meet the mental health needs of
    clients in this setting.
  • Sought and obtained funding from the Hogg
    Foundation for Mental Health for two years for a
    model of integrated trauma treatment which
    greatly expanded the services available to
    clients at GVFVS.
  • Trauma theory provides an interdisciplinary model
    which blends the systemically separate issues of
    domestic abuse, mental health, and substance
    abuse.
  • Challenged ourselves to become trauma-informed,
    that is, to gain understanding of abuse and its
    effects in the lives of service consumers, as
    well as to design a system of service delivery
    that accommodates the vulnerabilities of trauma
    survivors (Harris Fallot, 2001).
  • Service relationship is based on collaboration
    and cooperation rather than strict hierarchy
    (Freeman, 2001).
  • Trauma recovery is a vital part of supporting and
    empowering clients to live free from abuse and
    its effects.

3
Research Basis for Program Design
  • An extensive literature review documents the
    prevalence of PTSD, depression, and substance
    abuse among shelter populations and is available
    by request.
  • Three studies have been selected as examples
    regarding the cooccurrence of PTSD, Depression,
    and domestic violence
  • Astin, Lawrence, and Foy (1993) performed a study
    in which 53 American domestic violence agency
    clients were given standardized self-report
    measures to assess the prevalence of PTSD and the
    impact of abuse severity on PTSD. Two separate
    scales measured PTSD rates among this population
    at 55 and similarly at 58, and PTSD was
    positively correlated to severity and recency of
    abuse (Astin, et al., 1993).
  • Torres and Han (2000) conducted a study in which
    a sample of 62 White and 62 Hispanic abused
    women, a convenience sample obtained from
    domestic violence agencies and courthouses, was
    given the Conflicts Tactics Scale, the Structured
    Clinical Interviews PTSD scale, and the Beck
    Depression Inventory. This study, unusual in its
    inclusion of ethnic considerations, found that
    rates of PTSD in White women were 71.4, and of
    Hispanic women were 39.5 (55.5 overall).
    Depression scores fell more closely together,
    with 77.4 of Whites and 67.2 of Hispanics
    testing positively (72.4 overall).
    Interestingly, abuse exposure and severity of
    psychological distress were not consistently
    related, although physical abuse was
    significantly correlated with depression for the
    whole sample, and forced sex was associated with
    PTSD for the Hispanic group and the full sample.
  • Thompson, Kaslow, and Kingree (2002) attempted to
    identify risk factors for suicide among 200
    African American abused women (100 had attempted
    suicide 100 had not). The women were recruited
    from a hospital emergency clinic and a community
    clinic, and the investigators screened for
    domestic violence histories. The results showed
    that those who attempted suicide were
    significantly more likely to report high levels
    of depression and other issues (eg., drug abuse
    and childhood abuse). Women with 2, 3, or 4-5
    risk factors were 10, 25, and 107 times more
    likely to attempt suicide than women with no risk
    factors (Thompson et al., 2002).

4
Research on DV/Substance Abuse
  • Although less frequent in the literature than
    studies on Depression and PTSD, several studies
    on substance abuse and domestic violence show
    connections between the two.
  • The domestic violence advocacy literature does
    discuss alcohol and other drug (AOD) abuse as
    forms of self-medicating the effects of abuse
    (Dutton, 1992 Walker, 1994 Wilson, 1997). This
    hypothesis has not been empirically tested in the
    literature, though it is suggestive.
  • One study asserts that battered women are
    disproportionately represented among substance
    abuse treatment populations (Zubretsky, 2001).
  • Another study examines the relationship between
    substance abuse and partner abuse among women
    mandated to substance abuse treatment (n1,025)
    in Portland, Oregon and New York, New York
    (Wilson-Cohn, et al., 2002). The percentages of
    women who were physically or psychologically
    abused were above 65 in both cities.

5
Trauma Recovery Project Design
  • Research self-report assessments, pretest and
    posttest (over 3 months or less), measuring
    exposure to violence, depressive symptoms, PTSD
    symptoms, and substance dependence.
  • Direct Services increased services to address
    the needs of a growing number of nonresident
    clients, diversification of group and individual
    services to include trauma recovery,
    psychoeducation, cognitive behavioral
    interventions (including cognitive
    restructuring), and interpersonal psychotherapy
  • Outreach counseling services offered weekly at
    satellite locations in Gonzales, Karnes City,
    Floresville. Community education presentations
    provided to local MHMRs, CPS, schools, churches,
    hospitals, law enforcement, statewide advocacy
    groups, etc.

6
Hypothesis, Research Questions, Goals of the
Project
  • Hypotheses
  • Individuals entering a shelter for victims of
    domestic violence will present with clinically
    significant mental health symptoms.
  • Treatment of individuals seeking shelter from
    domestic violence decreases their mental health
    symptoms.
  • Research Questions
  • What are the frequency, severity, and types of
    mental health problems (defined as symptoms of
    posttraumatic stress disorder, depression, and
    substance abuse)?
  • What is the effect of individual and group
    counseling interventions on the mental health
    problems experienced by individuals receiving
    services from a shelter for victims of domestic
    violence?
  • Goals
  • To gain a better understanding of the frequency,
    severity and types of mental health problems
    experienced by a sample of domestic violence
    shelter service recipients.
  • To determine the effectiveness of individual and
    group counseling interventions on the mental
    health symptoms of individuals receiving services
    from a shelter for victims of domestic violence.

7
DefinitionsIntimate Partner Violence
  • Physical, sexual, and/or emotional abuse
    perpetrated by one intimate partner against
    another, usually in systematic attempts at
    gaining power and control over the victim.
    Occurs in all racial/ethnic, class, sexual
    orientation, disability, and age groups.
  • Physical intentional use of physical force to
    cause harm -- slapping, kicking, hitting, biting,
    use of a weapon, scratching, pushing, throwing,
    grabbing, choking, shaking, burning.
  • Sexual use of physical force or threat or
    coercion to compel sexual compliance against the
    victims will, or attempted or completed sex act
    involving a person who is unable to consent,
    whether due to age, disability, illness,
    influence of substances, or due to intimidation
    or pressure.
  • Emotional Verbal abuse, put-downs, shaming,
    blaming the victim for the abuse, accusations,
    interrogation, threats of violence, coercion
    (humiliation, controlling what the victim can and
    cannot do, isolating the victim, controlling
    access to basic resources, etc).

8
DefinitionsPosttraumatic Stress Disorder (1)
  • DSM-IV DSM-IV TR
  • Person has experienced a traumatic event in which
    both of the following were present
  • The person experienced, witnessed, or was
    confronted with an event or events that involved
    actual or threatened death or serious injury, or
    a threat to the physical integrity of self or
    others
  • The persons response involved intense fear,
    helplessness, or horror.
  • The traumatic event is persistently reexperienced
    in one or more of the following ways
  • Recurrent and intrusive distressing recollections
    of the event, including images, thoughts, or
    perceptions.
  • Recurrent distressing dreams of the event
  • Acting or feeling as if the traumatic event were
    recurring (reliving, flashbacks)
  • Intense psychological distress at exposure to
    internal or external cues that symbolize or
    resemble an aspect of the traumatic event
  • Physiological reactivity on exposure to cues

9
DefinitionsPosttraumatic Stress Disorder (2)
  • Persistent avoidance of stimuli associated with
    the trauma and numbing of general responsiveness
    (not present before the trauma), as indicated by
    three (or more) of the following
  • Efforts to avoid thoughts, feelings, or
    conversations associated with the trauma
  • Efforts to avoid activities, places, or people
    that arouse recollections of the trauma
  • Inability to recall an important aspect of the
    trauma
  • Markedly diminished interest or participation in
    significant activities
  • Feelings of detachment or estrangement from
    others
  • Restricted range of affect
  • Sense of a foreshortened future
  • Persistent symptoms of increased arousal, as
    indicated by two or more of the following
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
  • Duration of disturbance more than one month
  • Clinically significant distress or impairment in
    social, occupational, or other areas of
    functioning.
  • Acute less than 3 months chronic if 3 months
    or more with delayed onset if 6 months or more
    after stressor

10
DefinitionsPosttraumatic Stress Disorder (3)
  • Associated features guilt phobic avoidance of
    situations or activities resembling or
    symbolizing the trauma, which may interfere with
    interpersonal relationships or activities
    impaired affect modulation self-destructive and
    impulsive behavior dissociative symptoms
    somatic complaints feelings of ineffectiveness,
    shame, despair or hopelessness feeling
    permanently damaged loss of previously sustained
    beliefs hostility social withdrawal feeling
    constantly threatened impaired relationships
    with others change in personality.
  • Increased risk of anxiety disorders, major
    depressive disorder, substance related disorder
  • Disorders of Extreme Stress Not Otherwise
    Specified Complex PTSD

11
Significance of PTSD as a Diagnosis
  • The development of PTSD as a diagnosis has
    created an organized framework for understanding
    how peoples biology, conceptions of the world,
    and personalities are intextricably intertwined
    and shaped by experienceThe introduction of the
    PTSD diagnosis has opened a door to scientific
    investigation of the nature of human suffering.
  • B. van der Kolk A. McFarlane, 1996
  • Experience is culturally mediated.
  • Gaps exist in applying trauma theory to diverse
    cultures in the literature.

12
DefinitionsMajor Depressive Episode (1)
  • At least five or more of the following symptoms
    present during 2-week period and represent a
    change from previous functioning at least one
    of the symptoms is either depressed mood or loss
    of interest or pleasure
  • Depressed mood most of the day, nearly every day,
    as indicated by either subjective report or
    observation
  • Diminished interest or pleasure in all or almost
    all activities most of the day every day
  • Significant weight loss when not dieting or
    weight gain (change of more than 5 of body
    weight) or decrease or increase in appetite
    nearly every day
  • Insomnia or hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every
    day
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or
    inappropriate guilt nearly every day
  • Diminished ability to think or concentrate, or
    indecisiveness, nearly every day
  • Recurrent thoughts of death, suicidal ideation
    without a plan, or suicide attempt or plan for
    committing suicide

13
DefinitionsMajor Depressive Episode (2)
  • Symptoms cause clinically significant distress or
    impairment in social, occupational, or other
    important areas of functioning
  • Not due to substance or general medical condition
  • Not better accounted for by Bereavement

14
DefinitionsMajor Depressive Disorder(3)
  • Single episode presence of a single Major
    Depressive Episode
  • Not better accounted for by Schizophrenia,
    Schizophreniform, Delusional, or Psychotic
    Disorder NOS.
  • No manic or hypomanic.
  • Recurrent two or more MDEs

15
DefinitionsSubstance Use Disorders
  • Dependence
  • Maladaptive pattern of substance use, leading to
    clinically significant impairment or distress, as
    manifested by 3 or more occurring in a 12-month
    period
  • Tolerance (either need for increased amounts to
    achieve intoxication or markedly diminished
    effect with continued use of same amount of
    substance)
  • Withdrawal (either characteristic withdrawal
    syndrome for the substance or the same substance
    is taken to relieve or avoid withdrawal symptoms)
  • Often taken in larger amounts or over a longer
    period than was intended
  • Persistent desire or unsuccessful efforts to cut
    down or control use
  • Great deal of time spent in activities necessary
    to obtain the substance, use the substance, or
    recover from its effects
  • Important social, occupational, or recreational
    activities are given up or reduced because of use
  • Continued use despite knowledge of having a
    persistent or recurrent physical or psychological
    problem that is likely to have been caused or
    exacerbated by the substance
  • Abuse
  • Maladaptive pattern of substance use leading to
    clinically significant impairment or distressed
    as manifested by one or more of the following
    occurring within a 12-month period
  • Recurrent substance use resulting in a failure to
    fulfill major role obligations at work, school,
    or home
  • Recurrent substance use in situations in which it
    is physically hazardous
  • Recurrent substance related legal problems
  • Continued substance use despite having persistent
    or recurrent social or interpersonal problems
    caused by or exacerbated by effects of the
    substance
  • Have never met criteria for dependence.

16
Research Results Strengths Limitations
  • Strengths longitudinal, obtains information
    about a challenging population (known for being
    difficult to retain in logitudinal studies, L.
    McCloskey, et al., 2006), positive results for
    treatment methods, hypotheses confirmed,
    replicates literature on co-occurring domestic
    violence, sexual assault and mental health
    issues, implications for cultural competence,
    correlations between violence exposure and
    self-reports of distress, improvements of symptom
    reports on all measures.
  • Limitations convenience sample (results are not
    generalizable, except perhaps in a limited way to
    other victim populations), currently
    transitioning to use of Spanish translated
    assessments, self-report (may be subject to
    inaccuracies), only two racial/ethnic groups
    (Hispanic and non-Hispanic white) have adequate
    numbers for comparison.

17
Characteristics of the Sample
  • Convenience sample of 92 adult victims of family
    violence and sexual assault, both primary (91.3)
    and secondary (8.7, defined as first degree
    family member of a victim).
  • 98.9 female.
  • Racial/ethnic makeup 1.1 Asian, 6.5 African
    American, 54 (non-Hispanic) Caucasian, 2
    Caucasian and Native American, 33 Hispanic, 2
    Hispanic and Asian, 1 Native American.
  • Closely resembles U.S. Census 2000 for the area
    1 Asian, 5.4 African American, 33.2 Hispanic,
    58.8 non-Hispanic White, .7 Native American,
    and 1.1 reporting 2 or more races/ethnicities.
  • Residential status 55.4 Nonresident, 38
    Resident, 6.5 Both Residents and Nonresidents
    during study duration.
  • Geography 54.3 Rural, 4.3 Urban, 41.3
    Underserved Urban (underserved status based on
    mental health worker shortage areas HRSA,
    2005). Guadalupe County residents 45, Gonzales
    15.2, Karnes 5.4, Wilson 9, and other 25.4.
    Since the start of the project in 7/05,
    participation from the 3 rural counties rose
    dramatically from approximately 5 to 30.
  • Income Mean pre-services income of 20,000 and
    a mean post-services of 10,000, and so
    experienced approximately 10,000 in average
    income reduction due to changes in family
    structure, that is, the reduction of the family
    size by one person, usually the domestic partner
    of the victim.
  • Ages ranged from 18-69, with a mean of 36, a
    median of 34, and a mode of 24.
  • Children mean 2.

18
Primary/Secondary Victims
19
Race/Ethnicity of Research Participants
20
Census Race/Ethnicity for Guadalupe County
21
Diversity of population offered treatment
22
Residential Status of Research Participants
23
Location of Research Participants
24
Mental Health/Substance Abuse History
  • 62 present with a prior mental health diagnosis
    by an MD or other practitioner (usually PCP), 38
    no prior diagnosis.
  • Most common diagnosis was Major Depressive
    Disorder (43.6), with Bipolar I as the second
    most common (6.6), and a form of anxiety (5) as
    the third most common prior diagnosis. Only
    13.1 were diagnosed with PTSD, all of which were
    comorbid with MDD or Bipolar I.
  • 93.5 reported anxiety and distress over the two
    weeks prior to the intake.
  • 60.9 reported previous mental health treatment,
    and 55.4 reported having been prescribed
    psychoactive medications in the past.
  • 18.5 of participants reported needing help for
    alcohol or drug abuse, 23.9 stated they saw a
    connection between domestic violence and their
    own substance use. Denial and underreporting are
    thought to influence substance abuse statistics.
  • 97 stated they perceived that abuse had a
    negative impact on their mental health.

25
Prior Mental Health Diagnosis
26
Prior DiagnosesNote Categories Overlap
27
Distress During the Past 2 Weeks
28
Has your experience with domestic violence caused
negative effects on your thoughts and feelings?
29
Exposure to Interpersonal Violence in the Past
Year
  • Conflicts Tactics Scale-2 (CTS2), a 78-item
    self-report scale with 10 subscales Subject
    Negotiation, Subject Psychological Aggression,
    Subject Physical Assault, Subject Sexual
    Coercion, Injury by Subject, Partner Negotiation,
    Partner Psychological Aggression, Partner
    Physical Assault, Partner Sexual Coercion, and
    Injury by Partner. Respondents are asked to
    identify the frequency of a list of behaviors
    performed by themselves and their partners in
    relationships over the past year (1once,
    2twice, 33-5 times, 46-10 times, 511-20
    times, 6more than 20 times, 7not in the past
    year but it did happen before, and 0never). The
    scoring consists of adding the midpoints of the
    response categories chosen by the participant.
    The CTS has been widely used with domestic
    violence populations (Straus et al., 1996), and
    it has strong evidence of validity and
    reliability (Straus, 1990a). The revised version
    has augmented scales, new scales, improved items,
    and improved operationalization of minor and
    severe levels of abuse (Straus et al., 1996).
  • As expected, subjects scored high in Negotiation
    (105.7), or use of healthy communication
    strategies, given an appropriate context, while
    the partners scored comparitively low in
    Negotiation (29). Subjects had low scores in the
    other categories 37 in Psychological
    Aggression, 6.75 for Physical Assault, .82 for
    Sexual Coercion, and .32 for Injury by Subject.
    By contrast, subjects rated their partners at
    108.4 for Psychological Aggression, 72.14 for
    Physical Assault, 35.02 for Sexual Coercion, and
    21.21 for Injury by Partner.
  • Most frequently reported abuse was Psychological,
    followed by Physical Aggression. When viewed as
    approximations of the number of incidents in the
    past year, these numbers show frequent, repeated
    exposures to trauma for a majority of
    participants. Notably, the CTS-2 does not
    adequately measure the severity of some incidents
    encountered in the study one severe incident
    resulted in a fatality and another resulted in a
    near-fatality. The CTS-2 does not distinguish
    between self-defending violence vs. initiating
    violence.

30
CTS-2 Overall Results
31
Beck Depression Inventory 2
  • Adults were administered the Beck Depression
    Inventory II (Beck et al., 1996), a 21-item
    self-report inventory that is widely used in
    various populations. Each item corresponds to a
    symptom of depression with a severity of 0-4
    (with 4 being most severe). The scores are added
    and compared to a guideline (0-13, minimal
    14-19, mild 20-28, moderate 29-63, severe).
    The BDI2 has been reported by several studies to
    have high reliability, regardless of clinical
    population. The BDI2 has been modernized and
    revised to accord with the DSM-IV in diagnosing
    depressive disorders.
  • Mean score pretest was 31.3, or on the lower end
    of the Severe category and posttest was 17,
    mild.
  • Replicates some previous findings, which show
    rates of depression among shelter populations
    ranging as high as 72 (C. Warshaw H. Barnes,
    2003).

32
Beck Depression Inventory II Results by Category
33
Impact of Events Scale-Revised
  • To measure response to trauma, all participants
    complete the Impact of Events Scale-Revised
    (Weiss Marmar, 1997, based on Horowitz et al.,
    1979), a 22-item self-report scale in simple
    language measuring the intrusive, hyperarousal,
    and avoidant responses to traumatic life events.
    Respondents are asked to rate each item in the
    IES-R on a scale of 0 (not at all), 1 (a little
    bit), 2 (moderately), 3 (quite a bit), and 4
    (extremely), according to the past 7 days.
    Scoring involves adding the mean score for each
    subscale. Internal consistency of the 3
    subscales was found to be very high, and the 3
    subscales are reported to have good criterion
    validity (Weiss Marmar, 1997). The Revised
    version of the scale includes the hyperarousal
    subscale, which aligns it more closely with the
    DSM-IV diagnosis of Post Traumatic Stress
    Disorder (PTSD).
  • Mean at pretest was 54.8, and at posttest was
    38.2.
  • Replicates some previous findings, which show
    rates of PTSD ranging up to 88 in shelter
    populations (C. Warshaw H. Barnes, 2003).

34
Impact of Events Scale-R Scores Pretest and
Posttest
35
IESR Results Subscales
36
About the SASSI-III
  • The SASSI-3 is a self-report inventory consisting
    of 2 sides, one with 67 true/false questions,
    some of which appear not to be related to
    substance abuse, and another face valid side,
    with 26 questions that obviously relate to
    substance misuse. The time frame may be chosen
    by those administering the inventory for GVFVS
    purposes, the past 6 months will suffice. A
    transparent scoring key is used for scoring. It
    is reported to have an empirically tested
    accuracy of 94 in identifying subjects with a
    high probability of having a substance abuse
    disorder (Miller et al., 1997).
  • Denial and underreporting are thought to
    influence the substance abuse numbers. The
    Alcohol dependency rate of 3 is half of the
    lifetime prevalence for females at 6 (National
    Comorbidity Study). The Other Drug dependency
    rate of 12 is 4 times higher than the lifetime
    prevalence for females at 3.5 (C. Jordan, et
    al., 2004).

37
Face Valid Alcohol (FVA) Face Valid Other Drug
(FVOD) Results
38
CTS by Race/ethnicity
  • The Hispanic group (n30) showed higher rates of
    exposure to Psychological Aggression and Physical
    Assault (112, 80) than the Caucasian group (n50
    102, 62), but similar levels of exposure to
    Sexual Coercion (both scores were 36) and
    slightly less exposure to Injury than the
    Caucasian group (18 vs. 21). Preliminarily, the
    African American group (n6) scored their
    partners highest on Psychological Aggression
    (138). Exposure to Physical Assault reports were
    roughly the same for African American
    participants and Hispanic ones (80), but greater
    than Caucasian scores (62). African Americans
    reported less Sexual Coercion than either
    Caucasian or Hispanic participants (22), and
    African American reports of injuries was the
    highest of the three (26).
  • For the following groups, not enough data sets
    were collected to generalize Asian (n1),
    Caucasian and Native American (n2), Hispanic and
    Asian (n2), and Native American (n1).
  • For the African American group, (n6), patterns
    from the research are included as preliminary
    numbers only pending collection of more data
    sets. This group reported the highest levels
    Psychological Aggression (138), the same levels
    of Physical Assault as the Hispanic group (80),
    lower Sexual Coercion than either Hispanic or
    Caucasian groups (22), and the highest rates of
    Injury by Partner of the three (26)
  • As more data sets are collected, the two larger
    groups appear to move more closely together on
    measures of exposure to abuse (that is, report
    similar levels of violence).

39
Exposure to Violence by Race/Ethnicity
40
Comparison of African American, Hispanic, and
Non-Hispanic Caucasian Group Scores
  • For the Hispanic group, the pretest mean score
    was 33.7 for the BDI-II and 56.8 for the IESR,
    slightly higher scores than the Caucasian group.
    The African American group scored 27 and 47.
  • For the Caucasian group, the pretest mean score
    was 30.7 for the BDI-II and 54.0 for the IESR.
  • The Hispanic group scored higher than the
    Caucasian group on rates of alcohol abuse (2.86
    vs. 1.36), and the Hispanic group scored slightly
    lower than the Caucasian group on other drug
    abuse (3.0 vs. 3.34). No substance abuse was
    reported on the African American group.
  • At posttest, the Hispanic group (n22) scored
    very close to the Caucasian group (n34) on the
    BDI-II (mean for the Hispanic group 16 and mean
    for the Caucasian group 17), and scored lower
    than the Caucasian group on the IESR (mean for
    the Hispanic group 33 and mean for the Caucasian
    group 41). Posttest scores for the African
    American group were 8.5 and 34.
  • At posttest, the Hispanic group showed slightly
    lower rates of alcohol and substance abuse than
    the Caucasian group (.2 vs. .3, and 0 vs. 1).
  • This suggests that at this time, the Hispanic
    group shows higher rates of exposure to violence
    to Psychological Aggression and Physical Assault,
    higher rates of initial distress, and a similar
    response to treatment to that of the Caucasian
    group. The African American group scored lower
    on reports of initial distress and show a similar
    response to treatment.
  • As more data sets are collected, the scores for
    the two larger groups appear to move closer
    together. It is also interesting to note that
    the completion rates for the Hispanic group are
    higher than the Caucasian group (64 vs. 53).
    African American rates are 50.
  • The overall completion rate for this study is
    70. J. Miranda, et al., (2003), reported a
    similar completion rate (71), and suggest that
    treatment engagement for minority members with
    depression can be enhanced by intensive outreach.
    Please note that intensive outreach is not as
    feasible in a domestic violence setting due to
    safety reasons and agency policy limiting
    clinician-initiated contact.

41
BDI by Race/Ethnicity
42
IES by Race/Ethnicity
43
FVA, FVOD by Race/Ethnicity
44
Other points of comparison by race/ethnicity
  • Hispanic (63) and African American (83)
    participants are more likely to reside in an
    underserved urban location (in this case, small
    towns) whereas, Caucasians are more likely to
    live in a rural area (72).
  • This may result from how the population is
    distributed or it may be a function of factors
    influencing help-seeking behaviors on the part of
    members of different racial/ethnic groups.
  • Sixty-eight percent of Caucasian participants are
    likely to have a prior mental health diagnosis
    whereas, 56 of Hispanics and 33.3 of African
    Americans are likely to have a prior mental
    health diagnosis.
  • Fifty percent of African Americans in this sample
    reported prior mental health treatment at intake,
    whereas 68 of Caucasians and 50 of Hispanics
    reported prior mental health treatment. These
    numbers appear to reflect disparities in mental
    health care for minorities in this area.
  • African Americans lose an average of 5,000 in
    annual income on separation, Caucasians lose
    11,600 and Hispanics lose 7000. This may
    reflect differing levels of engagement in paid
    employment for members of the different groups.

45
BDI IES Primary Secondary
46
Measures of Central Tendency by Primary/secondary
Victims
  • Despite great differences in levels of exposure
    to violence, primary and secondary (direct and
    indirect) victims of trauma scored similarly on
    the mental health measures.
  • The means for the primary (n84) and secondary
    victims (n8) on the BDI-II were 31 and 32,
    respectively, and the means of the initial IESR
    scores were very close (55 for the primary
    victims and 56 for the secondary victims). This
    suggests that primary and secondary victims of
    trauma report similarly high levels of distress
    at intake, despite large differences in frequency
    and severity of exposure to trauma.
  • On followup, the two groups were close, with
    primary (n55) and secondary (n7) victims both
    scoring 17 on the BDI-II and both scoring 38
    (mean) on the IESR. This suggests that primary
    and secondary victims are receiving similar
    benefits from treatment.
  • It should be noted that more data sets were
    collected on primary victims than secondary
    victims.
  • Primary victims scored higher than secondary ones
    on both measures of alcohol and substance abuse
    (primary 1.9 and secondary .5 primary 3.2 and
    secondary 2.5), and response to treatment was
    closely similar (less than 1 on all).
  • Both primary and secondary victims were more
    likely to be from a rural area primary victims
    were more likely to have sought and received
    previous mental health treatment.

47
Measures of Central Tendency by Residential Status
  • The resident category (n35) showed the highest
    level of exposure to Psychological Abuse, and the
    combined category of resident and nonresident
    showed the highest levels of Physical Aggression,
    Sexual Coercion, and Injury by partner.
  • The combined resident and nonresident category
    showed the highest levels of distress at intake
    on both the IESR and BDI-II (mean of 59.3 and
    33.5, respectively), as well as the highest
    levels of exposure to trauma.
  • As more data sets have accumulated, the levels of
    distress at pretest shown by residents (n35) and
    nonresidents (n51) have moved closer together,
    with residents scoring 32 and nonresidents
    scoring 30.5 on the BDI-II, and residents scoring
    55 and nonresidents scoring 54 on the IESR.
  • Levels of exposure to trauma between residents
    and nonresidents have also moved closer together
    as more data sets have been gathered.
  • For the BDI-II at posttest, the combined resident
    and nonresident category has a lower mean score
    than the two categories separately.
  • For the IES-R at posttest, the residents appear
    to receive the most benefit from treatment.
    These trends suggest that although residents and
    nonresidents have the highest levels of exposure
    to trauma and the highest levels of distress at
    intake, the treatment is similarly beneficial to
    all groups.

48
CTS by Residential Status
49
BDI IES by Residential Status
50
Psychological Aggression is correlated to scores
on the IES at .01 level of significance.
51
Psychological Aggression is correlated to BDI
scores at the .01 level of significance.
52
Partners Physical Assaultiveness is correlated
to BDI scores at the .05 level of significance.
53
Partners Physical Assaultiveness is correlated
to IES scores at the .01 level of significance.
54
Partners Sexual Coercion is correlated with
scores on the BDI at the .05 level of
significance.
55
Partners Sexual Coercion is correlated to the
IES at the .01 level of significance.
56
Injury by the Partner is correlated with BDI
scores at the .05 level of significance.
57
Injury by the Partner is correlated with IES
scores at the .01 level of significance
58
Partner Injury correlated to IES2 posttest scores
at a.05 level of significance.
59
Paired t-test
  • Differences in mean scores on the BDI-II pretest
    and posttest indicate that patients significantly
    improved their scores after treatment.
  • On the BDI-II, t9.230, df 61, which was highly
    significant at .000.
  • Likewise, mean posttest scores for the IES-R were
    significantly lower after treatment.
  • For the IES-R, t10.342, which was highly
    significant at .000.
  • For the FVA, t.009, which was highly significant
    at .009.
  • For the FVOD, t3.204, which was highly
    significant at .002.
  • This suggests that treatment influences a strong
    downward trend in posttest scores on all
    measures.
  • Whether or not these changes are due solely to
    the counseling provided or are a combination of
    distance in time from the abuse, being in a safer
    environment, or having more control over their
    lives warrants further investigation.

60
(No Transcript)
61
Summary of Results
  • High scores on Psychological Aggression, Physical
    Assault, Sexual Coercion, and Injury by partner
    are correlated at a statistically significant
    level to high scores on the BDI and IES,
    suggesting that the greater the frequency of
    abuse, the higher the likelihood of measurable
    mental health effects on the victim.
  • Analysis of Pretest-Posttest differences suggests
    strongly that the intervention contributes to
    lower scores, and therefore reported improvement
    of mental health symptoms.

62
Interventions Overall
  • Individuals who do not participate in the
    research portion of the project are still
    eligible to receive counseling interventions.
  • Interventions occur in group and individual
    treatment modalities for each of the mental
    health sequelae of domestic violence.
  • Based on the assessments and in conjunction with
    the participants, the clinician recommends at
    least one group and/or one series of individual
    sessions per client. All interventions are based
    on a combination of psychoeducation,
    cognitive-behavioral strategies, and supportive
    therapy in which learning is applied to an
    individual clients experience.

63
Interventions PTSD
  • Group. Group sessions will be made available for
    all participants with a history of trauma, along
    the lines of the Trauma Recovery Empowerment
    model (M. Harris, 1998). For example, the topic
    of Emotional Boundaries contains information on
    saying no as a skill, questions on difficulties
    saying no, effective and ineffective strategies
    for saying no, and opportunities for practice.
    Understanding Trauma, Physical Abuse, Abuse
    and Psychological Symptoms, etc. The group will
    be ongoing, and its structure in topical units
    gives it flexibility in terms of group
    membership. Topics also include cognitive
    behavioral portions of the PTSD Workbook (cited
    below) and Healing the Trauma of Domestic
    Violence (E. Kubany, et al., 2003).
  • Individual. A series of individual counseling
    sessions will be offered to clients whose
    assessments indicate a need for in-depth
    treatment of PTSD. The sessions will cover the
    history of the client (Session 1),
    psychoeducation on avoidant and hyperarousal
    symptoms (Sessions 2 3), grounding exercises
    such as deep breathing and progressive relaxation
    (Session 4), helping oneself when a trauma is
    re-experienced (Session 5), coping with trauma
    with less avoidance and denial (Session 6), and
    dealing with guilt, shame, and loss (Session 7).
    Exercises may be used from M. Williams S.
    Poijula (2002) The PTSD Workbook and E. Bourne
    (2000) the Anxiety and Phobias Workbook.

64
Interventions Depression
  • Group. A group on the topic of depression is
    offered to clients whose BDI scores indicate
    depressive symptoms. Clients will be referred to
    psychiatric care if suicidality or psychoses
    appear to be present. M. Copelands (2002)
    Wellness Recovery Action Plan informs the groups
    structure, along with adaptations from CBT
    manuals, esp. Munoz Miranda (2000) Group
    Therapy Manual for CBT of Depression. Topics
    include psychoeducation on depressive diagnoses,
    abuse and depression, developing tools for
    wellness, daily maintenance plan, triggers, early
    warning signs, crisis planning, developing a
    support system, and self-care. CBT-related
    assignments include exercises on how events and
    thoughts influence feelings, mood tracking, and
    goal setting. Cognitive restructuring involves
    reframing negative thoughts and core beliefs.
  • Individual. A series of individual counseling
    sessions will be offered to clients whose BDI
    scores indicate clinically significant depressive
    symptoms. The individual series follows along
    the lines of the group, noted above.

65
Substance Abuse Treatment
  • Group. A relapse prevention group is offered to
    women with substance abuse histories. This group
    will consist of 7 sessions offered on a rotating
    basis. Topics will include the stages of change,
    abuse and addictions, psychoeducation on types of
    addictions, managing cravings, relapse, relapse
    prevention, and recovery. This group employs
    concepts from W. Miller S. Rollnick (1991)
    Motivational Interviewing, as well as the
    workbook Group Treatment for Substance Abuse by
    M. Velasquez, et al. (2000).
  • Individual. An individual counseling series
    consisting of 7 sessions, also based on relapse
    prevention, will be offered when individual
    treatment is recommended for substance abuse.
    The sessions will include the clients history,
    psychoeducation on types of addictions, stages of
    change, managing cravings, relapse, relapse
    prevention, and recovery.

66
Stages of Change--adapted from Miller
Rollnick, 1991
67
Case Study A CeciliaPresenting Issues
  • Cecilia is a 36-year-old Hispanic and Chinese
    American female with one female child aged one.
    She comes from Gonzales, Texas, where she is a
    newcomer, having lived previously in Arizona with
    family before her batterer found her there. She
    reunited with her batterer Mario, who moved her
    to Gonzales. She has no income.
  • She has never had a history of mental health
    treatment, though she did have to take anger
    management in Oregon due to a CPS case there for
    her other two children, whose custody she lost.
  • She has a history of childhood sexual abuse by an
    uncle and felt her parents did not do enough to
    support her.
  • Cecilia reports feeling depressed at times, and
    states that the abuse made her feel depressed
    and hurt. My feelings were confused.
  • In her case, the abuser hit her several times a
    week, choked her, threatened to kill her, refused
    to give her money for diapers and food, and kept
    her isolated from friends and family (by
    relocating her, by denying her access to a phone
    or transportation).
  • She noticed he would be abusive while sober, but
    became unpredictable when he used crack cocaine.
    She is a previous abuser of crack herself but
    reports quitting 2 years ago cold turkey.

68
Case Study A CeciliaInitial Assessments
  • On intake with the Conflicts Tactics Scale,
    Cecilia scored high on Subject Negotiation,
    suggesting that she attempted healthy negotiation
    skills during conflict.
  • She scored lower on Psychological Aggression,
    Physical Assault, Sexual Coercion, and Injury.
    She did appear to fight back with verbal and
    physical aggression, though her scores on these
    subscales were still lower than her partners (78
    or 39 and 60 or 20).
  • By contrast, Cecilia scored Mario as low on
    Negotiation, and high on Psychological
    Aggression, Physical Assault, Sexual Coercion,
    and Injury.
  • On the SASSIII, Cecilia did not report using
    alcohol, but reported recent cocaine use that
    suggests she is at high risk of having a
    substance dependence disorder (despite her claims
    of being clean for 2 years).
  • On the BDI-II, her score was 31, suggesting
    severe depressive symptomatology.
  • On the IES, her score was 68, suggesting severe
    posttraumatic symptomatology. On the Intrusion
    and Hyperarousal subscales, she scored 3, and on
    the avoidance subscale she scored 3.25.

69
Case Study A CeciliaTreatment
  • Cecilia engaged actively in treatment, which
    consisted of 2 groups per week and one individual
    session per week for 3 months, for a total of 36
    sessions.
  • The Trauma Recovery and Empowerment model was
    used for one group, in which psychoeducation,
    cognitive restructuring, and skills training are
    used to treat trauma and responses to it.
  • Individual treatment for PTSD focused on
    overcoming avoidance through psychoeducation,
    confrontation of avoidant behaviors, thoughts,
    and feelings, including denial, and learning to
    tolerate painful emotions without numbing out.
  • The Mental Health/Domestic violence group aims at
    increasing coping skills regarding hyperarousal
    and intrusive symptoms through relaxation
    training and cognitive restructuring.
  • To treat the mood symptoms, cognitive
    restructuring and interpersonal psychotherapy was
    used.
  • To treat the substance abuse, the relapse
    prevention model was used.
  • Associated features for Cecilia included
    deep-seated shame, self-blame, anger, grief and
    loss, and self-sabotaging behaviors.

70
Case Study A CeciliaFollow Up Assessments
  • At followup, client exhibited improvements, as
    observed by the clinician and as indicated by
    lower test scores 11 on the BDI (minimal), 31
    on the IES (mild), with no reported substance
    abuse.
  • Client verbalized her improvements in the
    following statement I realize I stop and think
    about what I want. I put my feelings first.
    After posttest, Cecilia obtained independent
    housing and secured part-time employment.
  • This case demonstrates the severity of
    posttraumatic and depressive symptoms in the
    aftermath of severe physical abuse, as well as
    the apparent success of treatment methods in
    addressing the symptoms.

71
A CBT Approach to Treating Attributions of
Self-Blame
  • Self-blame in the aftermath of repeated trauma is
    common among survivors, and can be associated in
    a client with depressive symptomatology and PTSD.
    Clients frequently blame themselves for the
    abuse, for leaving the abusive relationship, for
    staying in the abusive relationship, and for the
    effects of the abuse. Clients often experience
    blame from the abuser, from friends and family,
    and from legal and social service systems.
  • Veronica, who identifies as monocultural
    Hispanic, stated I feel like it is all my
    fault.
  • Therapeutic approach exercise on guilt related
    to the trauma and to what extent the client holds
    herself responsible, exercise on determining
    responsibility, uncover should statements,
    revise should statements, try out the revision.
  • Practice identifying guilt and underlying
    beliefs, thought stopping, modification of
    underlying beliefs, trying out a substitution of
    a different set of beliefs.
  • Results I dont feel like its all my fault
    anymore.
  • Cultural adaptation One issue which arose
    during treatment is Veronicas experience that
    her family held her responsible for the
    separation, which occurred after her abuser hit
    her, knocked her down, and kicked her repeatedly
    in front of their 2 children. He was arrested,
    skipped bail, and currently resides in another
    state. Her family did not invite her to a family
    birthday gathering immediately after the
    separation she perceived this as punishment.
    After exploring the importance of her connection
    to her family and culture, as well as the goals
    of the client, clinician offered training in
    assertive communication to be used with family.
    Client has reported increased assertiveness
    (esp., explained that the abuse was extreme and
    she did not wish to tolerate it) with and respect
    from her family and is no longer excluded from
    family gatherings at this time.
  • Client is a nonresident and met with clinician
    weekly for three months of individual sessions.

72
A CBT Approach to Treating Feelings of
Worthlessness
  • Feelings of worthlessness and of being
    permanently damaged occur frequently among
    participants, and may be associated with
    depressive and PTSD symptomatology.
  • Beth, who identifies as monocultural Caucasian,
    came to shelter the day after her husband John
    choked her during sex and sodomized her with a
    baseball bat. She reported at intake that her
    husband would choke her during sex several times
    a week for the past 3 months, and that the
    sodomizing was the last straw. Beth was
    immediately referred to a physician for medical
    care, and she was treated for vaginal and
    intestinal injuries. She refused to make a
    police report.
  • Client statement He made me believe Im not a
    good person, not a good wife, not a worthwhile
    person.
  • Therapeutic approach explore traumatogenic
    origins of these thoughts, explore to what extent
    these are misperceptions, restructure underlying
    beliefs, construct more adaptive beliefs, and
    behavioral skills training such as relaxation,
    assertiveness.
  • Client statement at posttest, I am working
    through panic issues. Im able to use self-care,
    change my negative thoughts, take care of my
    daily activities without being overwhelmed,
    communicating better with others, more vocal
    about getting my needs met.
  • Cultural adaptation Client is non-Hispanic
    Caucasian, and comes from a rural area. Her
    cultural background emphasizes rigid gender roles
    and divorce under no circumstances. During
    education and treatment, Beth has come to
    question and revise some cultural beliefs. After
    posttest, client obtained independent housing,
    completed a divorce, and obtained full time
    employment.
  • Beth was a resident whose treatment consisted of
    2 groups per week and two individual sessions per
    week for 3 months, for a total of 48 sessions

73
Intersections of Race, Class, Gender, Rural/Urban
Status, Domestic Violence, Sexual Assault,
Mental Health Sequelae
  • Most participant and nonparticipant clients
    experience vulnerability-enhancing clusters of
    factors, including racial/ethnic discrimination,
    gender role stereotyping, poverty, homelessness,
    geographic and financial barriers to treatment,
    victim status, and disability status.
  • Project designed to contribute to a
    strengths-enhancing approach by clustering
    strengthening interventions (advocacy, housing,
    financial support, education, mental health
    treatment, physical health treatment, etc.) to
    counteract the vulnerability-enhancing clusters
    of multi-problem families (poverty,
    stigmatization, racism, homelessness, mental and
    physical illness, etc.).
  • Like Miranda, et al., (2003), we found no ethnic
    differences in response to care, especially when
    poor and minority women were given support to
    overcome barriers to care.
  • Although clients have stated they believe that
    abuse is more prevalent or accepted in a given
    culture, TRP study indicates that the abuse
    occurs in all cultures served by the agency, and
    that mental health effects of the abuse also
    occur across categories.

74
Barriers to Treatment How TRP Addresses Them
  • Unfamiliarity with agency, abuse, and/or mental
    health effects of abuse.
  • Community client education, outreach,
    publicity.
  • Lack of family support in receiving outside help.
  • Provision of services for family members as well
    as primary victims.
  • Lack of cultural competence on the part of
    caregivers.
  • Cultural competency commitment, ongoing
    education, adjustment, including incorporation
    of client feedback into service design.
  • Transportation.
  • Outreach.
  • Limited financial means.
  • No cost to mental health treatment.
  • Lack of health insurance.
  • No cost to mental health treatment.
  • Readiness to change.
  • Designing interventions based on Stages of Change
    model, as appropriate, to meet clients where they
    are.

75
Cultural Competence and the TRP What We Are
Doing
  • In literature on the trauma model of
    intervention, gaps exist in the area of
    multicultural responses to trauma.
  • First, the TRP recognizes and acknowledges the
    fact that abuse occurs across racial and ethnic
    groups (G. Santiago, 2002 K. Wilson, 1997 TCFV,
    2004).
  • All assessments have been translated into Spanish
    to accommodate Spanish-speaking clients.
  • Cultural explanations of an individuals abuse
    history and mental health issues are taken into
    account, as are cultural elements of the
    relationship between participant and clinician
    (Bartocci, et al., 1998 DSM-IV, 1994).
  • Minority groups may be at greater risk of
    economic and social adversity (Marcella and
    Yamada, 2000 G. Santiago, 2002), and those risks
    are considered on a case by case basis.
  • Cultural considerations influence all aspects of
    treatment in the TRP, with staff striving for
    cultural sensitivity in all interventions. For
    example, in African American culture and in
    Hispanic culture, inclusion of key (nonabusive)
    family or community members may be important for
    support and retention of clients (Canales, 2000
    Raajpoot, 2000).

76
Cultural Competence What the TRP is doing (2)
  • As the TRP is based in part on an empowerment
    model, a clients existing network of supports,
    including religious and folk healing, are
    emphasized in treatment. The TRP provides
    options and support so that women can be
    empowered to make their own choices, including
    culturally and religiously influenced ones.
  • The Hispanic (used interchangeably with
    Latina/o), and is a heterogeneous group with
    regard to country of origin, education, income,
    age, religion, language, acculturation, and
    cultural values. Financial, language, and
    citizenship barriers can exist for battered
    Latinas. The TRP staff accepts cultural
    differences, opens them for discussion, and
    empowers women to make choices within her
    cultural and religious frame of reference.
  • Familial support networks have an important
    emphasis in African American culture. It may be
    difficult for the African American woman to seek
    help outside the family and community at a
    shelter or mental health setting in which the
    staff is predominately white (K. Wilson, 1997 R.
    Dana, 2002). Interventions at TRP would begin
    with attempts to understand a given African
    American womans situation and to provide support
    around culturally acceptable options for her.
  • As a matter of policy regarding employees and
    clients, GVFVS does not discriminate on the basis
    of gender, race, ethnicity, disability, religious
    affiliation, or sexual preference. In addition,
    GVFVS is committed to viewing cultural competence
    as a set of tools which is in the process of
    being continually adjusted based on active,
    sensitive engagement with a variety of cultures
    (Angel Williams, 2000).
  • The project addresses ethnic diversity through
    community education and outreach for a wide
    variety of audiences.
  • The TP Coalition has recruited for and includes
    members from ethnically and religiously diverse
    groups, especially Hispanic, Catholic, and
    African American, as they form the main diverse
    groups in the shelter population. Thus, key
    cultural informants are included in the structure
    of the program.
  • Linguistically competent staff are employed for
    oral and written translation of Spanish and
    English.
  • Staff is committed to ongoing multicultural
    education and analysis.

77
Program Self-Evaluation by Performance Measures
  • Strengths are predominantly in the service
    capacity and include
  • Knowledge and communication of population
    characteristics, social resources, service user
    characteristics.
  • Language interpretation services at first and
    subsequent contacts with linguistically competent
    staff. Service descriptions, assessments, and
    educational materials translated into Spanish.
  • Adaptation of services to cultures, adaptation of
    interventions to cultures, transportation
    assistance, accommodation of hours of operation,
    environment receptive to cultures, promotion
    assessment of culturally competent services.
  • Ongoing and comprehensive CC training for staff.
  • Recruitment, hiring, and retention of culturally
    competent staff, including representation of
    cultures among staff at all levels.
  • Consumer and family educational materials in the
    language of cultures.
  • Culturally diverse representation in board and
    coalition membership.

78
Cultural Competence and the TRP What We Need
To Do
  • Expand the number and types of treatment
    educational information available written in
    Spanish (currently, DV PTSD).
  • Train linguistically competent staff further in
    administration of assessments.
  • Improve linguistic competence for all staff.
  • Continue to monitor retention engagement of
    African American and biracial clients.

79
New Directions
  • Gather more information on bicultural
    individuals exposure response to trauma.
  • Expand research to include children as both
    primary and secondary victims.
  • Explore the Stages of Change cross-culturally as
    a means of reaching a population very much in
    need of services.

80
Implications
  • Systems change is necessary to accommodate the
    needs of violence survivors within mental health
    populations and mental health consumers within
    survivor populations.
  • Contextual factors, such as race/ethnicity,
    gender, class, and rural/urban location must be
    considered in developing and modifying services
    for clients affected by abuse and mental health
    issues.

81
How has your mental health improved?
  • I feel less guilty and talk about my feelings
    better.
  • I understand a lot more. Its ok to be upset.
  • I feel better about myself. Its an ease off my
    mind. I feel calmer about it.
  • Keeping myself occupied in positive ways.
  • I dont have so many down times.
  • Im looking at the things I can control versus
    trying to control everything.
  • I realize its not all my fault.
  • I am less scared.
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