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.

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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.

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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).

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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

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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

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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

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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.

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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

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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

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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

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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.

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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.

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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.

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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.