No commercial support was received for this educational activity.

1. Domestic ViolenceRebecca Hegel, FNP-S and Carrie Warner, FNP-SState University of NEW york: Institute of technology

2. No commercial support was received for this educational activity.

3. Objectives • List two community resources available for prevention and care to potential and actual domestic violence victims. • Discuss what population is at greatest risk for domestic violence. • Recall one alternative violence measure.

4. Scope of Problem Domestic Violence (DV) takes many forms and the subject matter is expansive ranging across the lifespan from preconception to elderly. Todays focus will be to discuss only 1 form of DV, known as Intimate Partner Violence. It is important to disclose that children and elderly are often victims with different risk factors.

5. Domestic Violence Domestic violence (DV) occurs when one person does a variety of things to control another person in an intimate relationship. • The shift in power can happen slowly, over a period of time, so that the other person cannot even remember when it happened. • Other times it can happen quickly after there is some sort of commitment or some change in the level of intimacy

6. DV takes many different forms and includes behaviors such as: • threats • name-calling • preventing contact with family or friends • withholding money • actual or threatened physical harm • sexual assault

7. Intimate Partner Violence (IPV) IPV includes: • stalking • physical violence • sexual violence • threats of physical or sexual violence • emotional abuse

8. IPV • Done by a current or former spouse or non-marital partner. • Exists along a continuum from a single episode of violence to ongoing battering.

9. Statistics • According to the Centers for Disease Control and Prevention: • 3 in 10 women and 1 in 10 men in the United States have experienced rape, physical violence, or stalking by a partner and report that the violence impacted them in some way. • For example, the act made them feel fearful or concerned for their safety, resulted in an injury or need for services, or they lost days from work or school. • In 2010: 1,336 deaths • accounting for 10% of all homicides. • 82% of these deaths were females and 18% were males. (CDC, 2012)

10. Statistics • In 2012, according to New York State Office for the Prevention of Domestic Violence (NYSOPDV), • 119,355 total assaults reported by police agencies outside New York City. Of these, 27% (31,911) were committed by intimate partners; females were the victim in 80% of these cases. • Since 2011, total assaults increased by less than 1%, but intimate partner assaults increased by 6%, and intimate partner assaults where females were the victim also increased by 6% (NYSOPDV, 2012)

11. Statistics • Adolescents and adults are often unaware that teens experience dating violence. • 9.4 percent of high school students report being hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend in the 12 months prior to the survey (CDC, 2011).

12. Risk Factors Relationship Factors • Marital conflict-fights, tension, and other struggles • Marital instability-divorces or separations • Dominance and control of the relationship by one partner over the other • Economic stress • Unhealthy family relationships and interactions Societal Factors Traditional gender norms (e.g., women should stay at home, not enter workforce, and be submissive; men support the family and make the decisions) (CDC, 2013)

13. Community Factors • Poverty and associated factors (e.g., overcrowding) • Low social capital-lack of institutions, relationships, and norms that shape a community's social interactions • Weak community sanctions against IPV (e.g., unwillingness of neighbors to intervene in situations where they witness violence) (CDC, 2013)

14. Individual Risk Factors • Low self-esteem • Low income • Low academic achievement • Young age • Aggressive or delinquent behavior as a youth • Heavy alcohol and drug use • Depression • Anger and hostility • Antisocial personality traits • Borderline personality traits • Prior history of being physically abusive (CDC, 2013)

15. Individual Risk Factors • Having few friends and being isolated from other people • Unemployment • Emotional dependence and insecurity • Belief in strict gender roles (e.g., male dominance and aggression in relationships) • Desire for power and control in relationships • Perpetrating psychological aggression • Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration) • History of experiencing poor parenting as a child • History of experiencing physical discipline as a child (CDC, 2013)

16. Cycle of Abuse • In 1979, psychologist Lenore Walker found: • violent relationships follow a common pattern or cycle. • The entire cycle may happen in one day or it may take weeks or months. • It is different for every relationship and not all relationships follow the cycle—many report a constant stage of siege with little relief.

17. 3 Part Cycle Tension builds over common domestic issues like money, children or jobs. Verbal abuse begins. The victim tries to control the situation by pleasing the abuser, giving in or avoiding the abuse. None of these will stop the violence. Eventually, the tension reaches a boiling point and physical abuse begins When tension peaks, physical violence begins. Usually triggered by the presence of an external event or by the abuser’s emotional state—but not by the victim’s behavior. This means the start of the battering episode is unpredictable and beyond the victim’s control. Some experts believe that in some cases victims may unconsciously provoke the abuse so they can release the tension, and move on to the honeymoon phase. Tension Building Acute Battering (Domestic Violence Roundtable, 2008)

18. 3 Part Cycle • Honeymoon phase: • Abuser is ashamed of behavior; Expresses remorse, tries to minimize the abuse & might even blame it on the partner. May then exhibit loving, kind behavior followed by apologies, generosity and helpfulness. Will genuinely attempt to convince partner that abuse will not happen again. This loving & contrite behavior strengthens the bond between the partners and will probably convince the victim, once again, that leaving the relationship is not necessary. • Cycle continues over and over, & may explain why victims stay in abusive relationships. The abuse may be terrible, but promises & generosity of the honeymoon phase give the victim the false belief that everything will be all right. (Domestic Violence Roundtable, 2008)

19. Power and Control Perspective Wheel Domestic violence involves a range of behaviors which can include physical and sexual violence; using coercion and threats; using intimidation; using emotional abuse, using isolation; minimizing, denying and blaming; using children; using male privilege; and using economic abuse. These forms of abuse do not occur in isolation from each other, but rather occur simultaneously. (NYSOPDV, 2012)

20. The Power and Control model of Domestic Violence identifies power and control as the goal of all of these tactics of abuse because victims' experiences consistently indicate that the behavior of their partners is not random or arbitrary, but purposeful and systematic. The goal of abusers' behavior is to exert control over their partners. This goal reflects their belief that they have a right and entitlement to control their intimate partners. The various forms of abuse, the different behaviors, are used a tactics of control. (NYSOPDV, 2012)

21. The Cycle of DV

22. Examples: Using Coercion and Threats • making and/or carrying out threats to do something to hurt her • threatening to leave her, to commit suicide, to report her to welfare • making her drop charges • making her do illegal things Using Intimidation • making her afraid by using looks, actions, gestures • smashing things • destroying her property • abusing pets • displaying weapons (NYSOPDV, 2012)

23. Using Emotional Abuse • putting her down • making her feel bad about herself • calling her names • making her think she's crazy • playing mind games • humiliating her • making her feel guilty Using Isolation • controlling what she does, who she sees, and talks to, what she reads, where she goes • limiting her outside involvement • using jealousy to justify actions (NYSOPDV, 2012)

24. Minimizing, Denying and Blaming • making light of the abuse and not taking her concerns about it seriously • saying the abuse didn't happen • shifting responsibility for abusive behavior • saying she caused it Using Children • making her feel guilty about the children • using the children to relay messages • using visitation to harass her • threatening to take the children away (NYSOPDV, 2012)

25. Using Male Privilege • treating her like a servant • making all the big decisions • acting like the "master of the castle" • being the one to define men's and women's roles Using Economic Abuse • preventing her from getting or keeping a job • making her ask for money • giving her an allowance • taking her money • not letting her know about or have access to family income (NYSOPDV, 2012)

26. Nursing Practice Implications

27. Significance According to AHRQ (2008): • 22% of providers have attended training • 60% who did attend training state they do not feel confident • 23% believe they can help • ≤20% ask about DV

28. Significance • Studies show knowledge, attitudes, and beliefs of physicians and nurses in domestic violence response have revealed important barriers to addressing DV. • Barriers include: lack of knowledge, training, patient disclosure, self-efficacy, system-level support, and time. • Effective identification of women experiencing violence is essential. We know that survivors of DV want to be asked by doctors but not pressured to disclosure, but patient disclosure is a prerequisite for clinician engagement with domestic violence. (Yeung, Chowdhury, Malpass, & Feder, 2012)

29. At-Risk Populations • African-Americans • American Indians • Asian-Americans • Hispanics/Latinos • Pregnancy • Immigrants • LGBT • Male Victims • Persons with Disabilities

30. IPV and Health Consequences • Mental Health Problems • 61% of women with depression • Physical Problems • Headaches • Chronic Pain • Sleep Problems • Vaginal Infections • Digestive Problems • STD’s • Urinary Tract Infections (Agency for Healthcare Research and Quality, 2004)

31. Pregnancy • 324,000 pregnant women are abused each year in the United States (American College of Obstetricians and Gynecologists [ACOG], 2012). • ACOG recommends that physicians screen ALL patients for intimate partner violence.

32. For women who are not pregnant, screening should occur: • at routine ob-gyn visits • family planning visits • preconception visits If pregnant:screening should occur at various times over the course of the pregnancy because women often do not disclose abuse the 1st time Screening should occur: • at the first prenatal visit • at least once per trimester, and • at the postpartum checkup. (AHRQ, 2008)

33. Screening Tools Health care providers are often the first and only professionals with whom those at risk come into contact. Therefore, medical professionals have the ability to educate and intervene early in the cycle of abuse. Because victims are not likely to disclose unless they are screened in a direct, non-judgmental manner, we recommend using RADAR: A Domestic Violence Intervention: • Routinely Screen Patients • Ask Direct Questions • Document Your Findings • Assess Patient Safety • Review Options and Referrals (Center for Prevention of Abuse, 2013)

34. DV screening can be conducted by making the following statement: and asking these three simple questions: “Because violence is so common in many women's lives and because there is help available for women being abused, I now ask every patient about domestic violence”. • Within the past year -- or since you have been pregnant -- have you been hit, slapped, kicked or otherwise physically hurt by someone? • Are you in a relationship with a person who threatens or physically hurts you? • Has anyone forced you to have sexual activities that made you feel uncomfortable?"

35. Now What? If assessment is positive for DV: • Believe patient and tell patient the behavior reported is abuse. • Assure patient violence is the fault of perpetrator and not the victim. • TREAT PATIENT • Assure patient that there are options and offer referral to IPV Program Social Worker or other appropriate resource. • Give patient hotline number. National (1-800-799-SAFE) and Local HOTLINE telephone number.

36. Documentation • Thorough documentation is essential • Can be used as evidence for obtaining protective relief (an Order of Protection) • Medical documentation can be helpful in corroborate police data • May be helpful in obtaining public housing, victim compensation • https://www.ncjrs.gov/pdffiles1/nij/188564.

37. How to Document • Take photographs of injuries known or suspected to have resulted from DV • Write legibly if not documenting in EMR • Use quotations or phrases such as “patient states” • Avoid using phrases such as “patient claims’ or “patient alleges” • Use medical terms and avoid legal terms such as “assailant” and “assault” (National Institute of Justice, 2001)

38. Avoid summarizing a patient's report of abuse in conclusive terms. If “rape”, “assault and battery” lack sufficient factual information, it is inadmissible. • Do not place DV in the diagnosis section of medical record. • Describe the patient’s demeanor, for example, indicate whether they are crying, angry, upset, calm, or happy. • Record the time of day the patient is examined and indicate how much time has elapsed since the abuse occurred. For example, Patient states that early this morning her boyfriend hit her.

39. Prevention Action+Awareness=Change “If violence is learned it can be unlearned.”

40. Levels of Prevention • Primary – Approaches that take place before domestic violence has occurred to prevent first time victimization or perpetration (before) • Secondary – To intervene, respond and/or prevent violence from happening again and deal with short-term consequences (after, intermediate) -i.e. arrest, emergency shelter, medical attention • Tertiary – To provide ongoing support to victims and ongoing accountability to abusers (after, long term) – i.e. Support Group and Batterer Accountability Programs through Probation.

41. Prevention • Centers for Disease Control goal is to stop IPV before it begins. • This can begin with the prevention of dating violence in teens. • Strategies that promote healthy behaviors in relationships are important. • Programs that teach young people skills for dating can prevent violence

42. All forms of IPV and domestic violence are preventable. • The key to prevention is focusing on the first time someone hurts a partner. • Screening for intimate partner violence is a suggested strategy to identify and reduce future victims (Institute of Medicine, 2011). • Community awareness of domestic violence and the resources available in the community may be instrumental in the prevention of future DV/IPV incidents

43. What Can Each of Us Do To Prevent Domestic Violence? • Call the police if you see or hear evidence of domestic violence. • Speak out publicly against domestic violence. • Take action personally against domestic violence when a neighbor, a co-worker, a friend, or a family member is involved or being abused. • Encourage your neighborhood watch or block association to become as concerned with watching out for domestic violence as with burglaries and other crimes. • Reach out to support someone whom you believe is a victim of domestic violence and/or talk with a person you believe is being abusive. • Help others become informed, by inviting speakers to your church, professional organization, civic group, or workplace. • Support domestic violence counseling programs and shelters. (Center for Prevention of Abuse, 2013)

44. Prevention efforts should eventually reduce the incidence of intimate partner violence through the promotion of healthy, respectful, nonviolent relationships. • By not only incorporating risk factors, prevention information, and information on promotion of healthy relationship behaviors, awareness of IPV may be raised in this age group and toleration for IPV behaviors may be decreased.

45. Resources for Victims • Every county in New York State has at least 1 agency specifically designed to provide services for individuals affected by DV and their children.  • Programs offer emergency 24-hour hotlines, information and referrals, education, support groups, advocacy and accompaniment.

46. How do Resources Help? • Create long-term safety for battered women and children • Tie visitation centers into coordinated community responses • Negotiate legal issues created by post-separation power-and-control tactics that use children • Help fathers who batter to shift their focus from controlling mothers to parenting children • Ensure on-going safety for battered women and children • Legal issues that arise when batterers continue their abuse by bringing the battle to the courtroom • Work with fathers who batter to shift their focus off of controlling her to parenting their children • Awareness and notification of protocols and policies that support safety for victims and accountability for offenders

47. Resource Examples • National Domestic Violence Hotline 1-800-799-7233 • NYS Domestic Violence Hotline 1-800-942-6906 • YWCA Mohawk Valley 24/7 (315) 797-7740 • Domestic Violence Program of Herkimer County (315) 866-0458

48. Recommended Clinical Guidelines 2013: WHO clinical and policy guidelines: Responding to intimate partner violence and sexual violence against women 2004: Agency for Research and Health Care Quality (AHRQ): Women and domestic violence. Programs and tools that improve care for victims.

49. Next Steps • Find community resources for victim AND offender • Promote Alternatives to Violence • Plan and/or Participate in “Coordinated Community Response” Activity

50. Audience Participation • Question 1: Please share 2 community resources that you can provide to patients. • Question 2: Identify 1 population at risk for domestic violence. • Question 3: What is 1 alternative violence strategy?