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Intimate Partner Violence in clinical practice

Intimate Partner Violence in clinical practice

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Intimate Partner Violence in clinical practice

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  1. Intimate Partner Violence in clinical practice Lisa V. Merchant, M.MFT, LMFT

  2. Welcome! Use the paper on your table to write down any of the following: • Questions you have about Intimate Partner Violence (IPV) • Things you hope we talk about today • Stories you would like to share about times you have worked successfully or unsuccessfully with violent couples, victims, or perpetrators • Your grocery list or doodles of cats

  3. Introductions • Tell us your name • One of the following: • Questions you have about domestic violence or topics you hope we talk about in the next three hours • A time you worked successful or unsuccessfully with a couple or individual in which violence was a problem • Your grocery list and/or cat doodle

  4. Agenda • Clinical Statistics • Types of Violence • Screening Tools • Conjoint IPV Intervention Tools • Guidelines • Conflict Safety Planning • Negotiated Time Out • Working with victims • Victim blaming • Victim Safety Planning • Victim Resources

  5. Statistics

  6. General population • 1 in 3 women and 1 in 4 men in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. • 1 in 4 women and 1 in 7 men have experienced severe physical violence by an intimate partner (e.g., hit with a fist or something hard, beaten, slammed against something) at some point in their lifetime. • 1 in 17 women and 1 in 20 men experienced rape, physical violence, and/or stalking by an intimate partner in the 12 months prior to taking the survey. • 1 in 6 couples experience violence within their relationship annually (Black, et al., 2011; Johnson, 2008)

  7. Clinical population • 36% to 58% report either M2F or F2M IPV • 71% of couples reported M2F, F2M, or reciprocal IPV • Only about 60% of clinicians screen for violence • What stops the other 40% from screening? • Why do you screen? • Why do you not screen? • (Cascardi, Langhinrichsen, & Vivian, 1992; Jose & O’Leary, 2009)

  8. Why address violence?

  9. Is all IPV the same?

  10. Four types of Violence • Intimate Terrorism • Physical violence tends to be more severe and more chronic though physical violence may be absent • More likely to involve sexual aggression • More likely to be M2F • Unidirectional • Dependent or Antisocial personality • Overarching patter of Coercive Control • Shelter population • Situational Violence • Mild or severe • Sporadic or chronic • Unidirectional or bidirectional • M2F or F2M • No ongoing verbal or emotional abuse • No overarching pattern of coercive control—violence related to poor communication and conflict resolution skills • General population—COPS • May be happy (Johnson, 2008)

  11. Coercive Control • Combination of violent and non-violent tactics to take general control over their partner • Non-violent control tactics • Threats • Intimidation (e.g., hurting pets, breaking things) • Monitoring • Relentless psychological abuse to undermine the will to resist—targets self-esteem and confidence • Limiting access to financial, educational, and social resources

  12. Four types of Violence • Violent Resistance • Victim’s violent response to intimate terrorism designed to end partner’s abuse • Mutual Violent Control • Two intimate terrorists in relationship with one another • Very rare

  13. Screening guidelines  instruments

  14. Screening Guidelines • If you don’t know what to do, do what will best ensure your clients safety • Listen to your intuition • Ask more questions • Consult with a colleague • Screen all couples and families • Use written and verbal screening • Screen individually • Maintain partner confidentiality when safety is threatened

  15. CTS2

  16. Intimate Justice Scale

  17. Coercive Control Thinking about your current partner, would you say s/he… • …tries to limit your contact with family and friends? • …is jealous or possessive? • …insists on knowing who you are with at all times? • …calls you names or puts you down in front of others? • …makes you feel inadequate? • …shouts or swears at you? • …prevents you from knowing about or having access to the family income even when you ask? (Johnson & Leone, 2005)

  18. Verbal Screening • Unless you have reason to suspect that the female is the primary aggressor, screen the female partner first • Screen individually • Be conversational • Start with a grand tour question: • “Therapy can bring up sensitive issues, so it is helpful for me to know how you two handle conflict. So, how do you handle conflict? What does it look like?” • Get specific: • “Have you ever been physically violent toward your partner, such as pushing, grabbing, slapping, or restraining your partner? Has your partner ever done these things to you?” • “Have you ever been verbally aggressive toward your partner, like calling him names, screaming at him, or saying things to purposefully make him feel stupid?”

  19. Verbal Screening • If either verbal or physical violence is reported, get more details: • When violence occurs, what normally happens? What does that generally look like? • What is the worst it has ever gotten? • Has a weapon ever been used? • Has anyone ever been injured? • How often does violence happen? • When was the last time there was violence? • Assess responsibility/blame: • Who would you say is most responsible for the violence? You, your partner, or both?

  20. Verbal Screening • Assess safety • I was planning on asking your partner the same set of questions I just asked you. It is likely they will guess that I asked you these questions. Do you feel safe if I ask your partner the same questions? • If “NO” then do not ask screen the other partner when you meet with them individually—talk about goals, why they are coming to therapy, etc. • Do you feel safe if we discuss the violence you reported with your partner as part of therapy? • If “NO” then conjoint therapy is not recommended • Are you willing to sign an agreement to not engage in physical violence? • If “NO” then conjoint therapy is not recommended.

  21. So, when is conjoint okay? • When partners’ reports of violence are fairly consistent with one another • When violence is mild to moderate • When coercive control is absent • When both partners feel safe discussing the violence in therapy • When both partners are willing to sign a no harm agreement • When the primary aggressor is able to accept at least some responsibility for the violence

  22. What if… • …Conjoint therapy isn’t recommended? • See them individually • …They don’t want to be see individually • Do not relent--It is unethical to provide a treatment that may be unsafe • Provide referrals to other services (shelters or batterer’s intervention) • …A couple qualifying for conjoint therapy doesn’t want to talk about violence since their presenting problem is something else? • Be understanding and reassuring, but also… • Be the expert and… • Sell the intervention • How common are these above scenarios?

  23. Stretch

  24. Conjoint tools Safety Plans  Negotiated time out

  25. IPV Intervention in Sum • Safety planning with each partner • 50 minutes, individually • Negotiated time out • 50 minutes, together IF SAFE • Miracle question • Help clients identify the effect of violence on the presenting problem and other aspects of their relationship • 50 to 75 minutes, together IF SAFE • Blame/Goals • 25 to 50 minutes, together IF SAFE Meet with each client individually before and after each session to check violence/safety

  26. Conflict Safety planning • Purpose of safety planning is to: • Identify signs of escalation that may indicate impending danger. • Identify and assess options for maintaining safety. • Create and implement a plan for maintaining safety • Safety planning is done individually • Safety planning is confidential • Two safety planning worksheets • Primary victim (person most likely to be injured) • Primary perpetrator • Use the worksheet, but be conversational • Safety planning is an ongoing activity

  27. Identifying escalation • Maybe start with: • Tell me more about what conflict looks like in your relationship. • You mentioned last week that…I was wonder if you could tell me more about the times when… • Use the Safety Planning Sheet to identify signs that anger is escalating and violence is imminent. • What are the first signs that tension is building? • How can you tell when things are about to get out of control? • What does he do when you… • What goes through your head when she… • Focus on behaviors, sensations, thoughts, and feelings.

  28. Preventing escalation • Identify steps he/she can take to reduce tension and prevent escalation: • What has worked in the past to prevent arguments from escalating to violence? • What else have you tried? • De-escalation could include breathing techniques, “walking on egg shells,” agreeing, going for a smoke, etc. • For non-violent partners, discuss protection strategies in case of violence and provide referrals: • Call 911 • Avoid bathrooms, kitchens, and bedrooms • Seek refuge (friends, shelters, fire stations, etc.) • Set aside cash and credit cards • Hide an extra phone or leave it with friends • Assess if they want this relationship to continue & that they feel safe continuing with therapy.

  29. Negotiated Time out • Couple can be in agreement about how to take a break from an argument without their partner feeling abandoned or abused. • Perpetrators learning timeouts alone sometimes use it as a punishment—they put their partner in timeout. • Learning it together can empower the non-violent partner. • It encourages resolution of disagreements once both parties are calm.

  30. NTO: Goals • Help each partner to recognize signs of anger, when anger is escalating, and when arguments are becoming unproductive and unsafe. • To teach each partner how to disengage from an argument before it leads to violence. • To teach each partner how to return safely to the discussion. • To create a plan agreed upon by both partners that addresses these goals.

  31. NTO: Seven Steps • Step 1: Awareness of Anger & Escalation • How can you tell when things are getting out of control? At what point to arguments become unproductive or unsafe? • Partners may have different “points of no return” that need to be respected. • Step 2: Stay in the Safe Zone • How will you know when it is time to take a break? • Either partner can call a timeout based on what they are personally thinking, feeling, or doing. • While a person may call a timeout based on their reaction to their partner, they do not call a timeout for their partner. For example, if a partner yells, the other may feel intimidated and call a timeout because they need a break, as opposed to calling a timeout “because you are getting out of control.”

  32. NTO: Seven steps • Step 3: Signaling • Help partners develop a clear, non-threatening signal and practice it in session. • Step 4: Acknowledging • It may be tempting to continue the argument even after the timeout has been called • Partners develop a way to respond to their partners timeout • How will respond when your partner calls a time out? How can you prevent yourself from pursuing the argument? How will you acknowledge the timeout? • If one partner is concerned about feeling abandoned by the timeout, discuss how to prevent those feelings.

  33. NTO: Seven steps • Step 5: Disengaging • Decide where partners will go, how long the time out will last, and who will care for the kids. • Timeouts generally last 15 to 30 minutes • Partners should not go to a shared space, like a bedroom or bathroom, if the other partner is going to need it. • Partners should not go somewhere the requires driving • If place is outside, have a back-up plan in case of bad weather • Only the partner calling the timeout implements their disengagement plan.

  34. NTO: Seven steps • Step 6: Calming • Active, non-aggressive activities generally work best for soothing anger—walking, meditation, listening to music, writing, praying, etc. • Watching TV, hitting things, going to a bar, having a drink and other similar activities are not recommended—may prevent conflict resolution and may escalate anger later. • Step 7: Returning • Call another time out • Calmly discuss the issue • Table the issue for a later date • Drop the issue altogether

  35. TTU IPV Intervention in Sum • Safety planning with each partner • 50 minutes, individually • Negotiated time out • 50 minutes, together IF SAFE • Miracle question • Help clients identify the effect of violence on the presenting problem and other aspects of their relationship • 50 to 75 minutes, together IF SAFE • Blame/Goals • 25 to 50 minutes, together IF SAFE Meet with each client individually before and after each session to check violence/safety

  36. Miracle Question • Imagine that while you are sleeping tonight miracle happens and the threat of (physical/psychological) violence is completely removed from your relationship. However, because you were sleeping when the miracle occurred you are not aware that it happened when you first wake. • What will be the first clue that the miracle has happened? • Who will be the first person in your family to notice that violence is gone from the relationship? • What will they notice? • What difference will this change make (on your relationship, family, etc)? • Who will notice first, you or your partner? • When do you think your children will notice and what will give it away? • Who outside of your immediate family will notice?

  37. Miracle Question • How will your relationship change as a result? • What will you be able to do/accomplish now that this change has occurred? • What will you and/or your partner start doing because of this change? • What affect will the change have on the reasons you came to therapy? • How will you and your partner handle conflict differently now that violence is gone from the relationship? • How will the way you and your partner interact/communicate change now that violence is gone? • What will you do that you were afraid to do before, now that violence is gone? • What will you be able to tell your partner about how the violence affected you?

  38. Take a Break Walk  stretch  refresh

  39. Working with victims Victim blaming  safety plans  victim resources

  40. The hardest thing about working with victims is… • …the emotional difficulty • Frustrated that they will not leave • Feeling helpless • Hard to witness the pain and their children’s pain • …there are not enough resources • Resources don’t exist • Red tape prevents access • System fails • …I don’t have the tools • What do I say? • What do I do?

  41. Dos and don’ts • Be aware of your own attitudes • If a woman doesn't like it, she can leave. • Some women unconsciously want their partners to control them. • Abusive men lose control so much that they don't know what they're doing. • Getting drunk can lead a man to hit his wife when he otherwise wouldn’t. • Women who make their partners jealous are just asking for it. • Domestic violence rarely happens in my neighborhood. • A lot of domestic violence occurs because women keep on arguing about things with their partners. • If a woman continues living with a man who beats her then it’s her own fault if she is beaten again. Peters, 2008

  42. Dos and don’ts Don’t get sucked into minimization and victim blaming Emily presents at your office for her initial appointment. She is here to fix her marriage. Her husband, Ed, refuses to come. Emily and Ed have been married for three years. Although their arguments have always been loud and volatile, in the last year their fighting has become more intense. Ed took a new high-stress job, Emily went back to school to work on her nursing degree, and they just found out that Emily is three months pregnant. Ed has started drinking nightly to relax. Ed complains about Emily’s cooking and housekeeping since she went back to school, as well as the financial burden of her education and soon-to-be baby. Emily complains that Ed doesn’t help around the house and fears that he no longer cares for her. A couple of months ago, after Ed had a couple of beers, Emily began complaining that Ed wasn’t helping her out with the housework. Ed rolled his eyes and went into another room. Emily followed him and kept complaining, but Ed continued to ignore her. Emily became angry and yelled at him, calling him lazy and selfish. Ed became enraged, grabbed her arm, and began screaming in her face that she was a bitch and a nag. Emily tried to pull away from Ed, but couldn’t break free of his grip, so she slapped him in the face. Ed slapped her back, knocking her to the floor. Although Ed had no lasting injuries, he left bruises on Emily’s face and arm. Afterward, Ed was very apologetic, and over the next couple of weeks he was very helpful around the house.

  43. Dos and don’ts • Recognize that leaving is complicated • There are 10,000 reasons to stay—finances, fear, children, guilt, isolation, love, hope, forgiveness, family values, depression, PTSD, homelessness, etc. • Leaving is dangerous—when she is most likely to be killed. • Some family, friends, & clergy may be telling her to stay, while others shame her for staying. • She is likely being blamed and blaming herself for the abuse. • Seek to understand what stops her from leaving. • Why victims stay varies case-by-case. • Seeking to understand why she stays may be a novel for her. • Helping her clarify and process why she is staying can lead to leaving. • Be curious. • Explore the parts that want her to stay and the parts that want her to leave.

  44. Dos and don’ts • Don’t use scare tactics • “He is going to start in on the kids next.” • “He is going to kill you.” • “It is only going to get worse.” • “How bad does it have to get before you leave?” • Do express your concerns—she probably has them, too! • “I’m worried that he is going to hurt you again and it is going to be worse.” • “I am worried about what this is teaching the kids.” • “I am concerned about you.”