7 IN DEALING WITH PARTNER VIOLENCE David Katerndahl, MD, MA - - PowerPoint PPT Presentation

7 IN DEALING WITH PARTNER VIOLENCE

David Katerndahl, MD, MA Department of Family and Community Medicine University of Texas Health Science Center San Antonio, Texas

SPEAKER DISCLOSURE

Dr. Katerndahl has disclosed that he has no actual or potential conflict of interest in relation to this topic.

MAGNITUDE OF THE PROBLEM

 Lifetime prevalence of rape, physical violence or stalking by intimate partner (2010)*

 36% U.S. Women  35% Texas Women

 Texas (2013)

 76,704 reported victims of Intimate Partner Violence (IPV)  Estimated 1.1 million Texas Women were battered (HHSC)

 Lower Rio Grande Valley (2014)

 Reported incidents of Family Violence  Edinburg = 943  McAllen = 539  Harlingen = 520

*CDC, 2010

MAGNITUDE OF THE PROBLEM

Spousal Homicide

 Gun in Home → Increases Homicide Risk 500%  72% of Murder-Suicides involve Intimate Partners

50 100 150 200 2010 2011 2012 2013 2014 2015

Wome n Kille d By Pa rtne rs

T EXAS

HEALTH CONSEQUENCES OF IPV*

*Miller & McCaw, 2019

LEARNING OBJECTIVES

By the end of this educational activity, the learner should be better able to:

• 1. Recognize seven sources of primary care provider

frustration in dealing with patients in violent relationships.

• 2. Set realistic expectations in dealing with partner

violence.

• 3. Identify strategies for minimizing the impact of

these frustrations.

LACK OF DISCLOSURE

 Focus Groups of 44 PCPs1

 Frustrated about nondisclosure by women  BUT PCPs:  Have unrealistic expectations about disclosure  Ignore patient hints about IPV

 Qualitative Interviews With Mothers (n=40)2

 More comfortable answering IPV questions if children NOT present Hispanics less comfortable  “What I share depends on how the (Doctor-Patient) relationship is going.”

 Victims want PCPs to ask about IPV3,4  Qualitative interviews of 142 women5

 63% say they would disclose if PCP asked

1Zink, 2004 2Zink, 2006 3Zink, 2007 4Burge, 1996 5Morse, 2012

LACK OF PCP RESPONSE

Qualitative interviews of 142 Women*

PCP Response:

 71% of PCPs told her to just leave (frustrating for women)  22% neutral about advice  31% gave safety information (rarely made safety plan)

Women’s feelings about PCP

 15% - PCP NOT open to talking about IPV  26% - PCP NOT knowledgeable about abuse

*Morse, 2012

[PCP] “All those times that you kept going back, I told you not to go back, now you are on your own.”

LACK OF PCP RESPONSE

 Focus groups of 72 Women1

 What Women want from PCP:  Open-minded  Listens  Unhurried  Respects confidentiality

 Focus groups of 44 PCPs2

 PCPs feel unable to respond  Barriers:  Lack of knowledge and skills  Lack of time  Attitude – “Not my job!”

1Usta, 2012 2Zink, 2004

*

Relationships are complex1

“Taking sides”

“[I felt] embarrassed and unprotected. I felt like [my doctor] defended my husband”2

Mutual violence2

9,643 daily reports of violence completed

 3,813 (40%) reports of husband-perpetrated violence  2,209 (23%) reports of wife-perpetrated violence  85% of women involved

1Zink, 2007 2Katerndahl, 2014

*

0.5 1 1.5 2 2.5 Frequency of Days with Violence Average Severity on Days with Violence Violence Burden (frequency + severity) Women Men

p<.001, all comparisons

*Katerndahl, 2014

“Complex Dynamics”

• 1. PATTERNS OF DYNAMICS

Periodic Dynamics Random Dynamics Chaotic Dynamics

• 2. NONLINEARITY = Output not proportional to input

12% 30% 59% 10 20 30 40 50 60 70 Periodic Chaotic Random PREVALENCE (%) DYNAMIC PATTERN

Prevalence of Dynamic Patterns (N =135)*

*Katerndahl, 2014

Distribution Of Nonlinearity Measurements*

P C RP Rw C Rp P Rw

P = Periodic, C = Chaotic, Rp= Pink Noise (Random), Rw= White Noise (Random)

Disorder Information

*Katerndahl, 2014

Importance Of Nonlinearity*

VIOLENCE

Outcome Frequency Or Severity Nonlinearity Measures Optimal Nonlinearity Attitudinal/Behavioral Positive Coping Negative Coping Positive Appraisal Negative Appraisal Hope / Support Clinical Symptoms / Dysfunction Medical Utilization Readiness To Act Mental Health Utilization – –

+

+ + – + +

*Katerndahl, 2014

Relationships Among Prior-Day Predictors*

Husband’s Hassles Alcohol Intake Marital HUSBAND- Emotional Wife’s WIFE- Distance PERPETRATED Upset Alcohol VIOLENCE + Feedback

• Feedback

Intake *Katerndahl, 2014 PERPETRATED VIOLENCE

Compared with Non-Victimized Women*

 Smaller Support Networks

 Number discussing important matters  Number socializing with

 Support Exchange

 Less support received

 Proportionally less support received  Fewer supportive contact in prior 3 months

 Support imbalance

 Fewer reciprocal relationships  Support given > support received

*Katerndahl, 2013

 Cautious about seeking support

 Family, cultural and societal sanctions1  Sense of isolation1  Sense of shame  Lack of perceived benefit

 Friends respond poorly (often in or witnessed violence)

 Do not know how to respond2  Reaction perceived as unhelpful3  Negative / mixed reaction can hinder taking action4

1Rose, 2000 2Latta, 2009 3Fanslow, 2010 4Bosch, 2004

AUDIENCE POLLING QUESTION 1

Which of the following statements is truly about women’s decision-making concerning their violent relationship?

• 1. Most women seen in primary care have never taken any action

before

• 2. Psychotherapy is generally rated as a positive experience
• 3. Forgiveness by women leads to bad outcomes
• 4. Taking legal action depends strongly upon her perceived need-for-

action

• 5. Having children at home is not important to women’s decision-

making

Decision-Making Measures*

OUTCOME TIME FRAME Prior Experience Readiness-For-Action Perceived Need-For-Action Action Taken Past Future Immediate DONE

READINESS-TO-ACT PRIOR ACTION NEED-TO-ACT ACTION TAKEN *Katerndahl, 2016

0% 10% 20% 30% 40% 50% 60%

PRIOR EXPERIENCE: Action & Experience*

Action (%) Experience (mean)

*Katerndahl, 2016 * Hispanics LESS

# Hispanics MORE

# # #

HELP LEGAL ACTION LEAVING

READINESS FOR ACTION*

 PRIOR ACTION TAKEN

 Only 28% of women have NEVER taken any action before  20% of women have taken at least 5 actions before

 READINESS-TO-ACT:

*Katerndahl, 2016

READINESS versus ACTION (# of women)*

*Katerndahl, 2016

BASELINE READINESS HELP-SEEKING

Readiness Action

LEGAL ACTION

Readiness Action

LEAVING

Readiness Action (Returning)

PRECONTEMPLATIVE (No Interest) CONTEMPLATIVE (Someday - 6 Months) PREPARATION (30 Days) ACTION (Trying Now) 10 0 38 1 11 1 44 5 60 3 28 4 0 0 15 5 39 0 0 49 0 3 0 0 0 15 10 0

CATASTROPHIC DECISION-MAKING (Readiness)*

NEED FOR DISTORTING FACTORS Help

• More Forgiveness

Legal Action

• More Children

Leaving

• More Children
• Less Hope & Positive Coping

*Katerndahl, 2017 Readiness→ Violence & Need→

Nonlinearity Of Need-For-Action*

*Katerndahl, 2016

P C R

w

R

P

P C R

P

R

w

P C R

w

R

P

P C R

P

R

w

P C R

w

R

P

APPROXIMATE ENTROPY LZ COMPLEXITY

P = Periodic, C = Chaotic, Rp= Pink Noise (Random), Rw= White Noise (Random)

LEAVING LEGAL HELP

NEED FOR HELP Violence Increasing Children Safety His Alcohol Perceived Control Forgiveness Stalking Her Violence

Positive Negative

INTERRELATIONSHIPS AMONG PRIOR-DAY PREDICTORS OF NEED*

NEED TO LEAVE Violence Increasing Forgiveness His Violence Keep Together Ready To Move On Effect On Children NEED FOR LEGAL Violence Increasing Children Safety His Alcohol Perceived Control His Violence Keep Together Stress Financial Concern

+

*Katerndahl, 2016

TAKING ACTION (Seeking Help)*  Prior Action Experience – Best Experience  Prior-day Predictors

Sense of control

 Same-day Correlates

Need for help Stress

*Katerndahl, 2016

TAKING ACTION (Legal Action)*  Prior Action Experience – Any Experience  Prior-day Predictors

Concern: Child safety and effect of violence His stalking

 Same-day Correlates – NONE

*Katerndahl, 2016

TAKING ACTION (Leaving [And Returning])*

 Prior Action Experience – Worst Experience As Barrier  Prior-day Predictors  Same-day Correlates  RETURNING AFTER LEAVING

 Prior-day correlates  His alcohol intake  His stalking

Triggers Barriers Perception Violence Increasing His Alcohol Intake Concern: Finances His Violence Triggers Barriers Need To Leave Stress Her Alcohol Intake His Seeking Forgiveness

*Katerndahl, 2016

SUMMARY (Important Factors)

PREDICTORS HELP LEGAL ACTION LEAVING

PRIOR EXPERIENCE

Best experience Any experience Worst experience (-)

READINESS DISTORTING

Depression Religious activity Frequent violence Forgiveness

• Children

Forced sex Children / ↓Hope & Positive Coping

NEED

Prior-Day: Increasing violence Concern (safety & effect of violence) Her violence His stalking Forgiveness Lacks control

• Prior-Day:

Increasing violence Concern (finances) Forgiveness Level of his violence

ACTION

Prior-Day: Control Same-Day: Need Stress Prior-Day: Concern (safety) Stalking Prior-Day: Perceived increasing violence His alcohol intake Same-Day: Need Stress

KEY FINDINGS: 1. Forgiveness does NOT keep her from taking action!

• 2. He seeks forgiveness and stalks her BECAUSE THEY WORK!

 Focus Groups of PCPs1 and Qualitative Interviews of Midwives2  Resources unknown (concerns about future support)  Agencies can be problematic

1Zink 2004 2Eustace 2016

DEALING WITH FRUSTRATIONS

• 1. Lack of Disclosure
• 2. Lack of PCP Response
• 3. Mutuality
• 4. Lack of Unpredictability
• 5. Lack of Support
• 6. Lack of Action
• 7. Lack of Services

“Expectation is the mother of all frustration.”

• --Antonio Banderas

OUTCOMES OF STUDIES INVOLVING VARIOUS PRIMARY CARE INTERVENTIONS

OUTCOME % Studies With Significant Improvement ANY POSITIVE OUTCOME 13 / 17 (76%) Reduction In Violence 5 / 11 (45%) Improved Health

• Specific Health Issues
• Fewer VLBW / Preterm Babies
• Improved Quality-Of-Life
• Less Depression
• Less Unprotected Sex / Coercion

6 / 12 (50%) 1 / 1 (100%) 1 / 4 (25%) 2 / 2 (100%) 2 / 2 (100%) Safety-Promoting Behavior 2 / 5 (40%) Use Of IPV Resources / Referral 6 / 10 (60%)

DEALING WITH FRUSTRATIONS

FRUSTRATION #1

Women in Shelters (n=32)1

 Ask about IPV  Explore clues given

 Controlling spouse  Passive patient  Physical injuries with poor explanation  Centrally-located / bilateral injuries  Defensive wounds  Nonspecific complaints  Mental health complaints

• Lack Of Disclosure

 Screening

 Context matters for her response2

 How performed  Who asks

 Preferably when patient alone  Screen EVERY visit

1Zink, 2004 2Miller & McCaw, 2019

DEALING WITH FRUSTRATIONS

FRUSTRATION #1 – Lack of Disclosure

 CASE STUDY:

 67 y/o with Schizoaffective Disorder and HTN  Always accompanied by husband who provided history  When alone, repeatedly denied IPV  Upon returning to practice after years:

 Volunteered that IPV present  IPV ended when she threatened leaving

DEALING WITH FRUSTRATIONS

SCREENING

 USPSTF: “All women of childbearing age should be screened for IPV” (“B” Evidence)  4-Item HITS (any “yes” = positive screen)*

 Does your partner…

 Physically hurt you? Yes / No  Insult you and talk down to you fairly often? Yes / No  Threaten you with harm? Yes / No  Scream or curse at you fairly often? Yes / No

*Shakil, 2014

UNIVERSITY HEALTH SYSTEM “Are you currently in any relationships that make you feel unsafe?” FAMILY HEALTH CENTER IPV Studies

IPV Prevalence 0.3% 20.7% – 22.5%

DEALING WITH FRUSTRATIONS

FRUSTRATION #2 – Lack of PCP Response IPV Skills

 Screening  Cultural competence  Education  Therapeutic alliance  Public awareness

DEALING WITH FRUSTRATIONS

Conversational Elements* IPV is Wrong – “No one deserves to be hurt!” Document – Signs and symptoms Support – “You are safe here, tell me how to help you.” Care and Concern – “Do you have a safety plan?” Resources – “Here, take this information…”

*Chang, 2005

DEALING WITH FRUSTRATIONS

Assessing Risk Of Injury

HIGH RISK: ≥3 = Risk of Homicide / Severe Injury*

• 1. Has violence increased in the past 6 months?
• 2. Has partner used / threatened you with weapons?
• 3. Is your partner capable of killing you?
• 4. Beaten while pregnant or ever been choked?
• 5. Is partner violently / constantly jealous?

 “Minimum” Safety Plan = Ready to Leave Immediately

 Clothes  Documents  Money  Unknown (to him) sanctuary

*Miller & McCaw, 2019

DEALING WITH FRUSTRATIONS

Mandatory Reporting Adult Protective Services Adults ≥ 65 years old Disabled adults Child Protective Services Any child abuse

DEALING WITH FRUSTRATIONS

FRUSTRATION #3 –

 Even if she is also violent, she is still a victim  Woman’s violence less frequent and intense

 SHE is at greater risk!

 If perpetrator as also your patient

 Men do want treatment*

 Important to Behavior Change: Key incidents, relationships, taking responsibility**  Cognitive Behavioral Therapy Works*

 Look for and treat Mental Illness

 Explore Relationship Dynamics

 Can she change his violence by changing HER behavior?

*Jarwson et al, 2015 **Sheehan et al, 2012

DEALING WITH FRUSTRATIONS

FRUSTRATION #4 – Lack of Predictability

 IPV Unpredictable and Complex

 Explore dynamics to understand predictability  Knowing dynamics may help with intervention

 Recognition of high-risk situations and avoidance possibilities  Possible interventions?

• 1. NONLINEAR → Simple interventions unsuccessful (except mindfulness?)
• 2. Individualized dynamics-based treatment
• 1. Periodic Dynamics – Predictable Response
• 2. Chaotic Dynamics – Focus On “Attractors” / Timed Interventions
• 3. Random Dynamics – Difficult / Terminate Relationship?

DEALING WITH FRUSTRATIONS

FRUSTRATION #5 – Lack of Support

 Encourage social involvement  Educate network members?  Women may “Tailor” their networks  Networks could provide access to resources  IPV support groups

DEALING WITH FRUSTRATIONS

FRUSTRATION #6

 REMEMBER:

 Victim chooses her action1  Action is process over time1

 Women in Shelters (n=32)2

 Women in contemplative stage need:

 Affirmation of IPV  Education  Documentation of Injury

– Lack Of Action

 Possible Intervention

 Prepare patient if leaving

 Expect his stalking

 Forgiveness?

 Positive effects  No decreased action

 Journaling?  Motivational Interviewing?  Assess: Prior Experience Readiness-to-Act Need-for-Action

 Encouraging Action (Discussing potential triggers)

1Zink, 2007 2Zink, 2004

AUDIENCE POLLING QUESTION 2

Which recommended intervention are women in violent relationships least likely to pursue?

• 1. Read about IPV resources available
• 2. Go to a women’s shelter
• 3. Make weekly office visits to their PCP
• 4. Make weekly telephone calls to a nurse about the

violence

• 5. Talk to a lawyer

DEALING WITH FRUSTRATIONS

LIKELIHOOD OF FOLLOWING PCP’S ADVICE (TAFP Foundation-Research)*

INTERVENTION HIGH LIKELIHOOD LOW LIKELIHOOD

READ ABOUT

IPV resources

CONTACT / ACTION

Counseling with psychologist Women’s shelter

REGULAR ACTIVITIES

• Daily Record Of Violence
• Weekly Telephone Contact
• Weekly Visit

Telephone Journaling PCP / Counselor Nurse / Violence expert Police officer PCP / Counselor Nurse / Violence expert Police officer

SOME LIKELIHOOD

Contact: Police, Lawyer, Family Justice Center, Leaving, Clergy Regular Activity: Online records, Social worker, Clergy, IPV group Family / Friends: Current, Trained in IPV

*Becho, 2018

DEALING WITH FRUSTRATIONS

HELPING WOMEN TO TAKE ACTION

WOMAN IN ABUSIVE RELATIONSHIP Any Readiness for ANY Action? Any Prior Action Taken? PRECONTEMPLATIVE PRIOR LEGAL ACTION READINESS / EXPERIENCE HELP-SEEKING OR LEAVING READINESS FOR HELP-SEEKING READINESS FOR LEAVING + POSITIVE BEST EXPERIENCE + NON-NEGATIVE WORST EXPERIENCE Encourage:

• Discuss Abuse With

Network

• Discuss Abuse

Experience Discuss:

• Child Safety
• Stalking

Address Need-for- Help Address Need-to- Leave LEGAL ACTION

DEALING WITH FRUSTRATIONS

HELPING WOMEN TO TAKE ACTION

NEED FOR ACTION SOUGHT HELP LEFT RELATIONSHIP Frequent Follow-up Stalking Expectations Discuss:

• Her Violence
• Concern (child safety)
• Increasing Violence
• Stalking
• Forgiveness

Discuss:

• Concern (effect)
• Level of Violence
• Increasing Violence
• Forgiveness

Discuss: Sense of Control Triggers: Barriers:

• Increasing Violence
• Finances
• His Alcohol Intake
• His Seeking Forgiveness

Address Need-for-Help Address Need-to-Leave

DEALING WITH FRUSTRATIONS

SHORT-TERM FORGIVENESS (Prior-day Effects)*

+ Feedback − Feedback *Katerndahl, 2014

DEALING WITH FRUSTRATIONS

FRUSTRATION #7 – Lack of Services

 Available Resources:

 Nationwide Crisis Hotline: 800-999-9999  National Domestic Violence Hotline: 800-799-7233  National Referral For Child Abuse, Domestic Violence & Elder Abuse: 800-222-2000  Local Texas Resources: http://tcfv.org/resource-center/

• San Antonio
• Family Justice Center

210-208-6800

• Family Violence Preventive Services

210-733-8810

• Women’s Shelters
• Battered Women’s Shelter

210-733-8810

• Magdalena House

210-561-0505

 WEBSITE: http://bit.ly/ipassprt*

*Sprunger et al, 2019

SUMMARY

 7 Frustrations

1. Lack of Disclosure – Screen Women (Clinic Routine) 2. Lack of PCP Response – Develop IPV Skills 3. Mutuality – Most Relationships Involve Mutual Abuse 4. Lack of Unpredictability  Understanding Dynamics May Help Intervention  Possibly Identify High-Risk Situations 5. Lack of Support – Encourage Social Involvement 6. Lack of Action – Tailor Intervention Based On:  Type of Action  Prior Experience  Readiness-to-Act  Perceived Need-for-Action 7. Lack Of Services – Know What is Available

 ABOVE ALL: Realistic Expectations!

ESTIMATING VIOLENCE NONLINEARITY