Interpersonal Violence. Prevalence of IPV. Prevalence of SA. Disclosure. Objectives 8/3/2014

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1 Communication Techniques Related to IPV, Sexual Coercion and Sexual Assault Survivors Serena Clardie, MSW, LCSW Riverwalk Psychotherapy Associates, LLC Milwaukee, Wisconsin Interpersonal Violence Defined as a pattern of assaultive behavior and coercive behavior that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation and reproductive coercion. 1 Perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship Aimed at establishing control of one partner over the other Disclosure Nothing to disclose Prevalence of IPV 20-30% of women and 7.5% of men have been physically or sexually abused by an intimate partner in their adult lives 1 Women aged experience the highest per capita rate of IPV 2 Children exposed to IPV are seen with more frequency and regularity in the health care system as children and as adults 1 Objectives Prevalence of SA Recognize how a patient's experience of medical care may be impacted by current or past experiences of violence. Recognize how traumatized patients may present and report differently, including impact of dissociative experiences. Identify how to ask questions to patients around IPV/SA in a safe, sensitive and effective manner. Identify when inquiry around IPV and SA should occur in health care settings and when further assessment is indicated. Identify how best to respond to a patient who disclosed both recent/current IPV/SA as well as a history of abuse. Recognize issues unique to male survivors, differences among ethnic/racial groups and vulnerable populations. Learn how to develop a referral network in your area to assist patients. 1 in 4 females and 1 in 6 males have experiences sexual assault or abuse before the age of ,000 adult women and 92,000 adult men are forcibly raped each year in the U.S. 4 1

2 Consequences of IPV Consequences of Abuse and Assault Psychological Twice as likely to suffer from depression 7 Self-harm Suicide Alcohol and drug abuse 9 times as likely to be alcohol dependent and 8 times as likely to have used drugs in the past year 8 Consequences of IPV Acute physical injuries 20% of homicides directly associated with IPV 5 Severe injuries warranting medical treatment Less several injuries observed during routine care Post-traumatic Stress Disorder (PTSD) 9 Criterion A The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) Direct exposure. Witnessing, in person. Indirectly, by learning that a close relative or close friend was exposed to trauma. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties Consequences of IPV Non-acute presentations Related to arthritis, chronic neck or back pain, migraine/headaches, STIs, chronic pelvic pain, peptic ulcers, chronic IBS, frequent indigestion, diarrhea or constipation 6. PTSD (continued) Criterion B: Intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories. Traumatic nightmares. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli. Criterion C: Avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) Trauma-related thoughts or feelings. Trauma-related external reminders 2

3 PTSD (continued) Criterion D: Negative alterations in cognitions and mood Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) Inability to recall key features of the traumatic event Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. Persistent negative trauma-related emotions Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions. Why Do Some Develop PTSD and Others Don t? Risk Factors Presence of personal or family history of psychiatric disorder 10,11 Factors related to nature of trauma 10 Interpersonal violence Severity of trauma Chronicity of trauma Fear of dying Recovery environment associated with secondary stressors PTSD (continued) Criterion E: alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. Criterion G: functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational). Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness. Consequences of IPV More likely to miss work, have difficulty attending medical appointments, adhere to treatment plans, overcome adverse behaviors 12 PTSD (continued) Specify if: With dissociative symptoms. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization: experience of being an outside observer of or detached from oneself Derealization: experience of unreality, distance, or distortion Specify if: With delayed expression. Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately. Dynamics of Abuse 3

4 Phases of Abuse Tension Building Trying to make sure the abuser doesn t explode Walking on eggshells Acute Battering Incident No win situation, nothing can change outcome Relief or Honeymoon Period Promise abuse won t happen again, may apologize Calm period Screening for Abuse in Health Care Settings Why Don t They Just Leave? Power and Control Wheel Goals of Routine Screening 1 Identify patterns of violence Prevent escalation of violence Prevent cycles of abuse across lifespan IPV also associated with high health care costs to system and patient Reasons Victims May Feel Trapped Fear More likely to be seriously injured or killed when trying to leave relationship Worry for children (placement, safety) Impact of emotional abuse on self-esteem, confidence brainwashed Economic dependence Often related to control dynamics by abuser Isolation Relationships with outside supports have often been destroyed, so little help burned bridges Attachment to abuser It s not always bad Hope for change Marriage/religious values Differences in Assessment and Response between IPV & SA Inquire about IPV at every visit as new events may occur or relationships can change No need to inquire about childhood experiences of sexual abuse repeatedly Can be retraumatizing 4

5 Patient Experience in the Health Care System Around IPV Half of women reported IPV to health care provider (HCP) 13 Only 31% received safety planning 71 % felt provider was advocating that they leave relationship 37.5% were told directly to leave 65-85% felt comfortable and believed HCP to be knowledgeable and open regarding IPV Almost 2/3 disclosed only when asked and most who didn t disclose said they would have if asked Introductory Statements "I talk to each of my patients about if their relationships are safe because unhealthy relationships can have a significant impact on health. Because abuse is so common in people s lives, I ve begun to ask about it routinely. Unfortunately, assault and abuse are common and can affect people in many different ways. I ve started to ask my patients about these experiences to ensure that I can help them in the best way possible. Does training providers work? 14 Wide range of effectiveness Decrease in inappropriate prescriptions Increased positive professional attitudes towards IPV Increased patient satisfaction Mixed reviews on if it increases victim identification Education alone doesn't translate into increased screening or identification. Organizational barriers - what are they? Confidentiality and Reporting Learn about laws in your state around mandatory reporting Reporting Guidelines, Appendix J Inform patients of limits to confidentiality prior to asking them about their experiences. I want you to know that everything we talk about is confidential and private between the two of us, with the exception of the following situations, which I have to report to authorities: When a minor is abused physically or sexually If you are an immediate danger to yourself or someone else. Organizational Barriers Questions about the appropriateness and value of screening given patient presentation and clinical setting 2. Inadequate provider experience resulting in feelings of frustration. 3. Concerns about time and workload priorities. 4. Concerns about the process of screemimg 5. Concerns about the outcome and efficacy of screening. Possible Patient Presentations Discomfort when asked about relationship Avoidance of eye contact Fidgeting Getting small Denial of abuse as safety measure Zoning out Unexplained injuries 5

6 Medical Response to IPV 1. Inquiry asking if abuse occurred 2. Assessment finding out more about reported abuse 3. Intervention Offering assistance and support to patient around abuse When Should Inquiry Occur? 1 Inquire about past and current IPV during Routine health history/new patient encounter Standard health assessment (urgent care, ED) Inquire about current victimization only during Periodic health visits Visits for new health complaint Report of new intimate relationship When signs present Inquiry guidelines 1 Ask about current and lifetime exposure to IPV Physical, emotional and sexual abuse Adolescent and adult patients of all backgrounds Parents/caregivers of children When Should Inquiry Be Avoided? When private space is not available If it s thought to be unsafe for patient or provider to do so If interpreter is unavailable Note in chart so follow up can occure Have materials available in clinic or on discharge instructions Inquiry 1 Conducted routinely (regardless of if indicators are present) Conducted orally/face to face Included in written or computer based questionnaires Direct and nonjudgmental language Culturally appropriate Conducted in private After patient is informed of any reporting requirements Assisted, if needed, by translators Inquiry Questions Has your current partner ever threatened you or made you feel afraid? Has your current partner ever hit, choked or physically hurt you? Define hurt as being hit, slapped, kicked, bitten, pushed or shoved Has your current partner ever forced you to do something sexually that you did not want to do? Has anyone expressed concern for you about your relationship? Have you been hurt or afraid in any of these ways in a former relationship? Did anyone have sex with you without your consent or touch you in a sexual way that felt confusing when you were younger? 6

7 Assessment Goals 1 Create a supportive environment in which patient can discuss abuse after a disclosure Enable provider to gather info about health problems associated with abuse Assess immediate and long term health and safety needs for patient Danger Assessment 15 Danger Assessment Immediate safety Assessment Questions Are you in immediate danger? Is your partner here with you today? Do you want to (or have to) go home with your partner? Have there been threats of abuse or abuse of the children? Are you afraid your life is in danger? Assess Impact on Health How does their experience of abuse affect presenting health issue? Does partner control access to health care or how patient cares for self? How does it relate to other health issues? Additional Danger Assessment Questions Has the violence gotten worse or is it getting scarier? Is the violence happening more often? Has your partner used weapons? Has your partner held you or the children against your will? Does your partner watch you closely, follow you, or stalk you? Has your partner ever threatened to kill you, him/herself or your children? Does your partner abuse alcohol or drugs? Assess Pattern/History of Abuse How long has the violence/abuse been going on? Can you tell me about the most serious/worst incident? Have any other family members ever been hurt by your partner? Does your partner control your activities or finances? Have you ever been hospitalized because of the abuse? 7

8 Assessment Questions for Disclosure of Past Abuse When did abuse first occur? Do you feel still at risk in any way? Are you still in contact with ex-partner? Do you share custody of children? How do you feel it s affected you (emotionally and physically)? Interventions Information and Psychoeducation Violence tends to continue and worsen over time. Abuse will likely not stop on its own. Abuse can impact you in many ways, physically and emotionally. You are not to blame, but know that abuse in the home can hurt your children too. Interventions Interventions in Working with Patients Who Have Experienced Abuse Referrals Resource sheet to every client who discloses You deserve help in dealing with something so difficult. Could I help to connect you to someone you could talk more to about this? You can consider calling the police or getting a no contact order. The organizations on this sheet can help you sort through the options. Interventions Listen non-judgmentally Role is not to convince person to leave relationship Validation and normalization Unfortunately, this is a very common experience for many people. I m glad you shared this with me today. You don t deserve the abuse and nothing you did caused it to happen. It s not your fault. / What happened was not your fault. I m sorry you were hurt in that way. You are not to blame for what happened to you. Thank you for trusting me with such an important and private experience. Interventions Mental health providers who specialize in abuse/trauma Never refer for couples/marital counseling when abuse is occurring 8

9 Suggestions on Avoiding Revictimization Care Modifications Explain what you plan to do and the reasons for the prodecure before performing any exams or testing. Ask permission to touch the patient. While you are providing the care, keep patient informed as to what you are doing as you are doing it. Check in regularly as to how the patient is feeling. Modifying Care for Survivors Abuse can impact a patient s experience of medical care. Care may have to modified, both how it is discussed and presented, as well how it is administered Let me know how I can make you more comfortable as I take care of your medical needs. Suggestions on Avoiding Revictimization Move at the patient s pace and take breaks as necessary. Use grounding techniques if the patient seems to be in distress or disconnected. Calmly remind patient where they are, that they are safe, that the abuse is not currently happening. Restore a sense of control for the patient by providing her/him with as much choice as possible. Suggestions on Avoiding Revictimization 16 Greet the patient while she/he is still fully dressed. Avoid positioning yourself between the patient and the exit door. Ask what you can do to make the examination easier and less frightening. If possible, offer the presence of a third person in the exam room. Follow-up Care Offer follow up visit in response to disclosure Coordinate care with PCP and mental health providers Ongoing care visits Ask about further episodes of IPV Communicate concern for safety Review options 9

10 LGBT Patients Special Populations and Considerations Research shows IPV occurs at similar rates in gay/lesbian relationships 1 Higher rate in male same sex relationships than female 1 Use inclusive language to avoid assumptions about sexual orientation Have you ever been scared of your partner? Have you ever felt unsafe in your current relationship? Pregnancy Approximately 324,000 pregnant women are abused each year in the U.S. 17 Pregnancy complications, including low weight gain, anemia, infections and first and second trimester bleeding 1 20% of women with history of abuse experienced pregnancy coercion and 15% reported both control sabotage. 18 Cultural Differences Become familiar with different terminology to describe unhealthy relationships in populations seen in your practice - What would happen if someone from your culture (or a family member) was being hurt by their spouse/partner? How would others respond? Differences in presentation Shame around discussing personal details with someone outside of the family Avoidance of eye contact, silence in response to questions Immigrant women may fear deportation Adolescents 1 out of 10 female high school students reported experiencing physical violence from their dating partners in the past year 19 More likely to experience pregnancy, STIs, report tobacco use and mental health issues, including suicide attempts Role of social media in control and abuse for teens Older Adults An estimated 1-2 million U.S. citizens aged 65 years or older have been injured, exploited or mistreated by someone caring for them. 20 ⅔ are adult children or partners 21 10

11 Those with Disabilities May be more reliant on partners for help, which can create dangerous dynamic of control - Has your partner prevented you from using a wheelchair, cane, respirator or other assistance device? 22 - Has your partner refused to help you with an important need such as taking your medicine, getting to the bathroom, getting out of bed, etc? 22 Legal and Ethical Questions Men No clear guidelines on if screening should occur for all male patients given that the vast majority of perpetrators are male. Concerns include male perpetrators claiming victimization to avoid consequences or as tactic to further control victims. 1 May miss survivors in both homosexual and heterosexual relationships if screening doesn t occur. Reflections What if you think someone is experiencing abuse and doesn t disclose? What if you think they are putting their children in danger by staying in the relationship? What if you fear for their life? What if you think it s unsafe for them to leave your clinic with their partner? Other situations? Documentation Consult with administration on appropriate protocols for your facility Sample charting examples Photo documentation Note that inquiry was conducted, danger/safety assessment completed, verbal/written information provided, referrals provided, plans for follow up 11

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