Screening for physical violence in couple therapy: methodological, practical, and ethical considerations

Is It Safe Enough? An IPA Study of How Couple Therapists Make Sense of Their Decision to Either Stop or Continue with Couple Therapy When Violence Becomes the Issue

BACKGROUND

Couple therapists will encounter couple violence in their practice at some point. In this context, one of the main questions they must address is whether to continue with conjoint sessions. This study explores how couple therapists make sense of their decision whether or not to continue with conjoint sessions when violence has become an issue.

METHODS

This qualitative study used four semi-structured focus groups and Interpretative Phenomenological Analysis (IPA) to analyse the data from the twelve experienced couple therapist participants.

RESULTS

Our IPA analysis led to three main group experiential themes across the focus groups: (1) Is it safe enough? (2) Do we have a joint and regenerative project? (3) Three key sources for sense making.

CONCLUSION

Partner violence challenges the realm of couple therapy. This article explored how the couple therapists orient themselves and grapple with decision making when violence becomes an issue. The article offers unique insights regarding what the therapists orient themselves towards and how they try to form an impression of whether to continue conjoint sessions. We outline immediate clinical implications and propose measures for building individual and organisational capacity regarding "clinical sense making". Suggestions for further research are also addressed.

Universal screening for intimate partner violence: a systematic review

Intimate partner violence (IPV) is known to be prevalent among therapy-seeking populations. Yet, despite a growing understanding of the dynamics of IPV and of the acceptability of screening, universal screening practices have not been systematically adopted in family therapy settings. A rapidly growing body of research data-almost entirely conducted in medical settings-has investigated attitudes and practices regarding universal screening for IPV. This article is a systematic review of the IPV universal screening research literature. The review summarizes literature related to IPV screening rates and practices, factors associated with provider screening practice, the role of training and institutional support on screening practice, impact of screening on disclosure rates, client beliefs and preferences for screening, and key safety considerations and screening competencies. Implications for family therapy and recommendations for further inquiry and screening model development are provided.

Threats and acts of intimate partner violence reported by users at Norwegian women's shelters

Women (n = 87) at women's shelters in Norway, a country of high welfare and gender equality, reported a multitude of severe threats and actual acts of physical, sexual and psychological violence. An individual threatening to kill his partner represented a significant increased risk for experiencing serious acts of violence, especially when the threats were repeated. A self-administered questionnaire was sent to all the women's shelters. Experiences of violence were measured by The Severity of Violence against Women Scale (SVAWS) and the Psychological Maltreatment of Women Index (PMWI).

Domestic violence assessment procedures among couple therapists

Guidelines for addressing domestic violence (DV) in couple therapy have been published, but reports of whether therapists routinely follow these suggestions are few. A national survey of 620 couple therapists randomly selected from American Association for Marriage and Family Therapy members was conducted in 2000 to assess therapists' strategies for assessing DV and selecting a treatment modality when violence is discovered. Less than 4% of respondents indicated consistently following key published guidelines for DV screening (universal screening using separate interviews and questionnaires). A minority indicated that they consider the victim's safety as a factor in treatment modality selection. DV may be under-identified by couple therapists and therapists may be using conjoint therapy with couples for whom such therapy is contraindicated because of relationship violence.

Evidence-based approaches to assessing couple distress

This article describes a conceptual framework for couple-based assessment strategies grounded in empirical findings linking couple distress to a broad range of both individual and relationship characteristics. These characteristics can contribute to, exacerbate, or result from relationship problems. On the basis of these findings, the authors articulate specific targets of clinical inquiry reflecting relationship behaviors, cognitions, and affect as well as features of individual distress. Guided by this framework, empirically supported assessment strategies and techniques emphasizing relationship functioning across diverse methods are proposed, including the clinical interview, analog behavioral observation, and both self- and other-report measures. Discussion concludes with specific recommendations regarding clinical assessment of couple distress and directions for further research.

[Portuguese-language cross-cultural adaptation of the Parent-Child Conflict Tactics Scales (CTSPC), an instrument used to identify parental violence against children]

This article concerns the first phase of the assessment of the cross-cultural equivalence between the Parent-Child Conflict Tactics Scales (CTSPC) designed in English and used to identify child abuse and neglect, and a Portuguese-language version to be used in Brazil. Evaluating conceptual and item equivalences involved expert groups. Assisted by a broad literature review, discussions focused on the existence and pertinence of the underlying theoretical concepts and the corresponding component items in the Brazilian context. The appraisal of semantic equivalence involved the following steps: two translations and respective back-translations; an evaluation regarding referential (literal) and general (meaning) equivalences between the original instrument and each version; further discussions with experts in order to produce a final version; and pre-testing the latter on 774 women. It proved possible to establish a satisfactory conceptual, item, and semantic equivalence between the Portuguese-language version and the original CTSPC. Acceptability of the version was excellent. Albeit encouraging, results should be reassessed in the light of forthcoming psychometric analysis (measurement equivalence), as well as through ongoing criticism from interested professionals.

Setting Up a Domestic Violence Service

BACKGROUND

This paper describes some of the issues we confronted and resolved in setting up an independent dedicated domestic violence service.

METHOD

In our project we work with violent behaviour that is known or suspected in the contexts of both assessment and therapy. We describe our policy on domestic violence, including confidentiality, our reflecting practices, our relationships with referrers as a means of managing the risk of violence, and the assessment and evaluation procedures we use for the assessment of risk of violence. We include some discussion of the effects of domestic violence on children and the effects of doing this work on ourselves.

CONCLUSIONS

We conclude by discussing the moral issues involved for us as therapists in doing this work, the impact of the legal frame within which we work, and some of the social and psychological theories we find helpful in understanding the causes and effects of violent behaviour in the family.

The different faces of intimate violence: implications for assessment and treatment

Current research about violence in intimate relationships suggests that at least two qualitatively distinct types of violence exist. This new knowledge challenges the dominant conceptualization of intimate violence as solely a manifestation of patriarchal male dominance. Following a review of the research and analysis of illustrative clinical examples, a conceptual framework is presented that assists couple therapists in answering three salient questions: What type of violence am I most likely to be working with? How can I assess the differences between types of violence? And how might I proceed with treatment for different types of violence?

HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania

OBJECTIVES

Experiences of partner violence were compared between HIV-positive and HIV-negative women.

METHODS

Of 340 women enrolled, 245 (72%) were followed and interviewed 3 months after HIV testing to estimate the prevalence and identify the correlates of violence.

RESULTS

The odds of reporting at least 1 violent event was significantly higher among HIV-positive women than among HIV-negative women (physical violence odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.23, 5.63; sexual violence OR = 2.39; 95% CI = 1.21, 4.73). Odds of reporting partner violence was 10 times higher among younger (< 30 years) HIV-positive women than among younger HIV-negative women (OR = 9.99; 95% CI = 2.67, 37.37).

CONCLUSIONS

Violence is a risk factor for HIV infection that must be addressed through multilevel prevention approaches.

Battered women who were "being killed and survived it": straight talk from survivors

Findings from police reports and interviews with women who have survived an attempted domestic homicide revealed patterns in their experiences and sources of distress. The build-up in the year prior to the near-lethal attack involved tension from ongoing contact with an angry, controlling batterer. Most typically the perpetrator was an alcoholic or drug addict, a gun owner, and, if his victim had left him, her stalker. In the majority of cases, the victim had either left or announced that she was leaving the relationship. While he had often threatened her life and she feared him, she typically did not think him capable of killing her. She described the attack as shocking and terrifying, and she felt certain she was going to die. In the immediate aftermath, she received some support, but as time went by, she felt isolated and alone. Ultimately, the women became convinced that they must rely on their "inner strength" to get on with their lives.

Asking patients about violence: a survey of 510 women attending social and health services in Trieste, Italy

Violence against women is frequent, and has serious consequences for their physical and mental health. Until now, a common response of health services and professionals to victims has been the denial of the violence. The aims of this study were to estimate the prevalence of present and past violence among women attending social and health services in Trieste (Italy) for any reasons, and to evaluate the feasibility of asking them about violence. Five public health care facilities were involved: a hospital-based Emergency Department, two "Consultorio Familiare", and two community-based Social service centers. The final sample consisted of 510 women; the response rate among eligible women was 76% across all facilities. The study revealed a high prevalence of different kinds of violence, mostly perpetrated by men well known to the victim. Among the women interviewed, 10.2% had experienced physical/sexual violence in the last 12 months, regardless of perpetrator. Violence by a male partner or former partner, occurred in 6.4% of women; by other relatives, 1.6% of women; and by "other" persons 3.3% of women. The results demonstrated the feasibility of "asking about violence" in all cases; moreover, those women who had been abused were often eager to talk about it. A systematic approach to the issue of violence is a necessary condition for responding appropriately to the needs of women who have experienced or are experiencing violence. Nevertheless, to avoid the replication of a common bias against victims of violence, health and social personnel should be appropriately trained before "asking all cases" becomes a policy within health and social services.

[Recording of venomous bites and stings by National Information Systems in Brazil]

This paper highlights the epidemiological surveillance of venomous bites and stings according to four national information systems: SINAN (National Databank of Major Causes of Morbidity), SINITOX (National Information System on Poisoning), SIH-SUS (Hospital Information System of the Unified Health System), and SIM (Mortality Information System). The authors conclude that each information system has specific characteristics and addresses different demands. Although they contain large amounts of data, even if combined they fail to reflect the real magnitude of disorders caused by venomous bites and stings in the country.

Training family therapists to assess for and intervene in partner abuse: a curriculum for graduate courses, professional workshops, and self-study

Partner abuse is an epidemic with potentially dire consequences for individuals, families, and society. Family therapists must be able to competently assess for and intervene in abuse situations. This article presents a curriculum designed to provide family therapists with introductory knowledge and skills for the assessment and intervention of partner abuse. The curriculum, which is informed primarily by feminist and multicultural theories and practices, can be used in graduate courses, professional workshops, and for self-study.

Risk for domestic violence: factors associated with perpetration and victimization

The extent and potential dangerousness of the problem of domestic violence warrants systematic screening and assessment in all mental health settings. Few empirical studies have approached the question of domestic violence with the aim of identifying risk markers, making it impossible to identify a particular characteristic or set of characteristics that can be used to identify individuals at risk for perpetrating or becoming the victims of domestic violence. However, there are a number of factors that have been identified as correlates of domestic violence that may eventually prove useful for identifying individuals at risk, but the extant literature does not provide the empirical support at this time. Because many of these correlates may be brought to the attention of mental health and medical professionals (e.g., depression, substance use/abuse, physical injuries) and given the absence of established risk factors for domestic violence, there is a need for clinicians to systematically assess for violence among all of their patients. By identifying factors that might help clinicians realize that many of their patients are at risk for domestic violence, we hope to encourage them to attend to this potentially dangerous problem. Ongoing assessment in the context of knowledge regarding correlates of domestic violence can provide important information for evaluating risk of a particular violent incident. In addition, we outline strategies for assessing violence and violence risk in both perpetrators and victims in order to assist clinicians in approaching this difficult topic in a clinical setting. A careful assessment of the potential for violence within clients' ongoing relationships is necessary for clinicians to provide appropriate clinical care.

Battering and couples therapy: universal screening and selection of treatment modality

As family therapists begin to experiment with couples treatment models for batterers and their partners, a basic question is: Which couples can be safely treated with conjoint therapy? Following a definition of battering and a review of rationales for considering couples therapy in cases of domestic violence, a framework for assessment of domestic violence is outlined, including sample questions, criteria for excluding couples from conjoint therapy, how to conduct a lethality assessment, and how to conceptualize postassessment treatment recommendations. This article also introduces family and couples therapists to domestic violence literature that is often not well integrated in family therapy theory and practice.

Atrocities exposure in Vietnam combat veterans with chronic posttraumatic stress disorder: relationship to combat exposure, symptom severity, guilt, and interpersonal violence

Vietnam combat veterans (N = 151) with chronic posttraumatic stress disorder (PTSD) completed measures of atrocities exposure, combat exposure, PTSD symptom severity, guilt and interpersonal violence. PTSD symptom severity, guilt and interpersonal violence rates were similar to previously reported studies that examined treatment seeking combat veterans with PTSD. Controlling for combat exposure, endorsement of atrocities exposure was related to PTSD symptom severity, PTSD B (reexperiencing) symptoms, Global Guilt, Guilt Cognitions, and cognitive subscales of Hindsight-Bias/Responsibility and Wrongdoing. These results are discussed in the context of previous research conducted regarding atrocities exposure and PTSD.

Identification of child maltreatment with the Parent-Child Conflict Tactics Scales: development and psychometric data for a national sample of American parents

OBJECTIVE

To create a parent-to-child version of the Conflict Tactics Scales, the CTSPC.

METHOD

Description of the conceptual and methodological approaches used and psychometric data for a nationally representative sample of 1,000 U.S. children.

RESULTS

(1) Improved Psychological Aggression and Physical Assault scales. (2) New Nonviolent Discipline scale, supplementary scale for Neglect, and supplemental questions on discipline methods and sexual abuse. (3) Reliability ranges from low to moderate. (4) Evidence of discriminant and construct validity.

CONCLUSIONS

The CTSPC is better suited to measuring child maltreatment than the original CTS. It is brief (6 to 8 minutes for the core scales) and therefore practical for epidemiological research on child maltreatment and for clinical screening. Methodological issues inherent in parent self-report measures of child maltreatment are discussed.

Intimate justice: confronting issues of accountability, respect, and freedom in treatment for abuse and violence

Intimate justice theory is a set of nine interrelated concepts that describe the ethical dimensions of equality, fairness, and care in ongoing partnerships. Understanding ethical dimensions involves examining internalized beliefs and behavior in terms of their motivation and impact on the partner, particularly as they empower, disempower, or abuse power. The concepts of intimate justice theory are applied to confront disempowerment and abuses of power, to challenge internalized beliefs about how one should treat one's partner, to explore how internalized beliefs were developed through experiences in the family of origin, and to develop an awareness of the linkages between intimate partner abuse and social injustice. This article demonstrates how therapists can utilize three of the concepts --accountability, respect, and freedom--to structure the opening phase of treatment for abuse and violence. The primary focus of the opening phase is on establishing accountability for change in the abusive man and protecting the safety of the injured partner. This involves challenging the abuser's sense of entitlement and working to rethink what respect is and restoring freedom to his partner. The discussion incorporates the findings of an exploratory, qualitative study that investigated the experiences of 30 abusive men and their partners who were clients in a university-based counseling clinic. The article elaborates six interventions that can be utilized in clinical settings to structure treatment with abusive men.