Sarah M. Bannon and Jessica K. Salwen-Deremer
Intimate partner violence victimization (IPV; psychological, physical, or sexual acts against a current or former romantic partner) is a highly prevalent, yet sensitive concern for both patients and mental health professionals. Patients may worry about the potential consequences of disclosing experiences of abuse for myriad reasons. Practitioners may wonder about the best methods for identifying at-risk patients and for initiating a conversation. Using evidence from numerous studies on identification, assessment, and treatment of IPV, we present guidance for assessment in community settings and outline important considerations for mental health professionals.
A middle-aged woman begins her intake session by stating that she would like to build coping skills for depressive symptoms and her chronic pain condition. As you explore sources of stress, she describes having a highly conflictual relationship with her husband, with “frequent arguments around many different topics.” She reports that simple comments by either of them can quickly trigger raised voices and shouting. Noting the rapid escalation in their interaction, you wonder whether these arguments also involve physical violence or abuse, but the patient has not mentioned violence or expressed any concern about ongoing abuse. Should you ask about it anyway?
Intimate partner violence (IPV) is a term used to describe psychological, emotional, physical, and sexual acts of aggression against an intimate or romantic partner (Centers for Disease Control and Prevention, 2014). In addition to a heightened risk for severe injury and death, IPV victimization is associated with a host of negative outcomes, including declines in physical and psychological health, poor self-esteem, missed days of work, drug and alcohol use, and risky sexual behaviors (Lawrence, Orengo-Aguayo, & Langer, 2012). Routine and accurate assessment by community practitioners is essential, as they may be the first or primary source of contact for affected individuals and couples. We offer recommendations for assessment of IPV in community settings, and document several practical issues worthy of consideration by community practitioners.
Prevalence and Severity of IPV
Twenty-three percent of women and 19.3% of men report experiencing physical assault from a current or former intimate partner at least once in their lifetime (Desmarais, Reeves, Nicholls, Telford, & Fiebert, 2012). When IPV is assessed via questionnaires, the most frequently endorsed physical acts are in the “moderate” range, and include grabbing/shoving/slapping a partner, twisting a partner’s arm or hair, and throwing objects at a partner (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Severe physical violence (e.g., choking, beating, burning, or using weapons against a romantic partner) is less common, but endorsed on average by 2.3% of women and 2.1% of men in the general population (Straus et al., 1996).
Although physical IPV victimization occurs at similar rates for men and women in heterosexual relationships (Archer, 2004), women are significantly more likely to experience severe physical violence and injury than men (Desmarais, Reeves, Nicholls, Telford, & Fiebert, 2012; Straus & Gozjoklko, 2014). Women also more often report concerns for their safety as well as trauma responses to abuse (Breiding, 2014; Kar & O’Leary, 2010). Additionally, women report a higher frequency of coercion and victimization subtype of IPV, described as intimate terrorism (Holtzworth-Munroe, 2005), wherein a partner perpetrator exerts a high degree of coercive control and psychological aggression with the goal of isolating the victim. Not surprisingly, fear of a partner is also associated with increased risk for IPV (Kar & O’Leary, 2010).
Aggressive acts can occur from one partner (unidirectional) and therefore be conceptualized in a victim-perpetrator framework, or can be mutually occurring (bidirectional) and thus conceptualized in an interactional framework. Assessment of the directionality of IPV is critical for understanding the effect and contextual factors, which may provide important information for clinical work with couples. In community samples, partner violence is most commonly mutually perpetrated (Archer, 2004; Langhinrichsen-Rohling, Misra, Selwyn, & Rohling, 2012). Gender differences in reporting styles have been noted, with men tending to under-report their own IPV perpetration, while women are more likely to under-report victimization (Caetano et al., 2002). Prevalence studies, however, have thus far failed to document the complex situational factors (e.g., intent, circumstances prior to physical IPV) and consequences of abuse (Giles, 2004).
The Partner Abuse State of Knowledge (PASK) project involved over 112 researchers and was organized in 2010 by John Hamel, the editor of Partner Abuse. The project team examined over 12,000 studies on partner abuse and generated 17 articles on various aspects of intimate partner violence, and the articles were published in 2012 and 2013 in Partner Abuse. A 61-page highly detailed overview of their findings is available at www.domesticviolenceresearch.org.
Risk Factors for IPV
Researchers have found that substance abuse and history of IPV are the most reliable risk factors for a person’s own IPV perpetration (Wekerle, Wall, Leung, & Trocmé, 2007). A history of psychological aggression in absence of past physical victimization is also linked to an increased likelihood of perpetrating physical violence; however, psychological aggression is common in both clinical samples of couples and in couples recruited for research studies from communities, and severity of past experiences should be considered. A large, representative survey of parents with young children also identified perceptions of control issues, dominance, jealousy, and relationship dissatisfaction as risk factors for perpetrating IPV (O’Leary, Smith Slep, & O’Leary, 2007).
Lower socioeconomic status (SES) is also associated with both declines in relationship satisfaction/stability and increased relationship conflict (Conger, Conger, & Martin, 2010; Field & Caetano, 2004); clinicians should assess for financial stressors in determining risk for IPV. Models describing this link note that economic pressures promote angry or frustrating attitudes, which are expected to increase the frequency of arguments between partners and simultaneously decrease the number of positive interactions (Conger, Conger, & Martin, 2010). Patterns of communication between partners are also reliable markers for abuse; individuals who score in the upper 20% of scores on psychological aggression items of partner violence questionnaires were more likely to endorse perpetrating physical aggression (Salis, Salwen, & O’Leary, 2014).
Reviews have identified common risk factors for the perpetration and victimization of IPV that can inform the work of clinicians. For example, Stith and colleagues (2004) examined risk factors in a meta-analytic design and characterized factors based on their strength of ability to predict IPV. In terms of victimization, one large risk factor was identified: victims using physical violence against their partner. Additionally, moderate risk factors for victimization included the presence of depression in victims and fear of future abuse. In terms of perpetration, large risk factors were the presence of emotional abuse, coerced sex or rape, drug use, attitudes condoning violence, and low relationship satisfaction. Additionally, moderate effects for perpetration of physical abuse included perpetrator sex-role traditional ideology, anger/hostility, history of partner abuse, drug use, depression, and stressful life events. Of note, IPV victims’ use of violence (whether in retaliation or defense) was associated with an increased risk for subsequent physical victimization.
Though the full range of risk factors are important to consider, these variables are typically explored in heterogeneous groups of individuals (e.g., all female patients at a community clinic); clinicians should be careful to evaluate how such factors apply to a patient’s specific individual/relationship context. For example, though SES is associated with an increased likelihood for relationship distress and conflict, personal (e.g., social support) and cultural differences can influence the likelihood of low SES serving as a meaningful marker of relationship conflict. The increased risk for IPV observed among Latinos is only observed at family incomes less than $35,000 and for individuals with high school education or less (Ingram, 2007). These and other individual differences present challenges to clinicians, who may be more or less familiar with certain contextual factors.
Most importantly, research on risk factors associated with IPV compares individuals who differ along one dimension or another. It represents group differences, and thus primarily alerts the informed clinician to factors that may provide clues about the increased probability that a given patient might be involved in a situation that includes intimate patient violence. Risk factors do not represent key clinical assessment factors in most situations. Clinicians should always consider proximal and distal patterns for both the individual and couple that may have contributed to the development and/or maintenance of an abusive relationship.
Routine Screening for IPV
The U.S. Preventative Services Task Force recommends screening for IPV using predetermined questions for all women of childbearing age, regardless of risk status (US Preventative Task Force, 2004). Routine screening (e.g., yearly) for IPV in healthcare settings is linked to both improvements in safety and in perceptions of the quality of healthcare services received (Spangaro, Zwi, Poulos, & Man, 2010). Screening of women has demonstrated long-term reduction in feelings of isolation, increased abilities to evaluate abusive relationships, and improvements in awareness of the link between abuse and negative health consequences. Women also report benefitting from conversations with healthcare providers regardless of whether they disclose the experience of abuse. Routine screening and intake procedures may prompt disclosure, but, at a minimum, signal to the patient that the provider is receptive to talking about relationship concerns (Spangaro, Zwi, Poulos, & Man, 2010).
While screening may be done by any members of a patient’s primary care team, this role may be best suited to mental health providers, as they have in-depth training in both risk assessment and state reporting regulations. If patients are not being screened by mental health providers, the screening providers may benefit from training and/or supervision from mental health professionals.
The use of structured assessment tools is also recommended, as research has shown that individuals were more likely to disclose IPV when given questionnaires (44%), as compared to during a routine clinical interview (6%; O’Leary, Vivian, & Malone, 1992). If such written screening questionnaires are not utilized, practitioners may ask a series of “informal” questions to gauge the risk for IPV (see Table 1). A conversational approach allows the clinician to utilize patient-specific language and better attend to the emotional aspects of discussing this sensitive topic. The goal of this assessment should be to develop a sense of whether the patient’s safety is at risk, and whether the patient is potentially minimizing issues of safety. Speaking routinely about the safety and comfort of the home and close relationships can facilitate provision of support and other resources (Miller, McCaw, Humphreys, & Mitchell, 2015; Salwen, Gray, & Mona, 2016).
A patient may refrain from endorsing IPV for many reasons. Literature reviews have identified fear as the most common cross-cultural barrier to disclosing IPV victimization (Montalvo-Liendo, 2009). In addition, family, safety, confidentiality, and legal considerations may also impact an individual’s openness to disclosure (Miller et al., 2015). Spangaro and colleagues (2010) screened women (N= 363) in healthcare settings via surveys and found that 33% of the sample reported abuse, and an additional 9% experienced abuse but chose not to disclose when initially screened. The main reasons for not disclosing were not considering the abuse serious enough, fear of the perpetrator, and not feeling comfortable with the healthcare worker. Fear is a consistent barrier to disclosing abuse, in addition to patient comfort, and clinicians should be mindful of building a comfortable environment for patients to facilitate disclosures of victimization.
Clinical Assessment of IPV
In the introductory example of a patient presenting with depression and pain, but also intense arguments with her husband, the therapist then does a full assessment of areas of life in which the patient feels increased stress, pain, or symptoms of depression. The therapist asks about stressors the woman experiences at home, support systems that are available in her life, and interactions with family members, including when conflict tends to arise. The therapist discusses with the patient whether her stressors may be connected to relationship conflict.
This discussion of conflict is framed by the assumption that conflict exists in all households, which helps normalize the patient’s circumstances and facilitates a discussion of possible abuse. The therapist then asks if during arguments, the patient and her husband call each other names or threaten each other, and gives examples of common behavioral patterns instead of asking outright whether the patient experiences abuse or violence. She also asks if the patient and her husband ever hit each other with hands or other objects, or get physical in any other way during arguments. The therapist will also ask about sexual violence in this manner—assessing for behavioral and interactional patterns instead of assuming she and the patient mean the same thing when they use the word “abuse.” Lastly, the therapist asks whether the patient is afraid of her husband or afraid that her husband might get in the way of her medical care.
For each of these questions, the therapist slowly and purposefully goes from less severe (and more common) to more severe abusive behaviors, all while carefully monitoring the patient’s reactions. If the patient answers slowly, looks away, or makes statements such as, “I’m not sure,” the therapist might say something like, “is there a time you’re thinking about? Why don’t you describe to me what happened?” She is careful to not pressure the patient, giving her room to experience intense emotions, while also listening closely for any details indicating the patient may be in immediate danger.
The assessment of IPV is a continuous process. At following sessions, the therapist continues to monitor the patient’s safety at home. Communication, problem-solving, and de-escalation skills are most important. Impulse control as well as appropriate assertive behaviors can also be important. Whether the work is done with one partner or with the couple will depend on the unique characteristics and willingness of each couple, as well as safety concerns.
Staying Versus Leaving: Factors and Influences
In more extreme cases of IPV, the physical safety of one or both parties will be critical for the psychotherapist to assess and monitor. Situations of serious and severe IPV may be acute, reoccurring, or chronic. In acute cases, it may be necessary to immediately involve extended family or the police, and temporary alternative housing may be required. In cases where alternating periods of calm and upset occur, it will be essential for all parties to learn to observe themselves, each other, and the interaction between them for warning signs for increasing risk of IPV—and to learn to step back and de-escalate the situation. The possibility of sleeping in separate rooms or one person living outside the home temporarily should be considered.
In cases of high chronic risk, the option of separation must be considered; however, there are many barriers and fears related to leaving a relationship with IPV. Financial/economic dependence is the primary reason women who are being abused stay in the relationship (Anderson & Saunders, 2003). Women also report staying in abusive relationships for fear of retaliation (Barnett, 2001), and this fear is often grounded in reality. Risk of intimate partner violence/homicide does increase after a woman leaves an abusive relationship (Campbell et al., 2003). Low self-esteem and having an external locus of control are also major contributors to a woman staying in an abusive relationship (Kim & Gray, 2008). Of note, while the research on leaving versus staying in an abusive relationship focuses almost exclusively on men as perpetrators and women as victims, IPV and the complicated emotional and contextual factors are not limited to this specific gender pattern.
The assessment of potential IPV and the treatment of cases involving IPV are complex, and they may be ethically challenging. Providers must be aware of state reporting laws pertaining to violence and IPV for their license type, and ensure that these laws are discussed with patients. Financial concerns and safety risks should be addressed with a patient, as these issues arise. In addition to protecting minors and dependent adults, many states also have protections in place for individuals over the age of 65. Some states also have mandated reporting laws in place that protect victims of severe injury. For example, in New York State, firearm injuries, burns on more than 5% of a body, or other potentially life-threatening injuries are required to be reported (New York State Office for the Prevention of Domestic Violence, 2016). Additional ethical concerns and specific clinical considerations may arise if one of the partners suffers from a disability (Salwen, Gray, & Mona, 2016).
Interviewing patients about violence may be especially challenging for clinicians that have experienced some form of violence themselves (Ellsberg, Heise, Pena, Agurto, & Winkyist, 2001). Specialized training in asking questions can facilitate decreased discomfort, but clinicians should think carefully about their own competence and abilities to conduct risk assessments, and acquire more training until proficiency is achieved. This is consistent with the ethical standards described by the American Psychological Association (APA, 2017), which emphasize the responsibility that individual psychologists have to develop and maintain their competence. Furthermore, Kropp (2008) outlined the specific qualifications required of clinicians to assess intimate partner violence, which clinicians may consult in considering their own strengths and weaknesses in dealing with this important clinical occurrence, as with any other presenting problem. Clinicians and supervisors should also be aware of possible secondary traumatic stress, or the emotional toll produced from indirect trauma exposure, including listening to stories pertaining to abuse (National Child Traumatic Stress Network, 2011).
Sarah Bannon, MA, is a doctoral student in the Clinical Psychology program at Stony Brook University. She has conducted research on intimate partner violence perpetration and victimization, and recently published a manuscript on a novel treatment for perpetrators of domestic assault. She currently serves as a therapist in a community rehabilitation outpatient clinic, and is working to examine the clinic’s screening practices for partner abuse.
Jessica Salwen-Deremer, PhD, is a clinical psychologist in the Department of Psychiatry & Behavioral Sciences at Johns Hopkins School of Medicine. She has provided treatment for couples and individuals experiencing intimate partner violence and conducts research on the effect of violence and trauma on physical and mental health outcomes.
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