Term
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Definition
A normal reaction to an abnormal situation
• “Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life- threatening with lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.” - SAMHSA
• An experience that is overwhelming for that person.
• Trauma might look different for you or me, but we’ve all experienced it |
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Term
| What is Vicarious Trauma? |
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Definition
| a change in one’s thinking [world view] due to exposure to other people’s traumatic stories. |
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Term
| Personal Exposures to Violence and Secondary Traumatic Stress are Connected |
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Definition
• Lifetime exposure to violence is common
• Working with clients who are experiencing or have experienced violence can trigger painful memories and trauma
• Personal history of exposure to violence increases risk for experiencing secondary traumatic stress |
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Term
| Common Reactions to Caring for Survivors of Trauma |
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Definition
• Fear
• Helplessness
• Sleep disruptions
• Depressive symptoms
• Recurrent thoughts of threatening situations
• Feeling ineffective with clients
• Reacting negatively to clients
• Thinking of quitting clinical [contact with clients] work
• Chronic suspicion of others |
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Term
| Simple Strategies for Organizational Self Care |
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Definition
• Weekly (if possible) staff check-in
• Staff check-in that begins with ALL staff writing down three positive things about clients and colleagues
• Share a few positives before debrief of difficult cases
• Share a few more positives after the difficult cases |
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Term
| Intimate Partner Violence: What is it? |
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Definition
One person in a relationship is
using a
tactics to gain and maintain
pattern of methods and
power and control over the other person.
• It is a cycle that gets worse over time – not a one time ‘incident’
• Abusers use jealousy, social status, mental health, money, and other tactics to be controlling and abusive – not just physical violence
• Leaving an abusive relationship is not always the best, safest or most realistic option for survivors |
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Term
| Why do people stay in abusive relationships? |
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Definition
• Violence happens in a cycle
• Risk of leaving vs. Risk of staying
• Violence is not always a person’s priority
We need to move away from asking: “Why hasn’t the survivor left?” to asking:
“What can I do to support this person so that they can make their own decisions? |
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Term
| Who are victims/survivors? |
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Definition
§Cuts across all lines §Coping strategies
§ Love
§Expert of their own situation §Multiple traumas |
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Term
| Who are abusive partners? |
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Definition
§ Cuts across all lines
§ Jealous and controlling
§ Do not take responsibility and blames survivor
§ “I never would have thought!”
§ Can be loving
§ Not anger management problem
§ Trauma |
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Term
| What are some barriers to addressing IPV? |
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Definition
• Comfort levels with initiating conversations with patients about IPV
• Feelings of frustration with patients when they do not follow a plan of care
• Not knowing what to do about positive disclosures of abuse
• Lack of time |
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Term
| Prevalence of Intimate Partner Violence |
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Definition
1 in 4 (25%)
U.S. women report ever experiencing IPV |
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Term
| Intimate Partner Sexual Violence prevalence |
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Definition
1 in 5 women in U.S. has been raped at some time in their lives and half of them
reported being
raped by an intimate partner |
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Term
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Definition
• 1 in 59 men have been raped in their lifetime.
• 1 in 7 men have been the victim of severe physical violence by an intimate partner
• 1 in 19 men have been
stalked during their
lifetime |
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Term
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Definition
61% of bisexual women and 37% of bisexual men experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime.
44% of lesbian women and 26% of gay men experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime.
Of transgender individuals, 34.6% reported lifetime physical
abuse by a partner and 64% reported experiencing sexual
assault. |
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Term
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Definition
can be more vulnerable to intimate partner and sexual violence and have many different protective factors. Consider...
• Cultural responsiveness and language • Access
• Relationship with justice systems
• “Airing dirty laundry”
• Loss of community |
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Term
| Considerations for Immigrant and Non- English Speaking Survivors |
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Definition
Unique controlling behaviors: • Deportation
• Language privilege
• Immigration status privilege
Do not ever use family/friend as translator
• Use clinic translation or National DV Hotline as translation resource |
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Term
| Inclusive Health Practice |
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Definition
• Ask for all patients’ gender pronouns • Do not make assumptions about the
gender of your patients’ partner(s)
• Patients may not identify as LGBTQ or
come out to you, and that’s okay
• Connect with local and national LGBTQ-specific resources |
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Term
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Definition
Regardless of gender, it can sometimes be difficult to understand if the patient sitting in front of you is surviving violence or using violence to hurt their partner.
It is important to connect this patient to IPV services, where trained advocates will be able to conduct a more in depth screening and offer the patient appropriate services either way. |
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Term
| Healthcare Providers Can Make a Difference! |
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Definition
Women
Who Talked to Their
Health Care Provider
About Experiencing Abuse Were
4 times more likely to use an intervention |
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Term
| Unique contributions of primary care providers |
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Definition
Primary care-based interventions have been shown to reduce future episodes of IPV and improve health outcomes
• • •
Asking about relationships
Brief counseling and harm reduction
Referral to community resources |
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Term
| Strongly Recommended: Supporting Survivors |
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Definition
• Institute of Medicine’s Clinical Preventive Services for Women: Closing the Gap
• IPV screening is one of eight preventive services that would ensure women’s health and well being
• US Preventative Services Task Force recommends screening women of childbearing age (up to age 46) for IPV and conducting a follow up with any woman with a positive screen. |
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Term
| Injuries Among IPV/SA Victims |
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Definition
Injuries resulting from the assault: including, bruises, broken bones, burns, spinal cord injuries, lacerations, knife wounds, etc.
§
Traumatic Brain Injury (TBI): 71% of women experiencing IPV have incurred TBI due to a physical assault |
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Term
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Definition
| More than 2/3 of IPV victims are strangled at least once (the average is 5.3 times per victim) |
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Term
| Reproductive and Sexual Health |
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Definition
• Women who disclosed abuse were at an increased risk for rapid repeat and unintended pregnancy
• Increased incidence of low birth weight babies, preterm birth, and miscarriages
• Women disclosing physical abuse were 3 times more likely to have an
STI |
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Term
| Women who are sexually assaulted by their intimate partner are more likely to experience: |
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Definition
• Chronic headaches and backaches
• Chronic stress-related problems such as irritable bowel syndrome and hypertension
• Depression, poor self esteem
• PTSD and Rape Trauma
Syndrome
• Pelvic pain
• Pelvic inflammatory disease
• Bladder infections
• Sexual dysfunction
• Unintended pregnancies
• STIs
• Complex trauma |
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Term
| IPV and Sexually Transmitted Infections |
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Definition
Women disclosing
physical abuse
were
3 TIMES
more likely to experience a STI.
Women disclosing
psychological abuse
were
2 TIMES
more likely to experience a STI. |
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Term
| HIV and Domestic/Sexual Violence (D/SV) |
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Definition
| Over half of women living with HIV have experienced D/SV, considerably higher than the national prevalence among women overall (55% vs. 36%) |
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Term
| IPV and Behavioral Health Co-Morbidities |
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Definition
• Anxiety and/or Depression
• Post-traumatic stress disorder (PTSD)
• Antisocial behavior
• Suicidal behavior
• Low self-esteem
• Emotional detachment
• Sleep disturbances
• Substance dependency |
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Term
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Definition
§ Domestic violence is the strongest predictor of alcoholism in married women
Women experiencing abuse are:
2.6x more likely to use tranquilizers,
sleeping pills, or sedatives
3.2x more likely to use anti- depressants
2.2x more likely to use prescription drugs. |
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Term
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Definition
| Abusers rely on stigma related to mental health and substance abuse to undermine and control their partners |
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Term
Did You Know...
Many providers miss the underlying problem when they don't consider IPV |
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Definition
• Patients do not receive the care they need for the problem they have
• Treatment is often ineffective and the patient's health further compromised due to a partial diagnosis |
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Term
| What We’ve Learned from Research |
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Definition
Studies show:
§ Patients support assessments
§ No harm in assessing for DV
§ Interventions improve health and safety
§ Missed opportunities: patients fall through the cracks when we don’t ask |
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Term
| Evidence Based Interventions: Improved health outcomes |
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Definition
• Women receiving universal education intervention in
reproductive heath setting reported
odds for pregnancy coercion compared to control and
71% reduction in 60% more likely to end a relationship because it
were
felt unhealthy or unsafe. (Miller et al, 2010)
• Women receiving prenatal counseling on IPV had fewer recurrent episodes of IPV during pregnancy and the postpartum period and had better birth outcomes.
• At 6-weeks postpartum, women who received a brief
intervention reported significantly higher physical
functioning and lower postnatal depression scores |
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Term
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Definition
• Providers do not have to be D/SV experts to recognize and help patients experiencing IPV
• You have a unique opportunity for education, early identification, and intervention
• And to partner with D/SV agencies to support your work |
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Term
| Meeting the Triple Aim: Talking about violence with patients |
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Definition
| better health, better care, lower costs |
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Term
Not Just Adding a Question on a Form
Multiple approaches to assessment: |
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Definition
§ Validated assessment tools
§ Adding questions to intake
form(electronic or written)
§ Universal Education (UE):
§ Setting specific • Integrated
• Brochure based |
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Term
| CUES Universal Education Approach |
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Definition
C: Confidentiality
Disclose limits of confidentiality & see patient alone
UE: Universal Education + Assessment
Normalize activity: "I've started giving info on D/SV to all of my
patients”
Make the connection: Open the card and do a quick review: "It talks about healthy and safe relationships...and how relationships affect your health.“
S: Support Warm referral
Follow up at next appointment |
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Term
| C: Before any discussion of D/SV in the health setting providers must: |
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Definition
• Understand their reporting requirements
• See patient alone
• Disclose the limits of confidentiality |
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Term
| C: Safety, Confidentiality & Mandatory Reporting |
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Definition
§Always review the limits of confidentiality, even if you are not asking direct questions
§Consent forms should indicate the limits of confidentiality |
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Term
| C: Disclosing Limits of Confidentiality |
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Definition
Sample script
“Before we get started, I want you to know everything here is confidential. Meaning, I won’t talk to anyone else about what is happening unless you tell me that someone has hurt you, you are planning on hurting yourself, or you are planning on hurting someone else.” |
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Term
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Definition
• Always talk to patients alone and not within earshot of a partner or family member
• Never use a family member or friend as an interpreter, use medically trained interpreters only |
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Term
| Why Universal Education (UE)? |
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Definition
§ Screening w/o response is ineffective
§ Survivors often chose not to disclose
§ Not ready, distrust of formal systems, limited resources, fear of retaliation, CPS
§ For example, in family planning study 50% of women disclosed in study – but only 10% to trained providers
§ Universal education provides an opportunity to promote healthy relationships and increase
safety for survivors |
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Term
| UE: How to begin Universal Education |
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Definition
"We’ve started talking to all our patients so they know
how to get help for themselves or so they can help others.” |
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Term
| UE: Framing Education for Friends and Family |
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Definition
Peer to peer education:
• Always give more than one copy of educational brochure
• Using a framework about helping others helps normalize the situation and allows patients to learn about risk and support without disclosure
• Patients do use materials to help their friends and family
• Having the information on the brochure is empowering for them – and for the friends/family they connect with |
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Term
| Patient-centered approach to DV assessment |
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Definition
• Patientswantproviderstotalktothemabout DV
• Empowerpatientswithinformation,regardless of disclosure
• Patientsmaynotdiscloseduetoconcernsof how information will be used
§ Disclosure is NOT the goal |
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Term
| S: Support - Important reminder |
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Definition
| Disclosure is not the goal AND Disclosures do happen! |
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Term
| S: Support - Positive Disclosure - What now? |
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Definition
• Thankpatientforsharing
• Conveyempathyforthepatientwho has experienced fear, anxiety, and shame
• ValidatethatIPVisahealthissuethat you can help with
• Letthemknowyouwillsupportthem unconditionally without judgment
• Askpatientiftheyhaveimmediate safety concerns and discuss options.
• Refer to a D/SV advocate for safety planning and additional support.
• Followupatnextvisit. |
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Term
| S: Positive disclosure - One line scripts |
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Definition
• “I am so sorry this is happening. It is not okay, but it is
common. You are not alone.”
• “This is not your fault. Nothing you did caused this. Someone else made a choice to hurt you.”
• “What you’re telling me makes me worried about your safety and health”
• “Would you like me to explain options and resources that survivors are often interested in hearing about?”
• “Some survivors find talking to an advocate or counselor to be helpful”
• “What else can I do to be helpful? Is there another way I can be helpful?” |
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Term
| Supporting survivors: What not to say |
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Definition
• “You should call the police”
• “You are definitely in an abusive relationship”
• “That does not sound like rape to me...”
• “Your partner is crazy, you need to break up with them”
• “What did you do to set them off?”
• “So what happened after that, and what happened after that?” |
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Term
| Harm Reduction in Primary Care |
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Definition
§Support safe medication adherence §Alternate forms of birth control §Safer STI partner notification §Exercise and sleep plans
§What else? |
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Term
| Warm referral as a key component |
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Definition
• Increaseslikelihoodofsuccessfulreferral
• Opportunityforimmediatein-personorphone
safety planning
• Coordinatedcare
“If you are comfortable with this idea, I would like to call my colleague (fill in person's name), she has helped many people who have been in similar situations.” |
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Term
| Role of the Domestic Violence Advocate |
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Definition
• Assist those who have experienced IPV to think and act in a way to increase personal safety, while assessing the risks based on the perpetrator’s behaviors
• Connect clients to additional services like: § Housing
§ Legal advocacy
§ Support groups/counseling |
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Term
| How are DV advocates different than in- house behavioral health providers? |
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Definition
• Specialized training
• Confidentiality
• Free for clients
• Shorter wait time for appointments
• Access to other services
• Culturally responsive services
Advocates are an important complement to behavioral health services |
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Term
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Definition
• Was the patient screened for IPV or the reason the screening did not occur
• Patient's response to screening
• Health impact if any abuse disclosed
• Resources provided and discussed, such as safety cards
• Referrals offered |
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Term
| Although there is no specific CPT code for IPV screening, others can be used: |
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Definition
Code V82.89 (Special screening for other conditions)
Preventive Medicine Service codes 99381-99397 include age appropriate counseling/anticipatory guidance/risk factor reduction interventions. These codes could be used to record assessment and counseling for IPV. |
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Term
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Definition
T74.11X - Adult physical abuse
T74.31X - Adult emotional/psychological abuse
T74.21X - Adult sexual abuse |
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Term
| Resource: Guide to Preparing Your Practice |
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Definition
• Sample protocols, chart prompts, self- administered tools
• Information on confidentiality and mandatory reporting laws
• How to provide referrals to local DV programs
• Training suggestions for staff (update yearly)
• Quality assurance/Quality improvement tools
• How to document Intimate Partner Violence
• Sample Memorandum of Understanding (MOU) between your clinic and local DV programs |
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