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Module 8 - Alcohol and Intimate Partner Violence

PARTICIPANT HANDOUT

Introduction

Family violence is a relatively young field of research, with systematic study coalescing during the 1970s (Finkelhor, Hotaling, & Yllö, 1988). The umbrella term "family violence" includes abuse and violence against children, adolescents, adults, and elders that occur within the context of family and other intimate relationships (Carden, 1994). Over the past three decades, much has been learned about the epidemiology of family violence, the associated risk factors, and the outcomes or effects on victims, witnesses, and family systems. Family violence interfaces with the understanding, study, and treatment of the more general class of aggression and interpersonal violence. This module discusses the very clear yet complex associations between alcohol and intimate partner violence.

Learning Objectives

By the end of this module, learners should be able to:

A. Discuss epidemiology data concerning the associations between alcohol and intimate partner violence, for both victims and perpetrators;
B. Understand and critically analyze different explanatory theories and models addressing this association;
C. Be familiar with signs, symptoms, and means of assessing individuals who might be affected by, or engaging in, alcohol-related intimate partner violence;
D. Understand resources, interventions, and resource development issues related to alcohol and intimate partner violence.

Background

Intimate partner violence (IPV) refers to family violence (and/or the threat of violence) that occurs within the context of a relationship between intimate partners. IPV includes physical acts of aggression, as well as sexual, psychological, and emotional abuse. This term has begun to replace earlier terms such as domestic violence, spouse abuse, dating violence, date rape, battering, and marital violence. IPV is more inclusive across types of intimate relationships (e.g., married, cohabiting, dating, and ex-partners; heterosexual and same-sex partners), and includes a wide range of abusive behaviors and patterns (Begun, 2003). The Centers for Disease Control and Prevention (Saltzman, et al., 1999) are promoting consistency in IPV terminology with the goal of developing standardized data collection procedures. They recommend that relationship violence be categorized as: (1) physical violence, (2) sexual violence, (3) threat of physical and sexual violence, and (4) psychological/emotional abuse. This last category includes coercive tactics when there also has been prior (actual or threats of) physical or sexual violence. The continuum of abusive behaviors additionally includes stalking, harassment, economic abuse/control, and isolating a person from family and friends.

A chart of Life time IPV Exposure Women d

Intimate partner violence (IPV) is experienced by at least 22% of women and 7.5% of men during their lifetimes (Tjaden & Thoennes, 2000). Former U.S. Surgeon General C. Everett Koop is cited as stating that domestic violence is the leading cause of injury to U.S. women aged 16-44 years (Banks & Randolph, 1999). On average, 8 of 1,000 women in the U.S. (aged 12 or more) experienced IPV during each year between 1992-1996 (Greenfield et al., 1998). In other words, between 1.8 and 4.4 million women are battered by an intimate partner in any given year (Campbell & Soeken, 1999). Although women are the victims in at least 85% of IPV incidents, and women are approximately six times more likely than men to experience IPV, it is notable that approximately 1 in 1,000 men are the target of IPV by a current or former intimate partner (Bureau of Justice Statistics, 2000). During 1996, approximately 2000 lethal incidents of IPV occurred, with 30% of female and 3% of male murder victims being killed by an intimate partner (FBI, 1996). Furthermore, it appears that men who abuse alcohol run a higher risk of being killed by an abused spouse than do men who are batterers but do not abuse alcohol (Browne, 1997).

Despite all of these statistics, it is exceedingly difficult to establish a clear consensus as to the true scope of the problem because of wide variability in definitions and measurement approaches, and because unreported/unrecorded incidents may far exceed those that are recognized (Tjaden & Thoennes, 2000). The scale of the problem expands exponentially once the toll on individuals, families, and communities is taken into account. In addition to the direct, obvious physical "costs" associated with IPV, victims often experience psychological, mental health, legal, employment, child custody, long-term disability, and other consequences (Walker, 1984, 1999). Children who witness violence perpetrated by or against a parent are often powerfully, permanently, and negatively affected by the experience (CSAT, 1997; Edleson, 1999). In fact, witnessing parental IPV during childhood predicts both the perpetration of IPV and emergence of alcohol problems (Downs, Smyth, & Miller, 1996). Family disruption, dissolution, and separations may result from IPV episodes, as well.

It is recognized that IPV occurs in all strata of American society and in many countries around the world, although it may not occur proportionately across groups (Begun, 2003; Flowers, 2000; United Nations, 1996). In early research exploring the risk factors for IPV, it became clear that an association between alcohol problems and battering exists (Byles, 1978; Cleek & Pearson, 1985; Stewart & DeBlois, 1981). There is a wide discrepancy between studies concerning the proportion of IPV perpetrators who also have alcohol use disorders, largely due to methodological limitations and key differences in sampling approaches.

IPV  Perpetrators and Alcohol Problems

d

It is reasonable to conclude that, based on descriptions from women who have been abused, 35-38% of their abusive partners could be identified as having significant alcohol problems, and 22% as heavy drinkers (Leonard & Jacob, 1988). The numbers vary markedly from this range in studies involving special clinical populations (e.g., very low socioeconomic status, women in shelters) and depending on the definitions of both abusiveness and alcohol problems. O'Farrell and Murphy (1995) report more binge drinking, greater severity of alcohol problems, and earlier drinking problem onset among perpetrators of IPV than among non-violent men. Estimates of the presence of alcohol in IPV situations vary widely from under 20% to over 80%, but realistically alcohol is involved in around 25-50% of these incidents (Bennett, 1995; Greenfield, et al., 1998; Kantor & Straus, 1987; Leonard & Jacob, 1988; Pernanen, 1991; Saunders & Kindy, 1993). It is important to note that, even among individuals who have diagnosable alcohol problems, alcohol use may not be an immediate antecedent to IPV (Collins & Messerschmidt, 1993).

Individuals with alcohol problems attack more frequently, are more likely to inflict serious injury, are more likely to commit sexual assaults, and are more likely to be violent outside of the home than are batterers without a substance abuse history (Browne, 1997; Frieze & Browne, 1989; Walker, 1984). Substance abuse (alcohol and other drugs) represents one of the key risk markers for the most severe forms of IPV (Kantor & Jasinski, 1998). Substance use is a correlate of violence in intimate same-sex partnerships, as well (Renzetti, 1997; Schilit, Lie, & Montagne, 1990). It is important to remember that causality is difficult to infer accurately from correlational studies. While it is possible that alcohol and other substances play a role in the eruption of IPV, it is also equally likely that a history of experiencing and witnessing various forms of family violence (in the family of origin and/or in contemporary relationships) is a risk factor for abusing alcohol and other drugs. A third possibility is that substance problems and IPV are not causally linked, but are both predicted by another, third factor-for example, psychopathology, dysfunctional family of origin, dysfunctional social interaction and relationship skills (Downs, Smyth & Miller, 1996). In short, it is unwise automatically to assume that alcohol use is a primary cause of IPV; only that these two phenomena co-occur with some regularity (Bennett, 1995; Gondolf, 1995).

Alcohol and IPV Perpetrators

The actual role that alcohol and other substances play in the perpetration of IPV is complex, controversial, nd difficult to interpret (Banks & Randolph, 1999; Bennett, 2000; Flanzer, 1993; Geffner & Rosenbaum, 1990; Gelles, 1993; Gondolf, 1995). "For some men and some situations, psychoactive drug use may enhance violence. For other men and other situations, there is no relationship between their violence and their use of drugs, and for still other men, alcohol and drug use may actually prevent violence…." (Bennett, 1995, p. 761).

Alcohol Effects and Disinhibition Models

Alcohol is one of several psychoactive substances that may be associated with the specific pharmaco-logical action of stimulated arousal and aggression -the others being amphetamines, phencyclidine, cocaine, and alcohol-cocaine combinations (Fagan, 1990; Goldstein, Belluci, Spunt & Miller, 1989; Taylor & Chermack, 1993). Such substances may contribute to IPV, alone or in combination, by influencing brain chemistry or activity in ways that provoke aggression (Johnson, 1996). Withdrawal symptoms also might cause irritability, quick temper, anger, and stimulate hypersensitivity/hyper-responsiveness that may contribute to IPV (Saunders & Kindy, 1993). Such "direct cause" models are uncertain, however, because alcohol exerts highly complex, variable, and nonspecific central nervous system (CNS) effects, and there does not seem to be a single aggression center within the CNS (Conner & Ackerley, 1994; Johnson, 1996).

Possible models of the relation-ship between alcohol and IPV:

- Alcohol effects/Disinhibition
- Cognitive impairment/Distortion
- Disavowal/Rationalization
- Comorbidity

Alcohol is one of several psychoactive substances that may be associated with the specific pharmaco-logical action of stimulated arousal and aggression -the others being amphetamines, phencyclidine, cocaine, and alcohol-cocaine combinations (Fagan, 1990; Goldstein, Belluci, Spunt & Miller, 1989; Taylor & Chermack, 1993). Such substances may contribute to IPV, alone or in combination, by influencing brain chemistry or activity in ways that provoke aggression (Johnson, 1996). Withdrawal symptoms also might cause irritability, quick temper, anger, and stimulate hypersensitivity/hyper-responsiveness that may contribute to IPV (Saunders & Kindy, 1993). Such "direct cause" models are uncertain, however, because alcohol exerts highly complex, variable, and nonspecific central nervous system (CNS) effects, and there does not seem to be a single aggression center within the CNS (Conner & Ackerley, 1994; Johnson, 1996).

Cognitive Impairment/Distortions Model

A related, yet markedly different causal explanation is based on a cognitive impairment or cognitive distortions model. Some domestic violence experts believe that IPV is an unfortunate byproduct of substance use, due to disruptions and/or distortions in cognitive functioning, altered judgment, and/or enhanced perceptions of risk and threat experienced by the alcohol-consuming individual (Conner & Ackerley, 1994; Hastings & Hamberger, 1988). The use of alcohol can result in an increased risk for miscommunications and diminished ability to engage in rational dialog around points of disagreement (Collins & Messerschmidt, 1993), thereby increasing the odds that individuals will rely on less sophisticated strategies for problem solving-i.e., violence. The "alcohol myopia" model indicates that alcohol impairs cognitive functioning, restricts the range of situation cues attended to, and diminishes the meaning of those cues (Steele & Josephs, 1990). "When salient cues strongly motivate a response that, if one were sober, would be inhibited by further access to other cues and meanings…alcohol myopia makes the response more extreme by reducing access to the inhibitory cues" (Saunders & Kindy, 1993, p. 931). As such, the alcohol becomes an instigator of the violence (Flanzer, 1993; Saunders & Kindy, 1993).

The concept of disinhibition has also been invoked to explain another possible pathway for violence directed at intimate partners and others in the social environment. It is postulated that alcohol and other drugs suppress an individual's inhibitions against acting violently (Flanzer, 1993; Johnson, 1996; Kantor & Straus, 1989). In this way, the alcohol acts as a catalyst for violence (McKenry, Julian, & Gavazzi, 1995). An individual's inhibitions against aggressing may be weakened through desensitization from systematic overexposure to violence in the media, community, family, neighborhood, and peer group (Silva & Howard, 1991). The concepts of desensitization and disinhibition may not adequately explain the initiation or acquisition of alcohol-related IPV behaviors, but may contribute to the maintenance and persistence of the co-occurring problems (Banks & Randolph, 1999). Research evidence does not consistently support or refute this model, but does suggest that alcohol may play a role in the presence or absence of inhibitions and discrimination about the type or severity of violence that is perpetrated (Pernanen, 1991).

Disavowal and Rationalization Models

It has also been postulated that individuals who drink prior to committing acts of IPV do so to develop an "excuse" for the violence (Gelles, 1974; Kantor & Asdigian, 1996), by placing responsibility for the violence onto alcohol (McKenry, et al, 1995). According to this model, an individual who is expecting to engage in IPV behavior may first employ the "Bottle of Courage" (Silva & Howard, 1991). This type of cognitive processing model proposes that, over time and through experience, individuals learn that the consequences of their violence and aggression will be mediated by societal responses to knowing that alcohol or other substances were involved. According to social learning theory, escaping personal condemnation and negative consequences of IPV becomes a reinforcer for violence (Saunders & Kindy, 1993). If members of the individual's social context adhere to a belief that alcohol is a socially acceptable "excuse" for violence, the person is protected from some of the negative consequences of the behavior. Cultural systems are emphasized as powerful shapers of personal attitudes and individual behavior related to both alcohol abuse and IPV (Saunders & Kindy, 1993; Walker, 1999). In a review of research into the disavowal model of alcohol and IPV, Leonard (2002) concluded that the evidence for this model is quite weak-the belief in alcohol as a cause of violence does not appear to be longitudinally predictive of violence. In fact, within high conflict marriages, high amounts of severe violence were associated with both men having no expectancy that alcohol causes violence and with men drinking (Quigley & Leonard, 1999).

Alcohol as rationalization for violence (Flanzer, 1993) may play a role in IPV, not only because the perpetrators rely on the excuses, but also because their victims believe in the relationship between these two problems. Because alcohol abuse is so prevalent among perpetrators of IPV, victims (and others) often believe that the assaults would not occur without the use of alcohol or other drugs. Not only does this belief system provide individuals with an explanation for their partners' aggression, it also gives some of them hope that the violence will cease if only the partner would stop drinking (Browne, 1997).

Alcohol may be related to IPV in yet another manner: women may become victims as a result of raising concerns about a partner's drinking behavior. In a review of criminal complaint forms and requests for restraining orders, it was concluded that alcohol may figure into IPV "…when the drinking behavior meets intolerance. In six percent of the complaint forms, women noted that they were abused after raising the issue of drinking behavior with their partners. The goal of this violence and abuse appears to be, at least in part, the men's defense of their prerogative to get drunk at will, regardless of the consequences" (Ptacek, 1997). In a study of marital violence during the transition to marriage and the next 3 years, it was observed that the most violence during years 2-3 occurred in couples where the husband was a heavy drinker but the wife was not (Quigley & Leonard, 2000).

Comorbidity Models

An approach that argues for the existence of shared, common root causes between alcohol use disorders and IPV is represented in comorbidity models. Both problems are seen as observable manifestations of a common set of underlying factors, but neither is a cause of the other (Bennett & Lawson, 1994). A comorbidity approach would examine similarities in power and control concerns expressed both by individuals with alcohol use disorders and those who perpetrate IPV (Gondolf, 1995). Or, it might involve closer scrutiny of the intergenerational transmission of both phenomena, as well as examination of shared family-of-origin factors.

It is evident that the problems of IPV perpetration and alcohol abuse share many of the same social and family of origin risk factors and correlates (Downs, et al., 1996; Kantor & Asdigian, 1996). Witnessing IPV in the family of origin not only predicts the presence of each problem (Fitch, et al., 1983; Hastings & Hamberger, 1988; Kroll, 1985), but possibly their severity, as well. Social learning theory, invoking imitation of social models and classic learning paradigms, has been offered as explanation for at least some of the behaviors associated with both perpetrating IPV and problem drinking. Thus, an individual may have acquired (learned) both of these poor coping strategies through modeling dysfunctional behavior exhibited in the family of origin, as well as experiencing positive rewards/removal of noxious stimuli as a consequence of these behaviors.

A closely related framework is one suggesting that the two problems co-occur because of shared personality factors or situational correlates (Miczek et al., 1994). Some batterers are diagnosed with specific personality disorders that are characterized by a host of anti-social behaviors, and that "behavioral set" happens to include both substance abuse and interpersonal violence. Furthermore, situational variables may affect co-occurrence (Barnett, Miller-Perrin & Perrin, 1997; Holtzworth-Munroe & Stuart, 1994; Tolman & Bennett, 1990). For example, the violent subculture that surrounds drug acquisition may also contribute to violence being expressed in the intimate partner relationships of individuals who are substance users. Social skill deficits and certain social cognitions (beliefs about the social world) may be a locus of overlap between alcohol and IPV problems.

A final possibility that warrants further exploration is the set of indirect models of effect. Rather than emphasizing immediate, short-term effects of alcohol abuse, these approaches take into consideration the possible long-term, indirect effects of alcohol use problems on family systems (Flanzer, 1993). It is conceivable that living in a home with an "alcoholic family culture" results in support for a family culture of IPV, as well. As "evidence" of this position, Flanzer (1993) offers a list of similarities in behavior among family systems that include alcohol abuse or IPV: denial of the problem; minimization, rationalization, and isolation; parenting disruptions; tolerance of the problem; projection of blame; loyalty to the family secret; communication problems; control issues; disrupted affection; stress; and depression. However, the evidence is equally strong in supporting the opposite causal pathway: that violence contributes to alcohol abuse (Kantor & Asdigian, 1994).

Research Evidence

In short, the results of recent studies indicate that alcohol is not a clearly identified direct cause of IPV, though it clearly is a correlate and may be a contributing factor (Banks & Randolph, 1999; Gelles, 1993; Miller & Wellford, 1997). If alcohol were a direct cause of IPV, either through disinhibition or because of its cognitive distortion properties, consumption would precede the violence in a preponderance of instances. However, alcohol use sometimes precedes IPV, sometimes occurs during an IPV episode, sometimes follows an episode, and sometimes is absent in IPV events. In fact, more than half of IPV assaults are perpetrated by someone who is sober at the time (Browne, 1997), and 75% of the time, alcohol use is not an immediate antecedent to IPV (Kantor & Straus, 1989). Furthermore, if alcohol abuse were a direct causal factor in IPV, a cessation of the alcohol use should be associated with cessation of the relationship violence and abuse. Unfortunately, "…none of the evidence suggests that alcohol treatment alone will effectively change abusive behavior" (Banks & Randolph, 1999, p. 291)-but according to others, it certainly helps improve the situation (O'Farrell & Murphy, 1995; O'Farrell et al, 1999; Maiden, 1997). Thus, it is doubtful that a simple, direct, linear, causal relationship exists with regards to alcohol and IPV.

Alcohol use:
- Sometimes precedes an IPV episode
- Sometimes occurs during an IPV episode
- Sometimes occurs after an IPV episode
- Sometimes is not involved in an IPV episode



"Although violent abusers are often drinking when they engage in abuse, this behavior does not in and of itself explain where these violent tendencies originate or why alcohol and drugs do not lead to similar results for everyone who uses alcohol" (Miller & Wellford, 1997, p. 22).

 

For some in dividuals, the relationship between alcohol abuse and IPV is driven by the individuals' expectations of what alcohol will do, as opposed to the direct pharmacological or physiological effects of the alcohol consumption (Renzetti, 1997).

Alcohol and IPV Victims

Possible Models
  • Partmers abuse substances together
  • Subtance use is a means of coping with abuse
  • IPV results frim arguments about drinking
  • Both are learned in family of origin

Statistical associations between the experience of violent victimization and women's use of alcohol is well documented, however the nature of these relationships is not yet well established (Miller, Wilsnack, & Cunradi, 2000). Barnett and Fagan (1993) observed that abused women consumed far more alcohol than did their non-abused counterparts. There is a general lack of consensus as to the nature of the relationship between alcohol use and being abused by an intimate partner. One theory argues that women who use substances, including alcohol, are more likely to be abused by an intimate partner than are women who do not use (Banks & Randolph, 1999). This observation seems to be related to becoming a victim of relatively minor violence, but there does not seem to be a significant relationship with severe forms of violence (Kantor & Straus, 1989). One explanation is that an intoxicated person is less able to elude an aggressor or to self-defend against an attack. Another explanation is that the intoxicated person may become verbally aggressive, which may trigger a violent response and the perpetrator's perception that the attack was provoked. A series of research studies have indicated that women are more likely to become victims of IPV when they have been drinking (Kantor & Asdigian, 1994), especially if they are drinking along with their partners.

A second theory argues that alcohol use problems are a consequence or coping mechanism associated with having been abused. Between 41-54% of women frequently drink after an abusive event (Barnett & Fagan, 1993). This "consequences" argument becomes complicated, however, as it has been observed that some women stop drinking at the onset of severe or chronic violence, in order to remain alert to impending danger, while others show a marked increase in their alcohol intake to cope with the terror, grief, anticipation of future attacks, and pain (Browne, 1997). Thus, the research evidence does not clearly and consistently support this model of relating alcohol use to the experience of having been a victim of IPV. Further complicating the picture is the observation that substance abuse is not only related to becoming a victim, but also to post-violence outcomes. For example, drinking may interfere with safety planning and danger avoidance activities (Browne, 1997).

There are various explanations for the perceived relationship between substance abuse and becoming a victim or target of IPV. One explanation is that individuals who abuse substances tend to have partners who also abuse substances (Kantor & Asdigian, 1996), hence their risk of being victimized is due to those factors outlined in the discussion of alcohol and IPV perpetrators above. Another explanation is that victims of IPV may turn to substance use as a means of coping with the abuse and its sequelae-physical injuries, chronic pain, disability, emotional trauma, PTSD, job loss, social isolation, and so forth. A third explanation for the association between alcohol and victimization is that IPV may result from a couple's arguments about one or the other's substance use. An additional explanation references social learning theory and expectancies: victims may develop a belief, based on family-of-origin experiences, that IPV is a "natural and forgivable" consequence of drinking (Kantor & Asdigian, 1994). This would be exemplified by such statements as, "He didn't mean to hurt me-he was drunk when it happened", "He didn't know what he was doing because he was drunk," or "It wasn't really him that did it, it was the alcohol talking."

Of special concern is the issue of IPV during pregnancy (Parker, 1993). McFarlane and colleagues (1992) found that 17% of pregnant women in a sample of 691 (one in six) reported physical or sexual abuse during a current pregnancy. Over 60% of these women reported that the abuse was recurrent, and that it led to delays in their seeking prenatal care-into the third trimester. Not only does the violence present a risk to maternal and fetal health, but these consequences may be seriously compounded and confounded when alcohol is involved during the prenatal period, as well. Alcohol use appears to be involved in 20-50% of IPV incidents during pregnancy (McCauley, 1995). Abuse that occurs during pregnancy may also be abuse that continues into the period of child development.
  • IPV can occur during pregnancy and may lead to delays in seeking prenetal care
  • Alcohol use compounds pregnancy complications of IPV

Intervention Strategies and Issues

In 1998, approximately 1,800 programs existed in the U.S. for victims of IPV, many of which also provided batterer treatment services (Chalk & King, 1998). Many batterer treatment programs attempt to assess substance abuse problems at intake as a screening mechanism. A positive screen tends to result in diversion out of batterer treatment. Some IPV programs may continue to treat these individuals, as long as they are concurrently receiving substance abuse treatment. Most often, however, they are encouraged to re-enroll in IPV programs after they have succeeded in substance treatment. Unfortunately, there is a remarkably low rate of return to IPV treatment for these individuals. As a result, there are increasing pressures to abandon this approach and seek means of concurrently treating or addressing the two problems through integrated, parallel, and/or coordinated services. At the very least, discovery of one problem should trigger a screening assessment for the other: "The sheer statistical co-incidence of substance abuse and woman abuse mandates assessment for one problem after discovery of the other." (Bennett, 1995, p. 766).


Evidence also suggests that professionals in alcohol treatment programs tend to view IPV as a symptom of alcohol abuse (Silva & Howard, 1991). The result is that interventions fail to directly address IPV as a problem because it is assumed that the battering will stop once the perpetrator achieves sobriety (Silva & Howard, 1991). When IPV issues are under-determined or under-managed, the result is often a heightened risk of abuse for the partner (Bennett, 1995). Segregating alcohol and batterer treatment practices tends to contradict the evidence that the incidence of IPV is reduced in many alcohol-complicated marriages by concurrently addressing both alcohol use and marital problems (O'Farrell & Murphy, 2002).

Assessment: Batterers

Batterers are quite heterogeneous, both in their patterns of IPV and their use/abuse of alcohol (Hamberger & Hastings, 1988). Compared to non-violent alcoholic men, IPV perpetrators demonstrate more binge drinking, greater alcohol problem severity, and earlier onset of drinking (O'Farrell & Murphy, 1995). Individuals abuse intimate partners whether they are drunk or sober; however, IPV tends to be more frequent and serious among those with alcohol use problems than among those free of alcohol problems (Browne, 1987; Walker, 1984). Furthermore, psychopathology appears to be particularly prevalent and extreme among battering individuals who also abuse alcohol (Hastings & Hamberger, 1988).

A chart of Safe at Home Project d

The Safe At Home Project in Milwaukee, WI, incorporated a drinking and substance use checkup into batterer treatment intake with 1247 men. In response to the question of whether substances were involved in the IPV incident that brought them to batterer treatment, 44% said yes. These men indicated that the substance user was the batterer alone in 17% of the cases, the victim alone in 6%, and both in 21%. Alcohol was the most commonly used substance (32%). Use of other drugs, and both alcohol and other drugs, were far less common at 2% and 9% respectively. Over 68% of the batterers screened positive for a history of substance abuse while 15% were always abstainers and 17% were non-problem drinkers. Similarly, 64% of men in a batterer program had MAST (Appendix A; Selzer, 1971) scores indicative of alcoholism, even though program coordinators claim that they do not admit alcoholics to batterer treatment (Stith, Crossman, & Bischof, 1991).

Alcohol treatment programs seldom assess for IPV at intake, although there are several options available. The vast majority of programs that assess for the perpetration of IPV utilize instruments that examine violence expressed in the context of conflict situations. The most commonly used instrument is the Conflict Tactics Scales (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) or one of its derivatives. Elements classified as "minor" violence include throwing an object, pushing, grabbing, and slapping. "Severe" violence includes kicking, hitting, hitting with fist or object, beating up, choking, and/or threatening with/using a weapon. To assess a potential batterer, Saunders and Kindy suggest using the Woman Abuse Scale (Quinsey, 1994), which is modified from the Conflict Tactics Scale (Straus, 1979). In addition, they recommend assessment of the most commonly encountered risk factors:

  • Violence in family of origin (risk is highest if abuse is witnessed and experienced)
  • Low education and income of man (especially if partner is higher status)
  • Alcohol (especially chronic abuse of alcohol)
  • Behavioral deficits (especially if combined with a need for power assertion)
  • Personality disorders
  • Child abuser (half of violent husbands also severely abuse a child)
  • Anger (especially with marital situations)
  • Stress
  • Depression
  • Low self-esteem
  • Generalized aggression (violent outside of the home)
  • Antisocial traits (criminal lifestyle, lack of remorse for violence)

(See CSAT, 1997 TIP #25 for the Abuse Assessment Screen, the Psychological Maltreatment of Women Inventory, and the Revised Conflict Tactics Scale for couples; also see Saunders, 1999 review).

The Funneling Assessment Technique is offered as one means for reducing defensiveness, and avoiding denial and minimization on the part of a batterer (Hamberger, Feuerbach, & Borman, 1990). This approach begins with general questions about minor levels of abusiveness in a relationship and progresses to more specific questions reflecting greater levels of hostility. It is recommended that the interviewer not stop the process at the first negative response, because negatives for low-level violence do not preclude positive responses for higher levels. The goal of this type of interview is to estimate the lethality of the potential violence, including asking directly if there exists a wish to kill the partner or oneself.


 

The interview should be conducted with empathic acknowledgment of the individual's feelings, but not being sympathetic to the violence. The interview involves reminding the person that:
(1) although anger toward the partner may be valid, the use of violence is always wrong;
(2) the choice to use or abstain from violence is an individual's choice alone;
(3) IPV is under the individual's control; and
(4) the individual is solely responsible for IPV.

In addition, the interview involves exploration of the psychosocial and personal costs of IPV for the individual and family, and an analysis of potential losses (e.g., family, job, self-esteem, legal entanglement) and harm (e.g., partner may use violence or a weapon in self-defense).

Assessment: IPV Processes

Another aspect of IPV assessment is related to the recognized natural history and cycles of violence between intimate partners. The recognized cycle has three distinct phases, and varies in its expression between couples and over the lifespan of the relationship (Carden, 1994; Walker, 1979). This means that assessment requires sensitivity to the ways that the nature of relationships involving IPV fluctuate over time. The first phase, known as the "tension building" period, involves mounting tension, with the perpetrator generating threats of violence and increasing degrees of abusiveness (verbal, emotional, and minor physical incidents). The victim either attempts to appease the perpetrator, acquiesces to the control, and/or emotionally disengages. During this phase, the victim may experience denial, self-blame, anxiety/fear, and rationalization related to the impending violence. This phase may last for weeks, months, or years before progressing to phase two. This is when the acute act of violence actually erupts, and victims often describe the violence as a psychologically and physically paralyzing event. Professional help may or may not be sought by victims and/or perpetrators following the eruption of violence.

The third phase of the cycle, when it occurs, is often referred to as the honeymoon or reconciliation period. It is characterized by the perpetrator being remorseful, contrite, loving, and apologetic. The batterer and victim may engage in denial and minimization of the violence, and may sincerely intend that it will not happen again. This is when they are also likely to "blame" the IPV on alcohol or other influences. Victims may also engage in self-blame for the violence, believing that if they had continued doing the right things during the tension phase, the violence would not have happened. The cycle may repeat when tensions once again begin to mount. Over time, many couples experience an escalation of violence, both in terms of the severity of the acute events and as a compression of the time between incidents (Carden, 1994). However, it should be noted that there is tremendous variability in the ways that the proposed cycle proceeds. Many victims describe a two-step cycle of tension and violence that never involves the third stage, and partners vary tremendously in terms of the amount of time spent in each phase.

Assessment: Readiness to Change

Assessing batterers' readiness to change their IPV behavior is as important as assessing an individual's readiness to change drinking behaviors. Two validated instruments currently exist for use in assessing batterer readiness to change: the Safe at Home Instrument (Begun et al, 2003) and the URICA-DV developed by Levesque, Gelles, & Vellicer (2000). The Safe At Home Project detected several significant differences in batterer readiness to change related to drinking status. At both intake and batterer treatment completion, the 340 individuals who reported binge drinking (5 or more drinks at one session) scored significantly lower on taking action to stop their IPV than individuals who did not engage in binge drinking (n=554). This suggests that it is important to address both problems among perpetrators of IPV who also experience problems with alcohol

Readliness to Change IPV
Batterers:
- Safe At Home Instrument (Begun et al, 2003)
-URICA-DV (Leavesque, Gelles & Vellicer, 2000)
Victims:
-- PROCAWS (Brown, 1997)

 

Assessment: Batterers

Assessing batterers' readiness to change their IPV behavior is as important as assessing an individual's readiness to change drinking behaviors. Two validated instruments currently exist for use in assessing batterer readiness to change: the Safe at Home Instrument (Begun et al, 2003) and the URICA-DV developed by Levesque, Gelles, & Vellicer (2000). The Safe At Home Project detected several significant differences in batterer readiness to change related to drinking status. At both intake and batterer treatment completion, the 340 individuals who reported binge drinking (5 or more drinks at one session) scored significantly lower on taking action to stop their IPV than individuals who did not engage in binge drinking (n=554). This suggests that it is important to address both problems among perpetrators of IPV who also experience problems with alcohol.

Assessment: Victims

Many IPV victims fail to self-identify as abused persons, and are unwilling to be identified by professionals as being battered or abused (Silva & Howard, 1991). Among 100 women who were not identified as abused, but were married to an alcoholic, 72% described being threatened, 45% beaten, and 27% experienced potentially lethal attacks (Stith, et al, 1991).

The Massachusetts Medical Society offers the "RADAR" system, which is a way for professionals to frame their discussions with clients who may be victims of IPV:

R = Remember to ask if there is violence in their lives;
A = Ask directly, clearly, and unambiguously, but with respect and sensitivity;
D = Document findings, keep in mind that records may become criminal evidence;
A = Assess the client's safety;
R = Review options and make any appropriate referrals.

Massachusetts Medical Society, Department of Public Health and Education

An individual who is the victim of IPV may appear in social work settings with visible signs of physical abuse that include bruising, burns, areas of soreness/tenderness, limitations on normal range of motion, and first aid efforts (bandages, over-the-counter wraps/splints, use of pain medications). They may have a range of physical complaints, including headaches, chronic pain, excessive fatigue, or insomnia (Domino, 1987; Scarinci, 1994). Victims of IPV may present with mental health signs, such as depression, anxiety, PTSD, and bipolar disorders (AMA, 1992; Saltzman, 1999; Lechner, 1993; Saunders & Kindy, 1993). Clients who are involved in long-term social work interventions may have inexplicable absences or disruptions in attendance, behavior problems in their children, suicidal thoughts, or mood fluctuations. Thus, social workers in many different types of practice settings should consider routinely screening clients for IPV, and may need to repeat screening with clients who remain in services over a period of time. Regardless of the type of screening/assessment utilized, the social worker should be aware of the possibility of skewed, biased, and minimizing responses that victims, as well as perpetrators, might provide.

To assess the degree of danger to victims (and perpetrators) of IPV, Campbell suggests using the Danger Assessment measure (Appendix D, Campbell, 1995). The risk factors include access to/ownership of guns, use of weapons in prior abusive incidents, threats with weapons, threats to kill, inflicting serious injury in prior abusive incidents, threatening suicide, alcohol abuse or use of other drugs, forced sex, obsessiveness, extreme jealousy, and/or extreme dominance. Previous arrests for domestic violence offenses is a high risk factor. It is important to find out how safe the client feels at home and at work, as well as determining the safety of children and other family members (including pets). CSAT (1997) TIP #25 includes a danger assessment in its appendices, as well as a sample personalized safety plan for survivors of intimate partner violence.

Clients who reveal information about an abusive situation should be handled by:

  • nonjudgmental and empathic responding;
  • accepting the client's assessment of the situation;
  • assuring the client that she (or he) is not alone with this problem;
  • reminding the client that no one "deserves" to be hit, hurt, or abused;
  • recognizing the person's strengths;
  • being aware of the person's changed needs regarding personal space and the threatening nature of touch

Victims of IPV often need information about realistically accessible resources and options available to them. They may also need support to develop a safety plan for themselves and their dependent children. If a client intends to leave an abusive relationship, it is important to assess the safety and practicality of the plans. Social workers should develop an awareness and understanding of their own community's policies regarding mandatory reporting of IPV. In addition, social work professionals need to recognize the local justice and legal system's level of competence and responsiveness in dealing with these circumstances (e.g., obtaining restraining orders, mandatory arrest warrants, child protective service responses, etc.). Brown (1997) has developed an interview strategy, Process of Change in Abused Women Scales (PROCAWS), for assessing the victim's readiness to take action to end the violence in an intimate relationship.

Some responses to IPV have the unfortunate effect of re-victimizing the victim. Program policies that require a victim to terminate the relationship in order to receive services fall into this category. Many victims choose to remain in their relationships, for a wide variety of reasons. These include fear of escalating the violence by leaving, unwillingness to dissolve the family, lack of resources to become independent, believing that the person will change, feelings of love and affection despite the abuse, worry that the perpetrator cannot survive alone, or vulnerability to deportation (immigrants), as well as pressures from extended family, moral, religious, or cultural belief systems.

Treatment Sequencing and Change in Organizations

In some cases, family therapy to treat substance abuse is desirable. However, conjoint, couples, and family intervention is not always appropriate when IPV is involved (Silva & Howard, 1991). Many IPV interven-tionists argue that conjoint treatment actually increases the level of risk for a victim, or at best, is rendered ineffective by the power and control discrepancies that exist in violent partnerships (see Appendix C). Others have suggested that conjoint treatment (e.g., "couples therapy") is an effective form of IPV intervention among certain types of couples with a history of alcohol problems (O'Farrell & Murphy, 2002; O'Leary, 2001). Most often, however, some individuals with co-occurring IPV and alcohol problems enter alcohol treatment, while others enter batterer or victim treatment. Appropriate referrals across program types are rarely made (Stith, Crossman, & Bischof, 1991). Alcohol treatment providers have been shown not to commonly refer men with an IPV history to domestic violence treatment programs, and men who receive these referrals rarely followed through to receive the IPV treatment (Schumacher, Fals-Stewart, & Leonard, 2003). There are several options for sequencing treatment interventions for individuals who abuse both alcohol and their intimate partners. However, there are few formal, empirically tested models of support and treatment for victims of IPV who also experience alcohol use problems.

Issues for Debate:
- Do conjoint interventions (treating perpetrator and victim together) increase the level of victim risk?
- Sequencing issues: Do you treat both problems concurrently but separately, or treat IPV and substance use consecutively?
- Is it better to introduce alcohol interventions to batterer treatment programs and/or introduce batterer interventions into alcohol treatment?


One option is to treat both problems concurrently, but through separate, specialized programs. The perpetrator or the victim would attend one or two sessions per week for each problem. This strategy will be effective only in circumstances where both programs are based on similar philosophies and reinforce each other's strategies. Fortunately, cognitive-behavioral programs exist for both types of problems, allowing for overlap in language, techniques, and skills presented. This consistency and repetition may help to avoid client confusion and a sense of being overwhelmed. Other aspects of commonality that may exist in the two types of programs include: recognition of intergenerational aspects of the problem; appreciation of the ways in which work, family and friends are affected; addressing family secrets related to the problem; awareness of societal norms; acknowledging the progressive nature of the problem; recognizing how the problem relates to other social issues; and, awareness of cycles and patterns in the problem behaviors (Banks & Randolph, 1999).

Unfortunately, the basic philosophies and roots of alcohol and batterer treatments are often in direct opposition to one another. For example, programs that represent the alcohol dependent person as powerless against the disease of alcoholism are diametrically opposed to batterer programs that are based on the assumption of personal responsibility for behavior (Conner & Ackerley, 1994; Stith, et al, 1991)-and may ignore the role of personal responsibility for deciding to drink. Or, alcohol treatment goals may include risk minimization rather than abstinence, while batterer treatment requires abstaining from all violence that could result in harm to another person. While professionals argue about the feasibility of controlled drinking, none support "controlled" IPV in lieu of cessation and adoption of non-violent alternatives. Misunderstandings about these philosophical and practice bases, along with poor lines of communication between service providers, may result in uncoordinated treatment approaches within a community's service delivery system.

A second, and more commonly employed strategy is to treat the two problems consecutively. For example, inpatient alcohol treatment may be desired because it ensures partner safety during the period of treatment enrollment. However, the partner is not protected when the batterer returns home, and may have acquired a false sense of confidence about safety as a result of the alcohol treatment (Conner & Ackerley, 1994). More importantly, because IPV is immediately life-threatening, it should be addressed sooner rather than later (Silva & Howard, 1991). Sonkin (1985) recommends that the primary intervention target remain treatment of the IPV, but also addressing the alcohol use problems through referral to specialized services. In this way, both alcohol and IPV problems are addressed and their linkage remains in proportion-neither over- or under- emphasized. The Illinois Department of Human Services' manual for the treatment of co-occurring IPV and substance problems advocates application of a "Safety and Sobriety" paradigm (Illinois DHS, 2000). This suggests that individuals cannot recover from addiction when they (or their partners) are not safe, and that neither men nor women can be safe while they are abusing substances.

As noted above, these two problems become sequentially addressed by default if batterer treatment programs hold sobriety as a condition of participation. However, where low rates of alcohol abstention exist, there exists a heightened risk for ongoing IPV, as well (Conner & Ackerley, 1994).

A third, more innovative strategy is to introduce alcohol interventions to batterer treatment programs and/or to introduce batterer interventions into alcohol treatment. Research suggests that alcohol and IPV treatment programs serve remarkably similar clientele (Stith, et al, 1991). Ideally, social workers become trained and competent in both fields, and collaborate to create unified intervention approaches to address both alcohol and intimate partner abuse. At a minimum, it is recommended that social workers screen for IPV in programs that serve women who seek alcohol treatment (Miller et al., 2000) and that batterer treatment programs include information and education concerning alcohol abuse (Stith, et al, 1991). The approach of discussing relationships between alcohol and IPV, consciousness raising about the problems associated with alcohol, and the provision of referrals for alcohol treatment are integral to some batterer treatment programs (Rosenbaum & Leisring, 2001). Furthermore, alcohol treatment programs must take measures to ensure the safety of potential IPV victims throughout the screening, assessment, and treatment processes (Stith, et al, 1991). Gondolf (1995) cites a contemporary trend in substance abuse treatment programs to add components related to family violence. However, he also notes that this type of coordination remains an exception, not the norm. It appears that difficulties in coordinating IPV services are not unique to the U.S. (Malloch & Webb, 1993).

Significant and persistent barriers to cooperation exist between the systems for alcohol and IPV treatment (Bennett & Lawson, 1994), only some of which derive from discrepant philosophies and misunderstandings. Of substantial concern is the series of schisms and tensions that exist within the field of IPV intervention (Nurius & Asplund, 1994), as well as within alcohol treatment. A major barrier is that IPV programs seldom utilize DSM-IV or other standardized classification systems to define alcohol or other substance use problems among their clients (Rose, Zweben, & Stoffel, 1999). While IPV programs address a criminal behavior, not a mental illness (hence the lack of diagnosis), it might facilitate service integration to have screening and referral become part of the intake and client follow-up procedures. Referral to alcohol treatment increases a batterer's ability to comprehend and utilize what is being presented in IPV treatment, facilitates program attendance, and may increase partner safety (Bennett, personal communication, October 2002; Hamberger & Hastings, 1989; 1990). Similarly, alcohol and drug interventionists under-utilize standardized and empirically based means of screening (and referral) for IPV among possible victims and perpetrators in their programs.

Barriers to Coordination Between Substance Abuse and IPV Treatment Systems
- Discrepant philosophies/ misunderstandings
- No standard classification system
- No substance abuse screening and referral in IPV programs; no IPV screening and referral in substance abuse programs
- Diversity in agency and practitioner readiness to change their practices

Another significant barrier to coordination is the marked diversity in agency and practitioner readiness to change their practices (Backer, 1995; Nurius & Asplund, 1994). An agency's readiness to innovate in the area of practice is a function of: (1) general organizational readiness factors (motivation, staff readiness, organizational climate); and (2) institutional resources (facilities, personnel, finances). Many IPV programs, along with their alcohol treatment counterparts, lack sufficient resources and motivation to engage in coordinated efforts and drastic revisions of practice methodologies. Simple technology transfer efforts alone are not likely to result in a coordinated system of care. Achieving this goal will require a systematic plan for training, organizational intervention, supported trial usage opportunities, and support for programs and practitioners to move from trial of innovations to innovation adoption.

Classroom Activities

  1. Have each member of the class review the sample personalized safety plan for domestic violence survivors presented in Appendix D of the CSAT (1997) TIP #25. Then have individuals work in pairs to complete a safety plan for themselves. Discuss the issues, feelings, concerns, barriers and challenges addressed in making a realistic plan.
  2. Have each member of the class visit a relevant website and report on what was learned from the information provided there. Some examples are:
    http://www.ojp.usdoj.gov/vawo (Violence Against Women Office)
    http://www.cdc.gov/ncipc (National Center for Injury Prevention)
    http://www.ncadv.org (National Coalition Against Domestic Violence)
    http://www.cpsdv.org (Center for the Prevention of Sexual and Domestic Violence)
    http://www.ndvh.org (National Domestic Violence Hotline)
    http://www.wellesley.edu/WCW/infoproj.html (National Violence Against Women Prevention Research Center)
  3. Role-play alcohol screening with an individual who has been court ordered for batterer treatment services. Discuss the issues and techniques for improving effectiveness. Then, role-play IPV screening with an individual who has come for problems with alcohol use. First, screen the "client" as a perpetrator of IPV, then screen as if the "client" might be a victim of IPV. Discuss how your social work approaches might be similar and different in these three situations.
  4. Review the Federal Confidentiality Regulations (Appendix B of the CSAT, 1997 TIP #25) and discuss how they apply to coordination of care between IPV and alcohol treatment providers.
  5. 5. CSAT (1997) TIP #25 presents the case of Judy, "Profile of a Survivor". Present this case for class discussion.

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Appendix A: The Michigan Alcohol Screening Test (MAST)

The MAST Test is a simple, self scoring test that helps assess if you have a drinking problem. Please answer YES or NO to the following questions:

  1. Do you feel you are a normal drinker? ("normal"=drink as much or less than most people) YES or NO
  2. Have you ever awakened the morning after some drinking the night before and found
  3. that you could not remember a part of the evening? YES or NO
  4. Does any near relative or close friend ever worry or complain about your drinking? YES or NO
  5. Can you stop drinking without difficulty after one or two drinks? YES or NO
  6. Do you ever feel guilty about your drinking? YES or NO
  7. Have you ever attended a meeting of Alcoholics Anonymous (AA)? YES or NO
  8. Have you ever gotten into physical fights when drinking? YES or NO
  9. Has drinking ever created problems between you and a near relative or close friend? YES or NO
  10. Has any family member or close friend gone to anyone for help about your drinking? YES or NO
  11. Have you ever lost friends because of your drinking? YES or NO
  12. Have you ever gotten into trouble at work because of drinking? YES or NO
  13. Have you ever lost a job because of drinking? YES or NO
  14. Have you ever neglected your obligations, your family, or your work for two or more
  15. days in a row because you were drinking? YES or NO
  16. Do you drink before noon fairly often? YES or NO
  17. Have you ever been told you have liver trouble such as cirrhosis? YES or NO
  18. After heavy drinking have you ever had delirium tremens (D.T.'s), severe shaking,visual or auditory (hearing) hallucinations? YES or NO
  19. Have you ever gone to anyone for help about your drinking? YES or NO
  20. Have you ever been hospitalized because of drinking? YES or NO
  21. Has your drinking ever resulted in your being hospitalized in a psychiatric ward? YES or NO
  22. Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem? YES or NO
  23. Have you been arrested more than once for driving under the influence of alcohol? YES or NO
  24. Have you been arrested, even for a few hours because of other behavior while drinking? YES or NO (If Yes, how many times ________ )

SCORING: Please score one point if you answered the following:
  1. No 4. No 7 through 22: Yes
  2. Yes 5. Yes
  3. Yes 6. Yes

Add up the scores and compare to the following score card:
0 - 2 No apparent problem
3 - 5 Early or middle problem drinker
6 or more Problem drinker


Appendix B: Danger Assessment

Jacquelyn C. Campbell, Ph.D., R.N.
Copyright 1985, 1988, 2001 The Johns Hopkins University School of Nursing

Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation.

Using the calendar, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale:

  1. Slapping, pushing; no injuries and/or lasting pain
  2. Punching, kicking; bruises, cuts, and/or continuing pain
  3. "Beating up"; severe contusions, burns, broken bones
  4. Threat to use weapon; head injury, internal injury, permanent injury
  5. Use of weapon; wounds from weapon
(If any of the descriptions for the higher number apply, use the higher number.)

Mark Yes or No for each of the following. ("He" refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.)
____ 1. Has the physical violence increased in severity or frequency over the past year?
____ 2. Has he ever used a weapon against you or threatened you with a weapon?
____ 3. Does he ever try to choke you?
____ 4. Does he own a gun?
____ 5. Has he ever forced you to have sex when you did not wish to do so?
____ 6. Does he use drugs? By drugs, I mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack", street drugs or mixtures.
____ 7. Does he threaten to kill you and/or do you believe he is capable of killing you?
____ 8. Is he drunk every day or almost every day? (In terms of quantity of alcohol.)
____ 9. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here: ____ )
____ 10. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ____)
____ 11. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have you, no one can.")
____ 12. Have you ever threatened or tried to commit suicide?
____ 13. Has he ever threatened or tried to commit suicide?
____ 14. Does he threaten to harm your children?
____ 15. Do you have a child that is not his?
____ 16. Is he unemployed?
____ 17. Have you left him during the past year? (If have never lived with him, check here___)
____ 18. Do you currently have another (different) intimate partner?
____ 19. Does he follow or spy on you, leave threatening notes, destroy your property, or call you when you don't want him to?

_____ Total "Yes" Answers

Thank you. Please talk to your nurse, advocate or counselor about
what the Danger Assessment means in terms of your situation.

Appendix C: Interviewing Techniques

Social Worker Screening: Beginning Dialogue

"I'm concerned about prevention and safety, especially in the family. Are you in any relationships where you are afraid for your personal safety, or where someone is threatening you, hurting you, forcing sexual contact, or trying to control your life?"
Other questions such as:

  • "How are things going with your partner?"
  • "When you're angry with each other, how do you show anger?"

Hear "warning signs" of abuse

  • "Trouble" with children:
    - parent-child relations and behavioral problems
  • Marital and/or relationship problems
  • Family history of abuse
  • Report of seeing someone else abused

Look for "warning signs" of abuse

  • Bruises
  • Marks that don't seem congruent with explanations (e.g., black eye "caused" by running into a door)
  • Wearing heavy makeup
  • Wearing high coverage garments (e.g., long-sleeves, especially in the summer)
  • Slow, deliberate movements as if very sore or tender

Other "warning signs" of abuse

  • Client is always rushing home (from work, from therapy, from errands, etc.)
  • The client needs "permission" of partner before engaging in an activity
  • Client describes partner calling or visiting (at work) numerous times a day/week
  • Unexplained absences from work
  • Extreme worry or concern regarding a partner's reactions to things
  • Public ridicule by partner
  • Partner controls all resources

 

Updated: March 2005