Module 3.1: Health Professionals as a Vital Link to Support

Aim

This module aims to enable participants to recognise and develop their role as a link to support for victims and perpetrators of domestic violence.

Objectives

The objectives of this module are to:

Provide information about models of response to domestic violence
Provide information about the theories underpinning past and present models of response
Provide a platform to explore strengths and weaknesses of models of response
Provide information about the multidisciplinary approaches as a framework for response to domestic violence
Provide information about the models of response in relation to health professionals’ role, scope of practice and professional competencies
Provide information on a variety of approaches to working with victims of domestic violence
Provide opportunity to reflect on personal responses to issues raised in the module

Learning Outcomes

On completion of this module participants will be able to:

Discuss the models of response to domestic violence
Relate the models of response to underlying theories of domestic violence
Critically analyse the effectiveness of various models of response
Discuss the role of the multidisciplinary team in responding to domestic violence
Relate the models of response to health professionals roles, scope of practice and professional competency
Appraise the strengths and weaknesses of various approaches to working with victims of domestic violence
Reflect upon their personal responses to issue raised in this module.

Introduction

This module aims to present various models of response to domestic violence, link them to underlying theories and competent professional practice. Domestic violence is a major public health threat that creates ethical concerns regarding confidentiality and autonomous decision-making. The health care system is one avenue victims often use to seek assistance with domestic violence (Bohn 1996, Keys Young 1998, Nudelman & Rodriguez 1999). Health care professionals are often therefore the first and only professionals that victims see. In order to recognise and respond to victims it is useful to put in place a strategy that incorporates a variety of perspectives and includes a range of different professionals. Such a multidisciplinary framework can be a highly effective tool when dealing with domestic violence.

Models of Response to Domestic Violence

There are many available programs that can respond to domestic violence. It is important to emphasize that models traditionally used in the mental health field (which are appropriate for dealing with specific health problems) are not appropriate responses for working with domestic violence. Inappropriate models of response commonly focus on individual psychological issues that are not the cause of intimate partner abuse, and therefore fail to address the issue of domestic violence. The associated interventions of these models do not prioritise the safety of victims and their families, nor address the violent behavior of the perpetrator (Adams 1988). Effective responses to domestic violence must be based on a comprehensive understanding of the most effective strategies for the individual problem and should not be confused with the notion that perpetrators could possibly need additional services.

The purpose of this module is not to embark upon a detailed analysis of existing programs, but to provide a general overview of the broader models of response and the theories that underpin them.

The work of David Adams (1988) provides a useful overview of past and present models of response for domestic violence. While the models are presented here in a compartmentalised format Adams (1988) points out that many programs based on these models draw from a combination of the approaches. This section briefly outlines:

An overview of several response models and their theoretical underpinnings
An overview of inappropriate methods of responses
An overview of appropriate responses for working with victims and perpetrators of domestic violence.

Modules of Response and Theoretical Underpinnings

(See table 1 for more detailed discussion)

There are five main models of response. These are:

Insight Model

As the traditional model for understanding domestic violence, this model assumes abusive behavior is a symptom of underlying psychological problems (Adams 1988).

Ventilation Model

Takes the approach that behaviours such as anger need to be expressed (ventilated).

Cognitive Behavior / Psycho-education Model

According to this perspective violence is a learned behavior. Similarly it is assumed that non-violent behaviours can also be learned.

Interactive / Family Therapy Model

This model argues that violence is a result of dysfunctional relationships.

Pro-feminist Model

In very simple terms this model assumes that violence is a consequence of patriarchal (male dominated) society.

Table 1: Models of Response

Insight Model

Implicit in this approach is the idea that perpetrators of domestic violence have a fragile sense of self that must be addressed before violent and compensating behaviors can be dealt with. The conception of violent men is largely informed by the ‘sex role identity theory’ which puts forward that excessively masculine behavior such as aggression and violence are rooted in men’s unconscious anxiety about the feminine components of their personalities (Adams 1988). As such this model aims to therapeutically address psychological conditions and vulnerabilities with medical intervention and counseling to help the perpetrator develop insight into the effect of violent behavior on intimate relationships (Adams 1988).

Ventilation Model

1960’s psychologists thought suppression of anger was a contributory cause of many health related conditions (peptic ulcers, depression, and violence). Psychologists believed that encouraging perpetrators of domestic violence to openly express anger and resentment would release their stored hostility and so prevent violent outbursts (Adams 1988).

Interactive / Family Therapy Model

According to this perspective, domestic violence is not characterized as one partner attempting to control or dominate the other. Instead it is a reflection of the couple’s dysfunctional relationship, their combined communicational deficits, and their attempts to coerce and incite each other (Adams 1988). These impairments lead to frustration and anger, which are expressed as violence (Adams 1988). This response model targets intervention at improving interpersonal skills and correcting dysfunctional relationships through couple or family counseling (Adams 1988).

Cognitive Behavior / Psycho-education Model

Derived from ‘social learning theory’ this perspective regards behaviors such as violence as socially learned and self-reinforcing. This model therefore seeks to respond to perpetrators through learning alternative behaviors. Education is regarded as the key to generating behavioral changes, and commonly includes communication skills and assertiveness training to combat social skill deficits (Adams 1988). Importantly the cognitive-behavioral model makes violence the primary focus of the approach and is therefore seen as the dominating influence on relationship interaction (Adams 1988).

Pro-feminist Model

This perspective assumes the fundamental cause of domestic violence is the patriarchal social order, including patriarchal family structures (Johnson 1996). Domestic violence is regarded as behavior that reflects the imbalance of dominance of men over women. The fundamental issues of power and control inform therapeutic responses that challenge perpetrators attempts at controlling victims through physical and psychological tactics. This response model stresses empowering women, enforcing criminal prosecutions of men and advocates separate and distinct intervention programs for both men and women (Johnson 1996).

Activity
In small groups:

Brainstorm strengths and weaknesses of one model of response and then compare this with other groups’ findings for their models.
Construct a comparative table.

Inappropriate Models of Response

(This section taken with permission from Vermont Department of Corrections, Statewide Domestic Abuse Standards)

Practice techniques, models of response, or methods of therapy that include the victim in the responsibility for the violence are inappropriate ways to respond to domestic violence. Even with other methods some of these techniques cannot be included as techniques to bolster appropriate responses.

Psychodynamic individual or group therapy that center causality of the violence in the past
Communication enhancement or anger management techniques that lay primary causality on anger
Systems theory approaches that treat the violence as a mutually circular process, blaming the victim
Addiction counseling models that identify the violence as an addiction and the victim and children as enabling or co-dependent in the violent drama
Family therapy or counseling that places the responsibility for adult behavior on the children
Gradual containment and de-escalation of violence
Theories or techniques that identify poor impulse control as the primary cause of violence
Methods that identify psychopathology as a primary cause of violence
Fair fighting techniques, getting in touch with emotions, or alternatives to violence
Couples counseling in any form, including couples conjoint counseling or marriage enhancement groups.

Appropriate Models of Response

The current preferred Pro-feminist model provides the principles and context in which interventions can be appropriately employed.

The pro-feminist model recognises the need for effective communication; preparation required to care for others; the need to challenge relationships that are based on power and control; the need to plan for safety, and the need to ensure that the victim is aware of and can access resources and support.

Multidisciplinary Approach as a Framework for Domestic Violence Response

Collaboration and teamwork through effective partnerships are the keys to successful health care reform. If we can gain a better understanding of how and why health care and domestic violence workers should work together we have a better chance of effectively dealing with domestic violence. In order to address the complexities we should begin by respecting the professional expertise that each bring to the field. Central to this is sharing are knowledge and expertise and seeking assistance in areas where our knowledge base needs work.

Most workers who deal with victims of domestic violence are not experts on health care and most health care providers are not experts on domestic violence. Dual expertise is not necessary for a strong health care response to domestic violence, but health care professionals do need to recognise and capitalise on each other's knowledge and skills as a strengthened multidisciplinary approach to domestic violence. (Nudelman & Rodriguez, 1999)

Keys to an appropriate institutional response

This section encourages participants to address the roles that hospitals, clinics and community centres do and can undertake in response to domestic violence. The key points are drawn from Nudelman & Rodiguez, 1999).

Activity

In light of your own workplace develop a response for each of the following key areas of development
Gaining access to advocates for change
- Who are they in your workplace?
Developing Institutional commitment
- Whose job is it to respond?
What are the roles for responding to domestic violence and who has responsibility for them?
Are they prepared for those roles? Education? Support?
Multidisciplinary collaboration
Who is on the team already? Who should be on the team?
Are relationships between team members clear?
Are professional domains of response clear?
Are the administrators involved? Should they be?
Creating and institutionalising the response
Does you organisation have a response strategy? Protocol?
What screening tools are used? Are they suitable?
Professional development program
Is domestic violence addressed?
Are resource materials current and readily available?
Is there a system of monitoring?
Does the organisation collaborate with the domestic violence community?

Health care professionals are often the frontline crisis workers for the majority of domestic violence victims (Carbone 2002). It is beyond the scope of this package to detail the role and responsibility of individual health care professional response to domestic violence. Instead, it can be safely assumed that all health professionals work toward the common goal of protecting and maintaining each individual human rights. Human Rights are ‘… universal legal guarantees protecting individuals and groups against actions which interfere with fundamental freedoms and human dignity’ (The United Nations System and Human Rights: Guidelines and Information for the Resident Coordinator System, 2000). The World Health Organisation has summarised some of the most important characteristics of human rights. They are:

Guaranteed by international standards
Legally protected
Focus on the dignity of the human being
Oblige states and state actors
Cannot be waived or taken away
Interdependent and interrelated
Universal.

Scope of Practice

Professional practice is about structures and processes that help health professionals to achieve competent, compassionate and collaborative care to individuals and their families through a commitment in care, education, and research. The commonalities of health professionals aiming to protect the human rights of individuals beyond the traditional boundaries of practice include:

Maintaining the interests of clients at all times
Maintaining competent levels of knowledge and skills
Recognising own knowledge and skill deficits and engage in own professional development to address any deficiencies
Ensuring that existing professional standards are not compromised by new developments and responsibilities
Acknowledging professional accountability
Avoiding inappropriate delegation.

Position Statement on Domestic Violence

(Reproduced with permission from the New York State Nurses Association, 11 Cornell Road, Lathem, NY 12110-1499. The position statement is dated 9/17/98).

Domestic violence poses a major public health threat and raises ethical concerns regarding the victim’s rights to confidentiality and autonomous decision making. It is a pattern of coercive behavior which can include physical, sexual, economic, emotional, and/or psychological abuse exerted by one person over another with the goal of establishing and maintaining power and control (New York State Office for the Prevention of Domestic Violence, 1995). The violence expressed within the structure of intimate family relationships and most often perpetrated against women, children, and the elderly, and, sometimes men, is of epidemic proportion in our society. The Council on Ethical Practice has researched the issue of domestic violence and presents this position to assist the nursing community in caring for women and men who are victims of domestic violence.

Overview:
In particular, domestic violence is a major health problem for women and an underreported health issue for men. This position statement focuses on this problem. Battered women account for:

22% - 35% of women seeking care for any reason in emergency departments, the majority of whom are being seen by medical and non-trauma services.
19% - 30% of injured women seen in emergency departments.
14% of women seen in ambulatory care internal medicine clinics.
25% of women who attempt suicide.
23% of women who seek prenatal care.
45% - 59% of mothers of abused children. (AMA Diagnostic & Treatment Guidelines on Domestic Violence, 1992)
90-95% of all reported incidents of domestic violence are against women who are abused by their male partners.

1-2% of incidents are against men by abusive female partners. It has been determined that the rate of domestic violence in gay and lesbian relationships is 30%, which is also the rate between heterosexual partners (NYS Office for the Prevention of Domestic Violence, 1997).

Repeated physical blows also called battering is behavior that physically harms, arouses fear, prevents partners from doing what they wish or forces them to do something they do not want to do. The ultimate goal of the batterer is to intimidate, threaten, entrap and control the victim.

Women and men abused by verbal or physical assault develop tactics to live and survive the violence. Tragically, the actions of domestic abusers have long been accepted in American society. They often choose to remain in the abusive home and family situation because the victim is at greatest threat for bodily.

There is evidence that one tactic women and men use to survive domestic violence is to use the health care system (Bohn, 1996). Health care providers frequently are the first and only professionals victims turn to for help.

Position:
Since nurses provide health care in a variety of settings often accessed by victims of domestic violence, nursing practice should incorporate interventions that promote recognition and referral of victims within an environment that safeguards confidentiality and acknowledges the victim’s right to autonomous decision making.

Recommendations:
The Council recommends that:

Nurses reaffirm their professional and ethical obligation to become knowledgeable regarding the nature and dynamics of domestic violence.
Regardless of practice setting, nurses promote an environment that preserves the patient/victim’s right to privacy and protects the patient/victim’s right to make autonomous decisions.
Nurses advance societal efforts to break the destructive cycle of domestic violence.
Nurses advocate for current state and federal proposals addressing domestic violence.

Finally, the Council recommends that nurses refer to the following guidelines in caring for patients/victims of domestic violence.

Guidelines:
The Council suggests that in daily practice, the nurse:

Ensures universal screening for domestic violence as a part of routine history taking by all health care providers.
Advocates for the patient/victim based on the patient/victim’s right of autonomous decision making.
Affirms the patient/victim’s dignity and human worth by accepting the patient/victim’s account of battering and abuse.
Recognizes the potential threat to the patient/victim’s safety before intervening on her behalf in any manner.
Safeguards the confidentiality of the patient/victim encounter with the understanding that any breach of confidentiality could place the patient/victim at increased risk for violent activity by the batterer/abuser.
Documents accurately in the health record whenever domestic violence is suspected or has been disclosed, including that the patient/victim was appropriately screened, the patient/victim’s response, record of injuries, inconsistencies in the history of the trauma incident, and notification of victim’s rights.
Adheres to national, state and institutional protocols and standards including requirements to provide "victims rights notice" to patients who are known or suspected victims of domestic violence.
Uses community resources that can adequately address the needs of the patient/victim of domestic violence and of the referral process.
Assesses the patient/victim’s immediate safety from the abuser.

References:

American Medical Association. (1992). Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, IL: Author.

American Nurses Association. (1998). Culturally Competent Assessment for Family Violence. Washington, DC: Author.

Bohn, D. (1996). Sequela of abuse: Health effects of childhood sexual abuse, domestic battering and rape. Journal of Nurse Midwifery, 41, 442-456.

Family Violence Prevention Fund. (1993). Men beating women: Ending domestic violence, a qualitative and quantitative study of public attitudes on violence against women. New York, NY: Author.

Jezierski, M. (1998). Nurse educator: Hospital-wide domestic violence education. Journal of Emergency Nursing, 24, 275-277.

New York State Office for the Prevention of Domestic Violence. (1992). RADAR: A domestic violence intervention. Albany, NY: Author.

New York State Office for the Prevention of Domestic Violence. (1995). Recognizing and treating victims of domestic violence. Albany, NY: Author.

New York State Office for the Prevention of Domestic Violence. (1995). The health care professional’s response - Basic packet. Albany, NY: Author. (Available in the New York State Nurses Association’s library)

New York State Office for the Prevention of Domestic Violence. (1997). Domestic violence - Finding safety and support. Albany, NY: Author.

Activity

How could this document be amended to reflect a position statement that is relevant to the Australian context?

Responding to people who experience domestic violence

(Adapted from Laing 2000: Working with women: Exploring individual and group work approaches, Clearinghouse, Australian Domestic and Family Violence, Issues Paper 4.)

Living with violence or abuse as an expression of control and power has serious effects on women (Laing 2000). Providing opportunities for women to verbalise their experiences is recognized as a way of assisting women to overcome these effects (Laing 2000). One of the difficulties of providing such intervention however, is that domestic violence is regarded both as a social issue and a personal problem (Laing 200). As such the appropriate level of intervention, individual or social, becomes difficult to determine (Laing 2000).

Approaches to working with victims of domestic violence

(Taken from Laing, L, 2000, Working with women: Exploring individual and group work approaches, Clearinghouse Australian Domestic and Family Violence. Issues Paper 4.)

Five approaches to working with domestic violence are presented here for discussion and consideration. They are:

Individual
Group work
Trauma based
Safety planning
Postmodern approaches

Individual Approaches

Programs that are designed to work with women on an individual level aim to provide interventions that do not pathologise the issue or blame the victim (Laing 2000).

Dutton (1992, p. 4) identifies three goals of her individual approach to victims of domestic violence. These include:

increasing safety
re-empowerment through decision-making
and healing the psychological trauma of the abuse.

This approach is entrenched in the idea that “addressing the trauma of abuse cannot occur until safety has been established” (Laing 2000). The components of Dutton’s include:

A detailed exploration of the nature and pattern of the abuse
Its psychological effects
The women’s survival strategies
And the factors (such as social support, institutional responses and positive and negative qualities of the relationship with the abuser) which ‘mediate both the effects of the abuse and the survival strategies used to respond to it’. (Dutton, 1992, p. 4)

See: Dutton, M 1992. Empowering and Healing Battered Women.

Group Work Approaches

Group work is regarded as a potentially effective intervention for working with women who are victims of domestic violence (Laing 2000). It is supported as a strategy for women because it provides an opposing experience to that of the isolation victims commonly experience as a result of domestic violence (Laing 2000 citing Flannery et al 2000). Group work is a powerful approach for allowing women to verbalise their experiences, share information and resources, recognise their strengths and dispel the notion that the women is at fault for her situation (Laing 2000).

More recent group work programs have diversified the application of the programs, increasing access opportunities for multi-cultural victims, homosexual victims and those from non-English speaking backgrounds (Laing 2000). Group work can also be adapted to address the needs of culturally sensitive groups, such as indigenous people (see Anti-violence Against Koori Women and Children Group 1999).

Discussion Questions

What are some specific behaviours workers that work with women who experience domestic violence in groups can use to facilitate empowerment?
In what ways might working with women as victims of domestic violence through group work undermine the aim of empowerment?

Trauma based Approaches

The theories that underlie this approach are embedded in the psychiatric disorder category. Its perspective is entrenched in the belief that a person who has experienced a traumatic stress will have compromised coping abilities (Laing 2000).

See: Herman (1992)

This author provides a model of therapy based on the impact of trauma. The model encompasses three stages, recovering safety, reconstructing the trauma story, and restoring connection between the survivors and the community”. Empowering the survivor is a key concept throughout the book.

See: Stark & Flitcraft (1996)

In an attempt to move away from the concept of battered women syndrome these authors prefer to approach their work from a notion of ‘dual trauma’ that involves coercive control and inappropriate clinical intervention (Laing 2000). The result is a revised trauma model that emphasizes a woman’s strengths, incorporates the experience of help seeking and includes liaison with shelter and criminal justice services and advocacy (Laing 2000).

Safety Planning

Safety planning includes a variety of responses that enable women to become more informed about the issue of domestic violence and the resources available to assist with decision making.

See: Davies et al 1998

Post Modern Approaches

The philosophical basis for this perspective is commonly related to the work of Foucault (Laing 2000). Violent behaviours of perpetrators are regarded as displays of oppressive power through physical and sexual tactics. Women who experience abuse in this way are understood as being subjected to the ‘power of certain dominant discourse’ (Laing citing Foucault 2000). This perspective is particularly useful for understanding the experiences of older women whose era frowned upon divorce. Dominant institutions were significantly influential in shaping women’s response to domestic violence within their marriages (Laing 2000).

Narrative therapy is one approach that enables victims to use the process of story telling to make sense of their life experience (Laing 2000). This approach to counseling addresses the broader socio-political context of women’s experience of domestic violence through understanding the influence of dominant discourses have on individuals lives (Laing 2000).

Discussion Questions
In small groups consider the five approaches and discuss the following:

What are the strengths of each approach?’
What are the weaknesses of each approach?
Could the approaches be used separately?
How might the approaches be used in combination?

Opportunity to reflect upon personal reactions to issues raised in this module

Questions to Guide Reflections
(Questions 1-3 are drawn from Styles & McGregor 1991)

What have we done in this module?
How have we done it?
Why did we do it?
How is it relevant to responding appropriately to domestic violence?
What were my beliefs and attitudes to responding to domestic violence before I engaged in this module?
Were any of my beliefs and attitudes challenged by the material in this module?
If so, what beliefs/attitudes were challenged and why?
How might this impact upon the way in which I respond to people involved in domestic violence situations?

References

Adams, D., 1988, Treatment Models of Men Who Batter: A Pro-feminist Perspective on Wife Abuse, in Feminist Perspective on Wife Abuse, eds. Yllo, K. & Bograd, M. Beverly Hills Sage, London.

Bohn, D., 1996, Sequela of abuse: Health effects of childhood sexual abuse, domestic battering and rape, Journal of Nurse Midwifery, 41, 442-456.

Carbone, N., 2002, Domestic Violence: An Update, Bert Rodgers Schools of Continuing Education

Dutton, M., 1992, Empowering and Healing the Battered Woman, Springer Publishing Co., New York.

Flannery, K., Irwin, J., & Lopes, A., 2000, Connection and cultural difference: women, groupwork and surviving domestic violence. Women against Violence, 9, 14-21.

Herman, J. L.,1992, Trauma and Recovery, USA: Basic Books.

Stark, E., & Flitcraft, A., 1996b, Women at Risk: Domestic violence and women’s health, Thousand Oaks: Sage.

Davies, J., Lyon, E., & Monti-Catania, D., 1998, Safety Planning with Battered Women: Complex lives/difficult choices, Thousand Oaks: Sage.

Styles, W & McGregor, H., 1991, NSW Domestic Violence Core Training Package: A Model for Training Service Providers, Trainers Manual, Women’s Health & Sexual Assault Education Unit, Women’s Coordination Unit, Department of Family & Community Services Training & Development Branch.

Keys Young, 1998, Against the odds: How women survive domestic violence – The needs of women experiencing domestic violence who do not use Domestic Violence and related crisis services. Office of the Status of Women, Barton, ACT.

Laing, L., 2000, Working with women: Exploring individual and group work approaches, Clearinghouse Australian Domestic and Family Violence, Issues Paper 4.

Nudelman J. & Rodriguez H., 1999, Building Bridges between domestic violence advocates and health care providers, National Resource Centre on Domestic Violence and the Family Violence Prevention Fund’s Health Resource Centre on Domestic Violence.

New York State Nurses Association Position Statement on Domestic Violence, 11 Cornell Road, Lathem, NY 12110-1499. Position statement is dated 9/17/98.

World Health Organisation (WHO). http://www.who.int/health_topics/human_rights/en