Domestic
Violence Update #1
Daniel
Sonkin, Ph.D.
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How to complete this program
Just read the material online, save a copy to your computer
or print out a copy.
You may have questions as you watch the program. If
so, just click on the highlighted ÒContact Dr. Sonkin by emailÓ link placed on many pages to contact me.
I hope you find the presentation useful in your clinical
practice.
What will you learn in this training?
á
Legal
update
á
Defining
non-physical violence
á
Typology
of perpetrators and victims
á
Risk
assessment
á
Psychopharmacology
á
Neurobiology
of violence
á
Outcome
of treatment studies
Click on the link below to read the California Rules of Court:
http://www.courtinfo.ca.gov/rules/index.cfm?title=five
Click on the link below to read the current Family Law Codes as they relate to Domestic Violence
Domestic Violence and the California Family Code
Defining non-physical violence
One of the most elusive issues in the domestic violence
field is how we conceptualize non-physical, psychological or emotional abuse.
The simple fact that we have different names suggests that defining and
identifying this form of interpersonal violence is not always easy.
Why is this important?
á
Outcome
studies suggest that while there can be a forty to sixty percent drop in
physical and sexual abuse during treatment and for some time afterwards, there
may be a less than ten percent reduction in non-physical violence.
á
Some
researchers suggest that psychological abuse is a precursor or vulnerability
factor for physical abuse.
á
Non-physical
abuse can be as traumatic and harmful to victims and witnesses as physical
violence.
á
Non-physical
abuse is essentially acting out, as is physical violence, and therefore therapy
is not successful until this problem is addressed.
Three models of non-physical violence
á
Amnesty
International model.
á
Penal
code model which is the main concern of the courts.
á
The
model used for the Psychological Maltreatment toward Woman Inventory described
earlier.
Amnesty International
¥ Isolation of victim
¥ Induced debility producing exhaustion
¥ Monopolization of perception (obsessiveness
& possessiveness)
¥ Threats (self, partner, family, friends, sham
executions)
¥ Mental degradation
¥ Forced alcohol and drug use
¥ Altered states of consciousness produced by a
hypnotic state.
¥ Occasional indulgences that keep hope alive.
Amnesty International
The
Violence Inventory developed by Daniel Sonkin uses this model to describe
non-physical violence. The following slide illustrates how several of
these categories are operationalized.
Amnesty International
á
Isolation:
á
Locked
in room or closet
á
Tied
up with rope, chains, handcuffs, etc.
á
Induced
debility producing exhaustion:
á
Forced
to take on role of servant
á
Not
allowed to sleep
á
Monopolization
of perceptions:
á
Pathological
jealousy
á
Stalked
(following, harassing, vandalizing personal property, trespassing, violating
restraining orders)
Domestic Violence Inventory
You can examine this inventory online at: http://www.daniel-sonkin.com/software.html
Penal Code
á
Simple
assault may be a verbal act but is most commonly accompanied by a physical gesture,
such as threatening with a fist or an object.
á
Aggravated
assault is usually a threat to kill as indicated by the use of a weapon, such
as a knife or a gun.
á
Threats
to kill or terrorizing threats
á
Stalking
any attempt on the perpetratorÕs behalf to follow, watch, harass, terrorize, or
otherwise contact his partner against her desires.
Psychological Maltreatment Toward Women Scale (Tolman,
1989)
The PMTW has 58 questions each scored on frequency of
occurrence which consist of three scales:
á
Domination/isolation
(which included isolation from resources, demands for subservience, and rigid
observance of traditional sex roles)
á
Emotional/verbal
(which included verbal attacks, behavior that demeans the woman, and
withholding of emotional resources).
á
Threats
Psychological Maltreatment Toward Women Scale
You can access this scale online at: http://www-personal.umich.edu/~rtolman/
Each model includes:
á
Verbal
abuse, degradation or name-calling.
á
Threats.
á
Non-physical
means of control (e.g. through jealousy, compliance with expectations,
withdrawal of affection, threats of violence).
á
Isolation
(particularly from family and resources).
What do these forms of non-physical abuse have in common?
á
They
all create a stressful family environment that neither feels physically or
emotionally safe or nurturing.
á
Over
time can have a profound psychological and health effects on victims and
witnesses
á
Prolong
exposure to stress such as this may have negative impact on the brain.
á
The
manifestation of any of these forms of violence are indicative of the need for
continued treatment for perpetrators.
Psychological abuse and domestic violence
To read an online article on defining non-physical abuse in
domestic violence relationships go to: http://www.daniel-sonkin.com/PsychAb.html
If you have questions about non-physical violenceÉ.
Psychiatric Diagnosis and Typology
One of the most fascinating areas of study in the past ten
to fifteen years has been the issue of typology and diagnosis. The concept that
batterers represent a heterogeneous population is not just a philosophy - it is
a fact based on empirical research. Similar research is now being done on
victims of abuse. LetÕs look at what is known to date.
What are the most common diagnoses observed in
perpetrators and victims
á
Depression,
anxiety or a combination of the two
á
Psychoactive
substance abuse and dependency
á
Post-traumatic
stress disorder
á
Neurological
disorders
á
Personality
disorders
Therefore evaluatorsÉ..
á
Need
to assess for diagnosis with each client (ideally both clinically as well as
psychometrically).
á
Make
appropriate referrals for medication assessment and management.
á
Consider
diagnostic criteria when making custody recommendations.
á
Take
into account diagnostic criteria when developing parenting plans.
Batterer Typology
From early on, clinicians noticed that not all batterers fit
the prototype described by the early writers in the field. As early as
the late 1970s clinicians were writing about the different types of
batterers. Although these conceptualizations were based solely on clinical
observation, researchers quickly took notice of this and began to look for
distinguishing qualities. What emerged was very similar patterns identified by
different research groups across the US and Canada.
Ironically, each research group identified three types of
batterers that followed a consistent pattern. One type was characterized
as impulsive and emotionally reactive, another was described as cold and
calculating and a third group that was over-controlled with periodic
explosions. Each group clustered into different diagnoses or personality
disorders which suggested that treatment for each type may be uniquely
different. What follows are each research group and the types of
batterers identified.
Batterer Classification Systems
Hamberger and Hastings 1986:
á
Antisocial/Narcissistic
á
Schizoid/Borderline
á
Dependent/Compulsive
Holzworth-Munroe & Anglin (1991)
á
Generally
violent/antisocial
á
Low
level antisocial was identified in 2000
á
Dysphoric/BorderlinePassive
á
Dependent
(Family only)
Saunders (1992)
á
Generally
violent
á
Emotionally
volatile
á
Emotionally
suppressed
Dutton (1999)
á
Psychopathic
á
Borderline
á
Over-controlled
What do these typology systems have in common?
á
They
each include an antisocial or psychopathic group whose violence is more
deliberate or instrumental.
á
They
each include a dysphoric group whose violence is more impulsive.
á
They
each include a lower-level violence, a slightly higher psychologically
functioning group whose violence is more sporadic.
LetÕs look at one system developed by Don Dutton at the
University of British Columbia, and described in his book, The Abusive
Personality.
Dutton describes his typology of batterers across two
continuums. Overcontrol vs. undercontrol and Impulsive vs. Instrumental.
á
Overcontrolled: deny rage while experiencing
chronic frustration and resentment
á
Undercontrolled: act out frequently
á
Instrumental: use violence ÒcoldlyÓ to obtain
specific objectives
á
Impulsive act out in response to a building
inner psychological tension
LetÕs look at what psychological patterns Don Dutton found
empirically in each of the types of batterers he identified.
Psychopathic Batterers
á
Violence
inside and outside home
á
History
of antisocial behavior (car theft, burglary, violence)
á
High
acceptance of violence
á
Negative
attitudes of violence
á
Usually
victimize by extreme abuse as a child
á
Low
empathy
á
Associations
with criminal marginal subculture
á
Attachment:
Dismissing
á
MCMI:
antisocial, aggressive-sadistic
Batterer Typology
Jacobson called
these batterers ÒVagal Reactors.Ó Despite acting in an emotionally
aggressive fashion, these men remained inwardly calm. The term stems from that
idea that excitation of the vagus nerve suppresses arousal. The result of this
autonomic suppression is to acutely focus attention on the external environment:
the wife/antagonist. Jacobson found these men to be the most belligerent and
contemptuous men he studied and showed the greatest heart rate decrease.
Flat emotional response + exaggerated control are two
defining criteria for psychopaths (Hare, et. al).
Borderline Batterers
á
Cyclical
phases (Lenore WalkerÕs cycle of violence)
á
High
levels of jealousy
á
Violence
predominantly/exclusively in intimate relationship
á
High
levels of depression, dysphoria, anxiety based rage
á
Ambivalence
to wife/partner
á
Attachment:
Fearful/angry
á
MCMI:
Borderline
Over-controlled Batterers
á
Flat
affect/constantly cheerful persona
á
Attempts
to ingratiate therapist
á
Tries
to avoid conflict
á
High
masked dependency
á
High
social desirability
á
Overlap
of violence and alcohol use
á
Some
drunk driving arrests
á
Lists
ÒirritationsÓ in anger journal
á
Chronic
resentment
á
Attachment:
Preoccupied
á
MCMI:
avoidant, dependent, passive-aggressive
Typology and assessment
One can assess typology through both the clinical interview
(identifying the listed characteristics) and psychometric testing (e.g.
MCMI). One can also use one of the self-report attachment measures which
will be discussed more thoroughly later.
Although similar in some ways, each type is significantly different in
the psychological etiology of their violent behaviors. Treatment
interventions need to consider these differences in order the increase the
likelihood of successful outcome.
Typology and Risk
According to Dutton, the borderline batterers have the
highest re-offense rates in treatment. This is because of their extreme
difficulty with emotion regulation and impulsivity. The Psychopathic and
Overcontrolled batterers tend to have the most severe violence.
á
For
the Psychopathic
batterers, their violence is ego-syntonic and their low empathy makes them less
likely to experience violence inhibition.
á
The Over-controlled batterers are compensating for
inadequacy and, when overwhelmed, are likely to use violence to turn their
feelings of impotence into feelings of omnipotence.
Typology and Risk
What is this data likely to mean during a divorce?
á
Because
of their general problems with impulsivity, borderline batterers are likely to
act-out with the most frequency. However, a clear structured plan, in
conjunction with treatment, could reduce this possibility to some degree.
á
The
psychopathic batterer is like to present well in evaluations and court, but
will act-out in subtle and not so subtle ways that only the victim (who knows
this pattern well) will recognize. These victims often come across histrionic
to evaluators and therapists not familiar with the psychopathic batterer.
However, it is important to take serious these women and follow up accordingly.
The overcontrolled batter, like the psychopath, can present
well in treatment - not because he is trying consciously to manipulate like the
psychopath, but because he values control and rationality. These clients
often test with high masked dependency and during separations and divorce are
likely to experience the greatest anxiety and depression. Dutton says
that these batterers can snap and perpetrate extreme violence as a means to
regulate their dysphoric affect.
According to some researchers, there is a group of batterers
that test out secure on attachment measures. What does this mean in terms
of divorce? I would predict that this group would manage the process in
the most positive manner. Not that they wouldnÕt be upset - who wouldnÕt
get upset during a divorce process? However these batterers have more
psychological resources available to them that makes them able to tolerate the
process better and more effectively cope with their emotional reactions.
As you will learn later, secure individuals are more flexible, pro-social and
able to regulate attachment distress in more functional ways than insecure
individuals.
DuttonÕs Typology System
To read more about Don DuttonÕs typology system as well as
other excellent online articles describing his treatment and research go to his
web site at: http://www.drdondutton.com/
Is there a similar typology of abused people?
á
According
to research and clinical experience, many, but not all, victims present with
PTSD symptomology.
á
We
also know that many victims of domestic violence likewise present with personality
disorders and unresolved childhood trauma.
á
Research
on abused women from an attachment theory perspective suggests that a
significant percentage of victims present with insecure attachment.
á
Many
victims also experience psychoactive substance abuse
á
Depression
and anxiety is also common with victims.
á
Some
research suggests that there are higher rates of traumatic brain injury with
victims of violence.
Is there a similar typology of abused people?
Given these facts, no one has developed as comprehensive
typology system as we have seen with perpetrators. Why is this?
Perhaps there is concern that a typology system will somehow be construed as a
way of pathologizing victims. This has been a problem for many years, yet
ignoring the fact that many victims do suffer from serious psychiatric
disorders, does little to help them protect themselves from further
victimization. In spite of the
pressure to not explore these issues, some researchers are putting aside
politics and asking important questions about the psychological characteristics
of victims of domestic violence. LetÕs look at a few of these studies.
Substance abuse and DV (NIJ)
á
In a
study by the National Institute of Justice, it was found that the majority of
women in substance abuse treatment had experienced child abuse or partner abuse;
á
It was
also found that over 50% of the women in substance abuse treatment, who also
experienced partner abuse, had greater alcohol or drug problems.
á
The
abused women in shelters or safe homes, who also had alcohol or drug problems,
experienced greater levels of partner abuse.
á
They
also found that women who were abused as children had more severe substance
abuse problems.
á
Almost
half of the women in the shelter or safe home sample had levels of depression
or anxiety classified as moderate or severe;
á
In
addition, a diagnosis of alcohol dependence was associated with higher levels
of psychiatric disorders;
á
Lastly,
experiences of childhood abuse were associated with higher levels of
psychiatric disorders.
Child abuse and Adult Revictimization
In a study by Jeremy Coid and colleagues, they found that
severe childhood physical abuse and sexual abuse significantly increases the
risk for adult re-victimization. This finding has been corroborated in
other studies as well.
Attachment and abused women
In a study by Jolly and Liller, using an attachment theory
perspective, they found that all women are susceptible to abuse regardless of
attachment status. Yet women with a preoccupied attachment classification appeared
to be more likely to experience physical abuse, severe psychological
aggression, and frequent psychological abuse. They also found that preoccupied
and disorganized woman are more likely to have difficulty getting out of
relationships. These attachment categories will be discussed later.
á
In
their study, they found that over 60% of abused women have insecure attachment
(as compared to 40% of the general population)
á
Preoccupied
women were 7x more likely to have experienced severe psychological abuse
á
Preoccupied
women were 3x more likely to have experienced severe physical abuse
á
Preoccupied
women women had higher anxiety and anger, were more dependent and have more
negative self mental models.
á
Overall
they found a significant association between depression and abuse experience,
current abuse, psychological abuse, severity of psychological abuse, frequency
of psychological abuse, physical abuse, severity of physical abuse, and
frequency of physical abuse
What does this data suggest?
á
Although
a specific typology of victims has yet to be identified, we can begin to look
at certain variables to help us organize how to approach intervention with
victims.
á
Substance
use/abuse, insecure attachment, trauma symptomology, other affective disorders,
previous victimization, personality disorders and history of child maltreatment
to one degree or another have been significant variables in differentiating
abused women.
á
Therefore,
although separation of the parties is an important first step, evaluators
should not be lulled into a false sense of security that effective parenting
will be a given, because of the severity and complexity of these disorders.
If you have questions about diagnosis or typologyÉ..
É.contact Dr. Sonkin by email.
Violence and itÕs effect on child attachment
As itÕs already been discussed, witnessing violence is
traumatic to children and the associated stress will have a deleterious effect
on the developing brain. When a caretaker is being victimized, itÕs going to
effect her or his ability to parent which will in turn effect the attachment
relationship between the caretaker and the child. LetÕs look of some of the
research in this area.
á
Sullivan-Hanson
(1990): No subjects in shelters were secure, and that many fit the Òfearfully
preoccupiedÓ subcategory. All of these women were at risk for having
insecurely attached children.
á
Steiner,
et. al.: Mothers who reported higher levels of partner violence were more
likely to have disorganized infants.
á
Women
who witnessed martial violence as children were as likely to have disorganized
infants as women who were directly abused (Lyons-Ruth, 1996).
á
Mothers
with unresolved trauma in relation to witnessing abuse as a child were more
likely to have disorganized infants (Bearman and Ogawa, 1993)
Violence and itÕs effect on attachment
In general, the studies suggest that when fathers are
physically violent with mothers, infants are more likely to be insecurely
attached to their mothers. This is partly due to the fact that mothers can not
be sensitve to the cues of their children if they are experiencing the stress
of victimization. Roger Kobak from the University of Delaware states:
ÒWitnessing
violence between parents may also threaten a childÕs confidence in the parentÕs
availability. The childÕs appraisal of marital violence is likely to
include the fear that harm may come to one or both of the parents.
Parents who are living with constant conflict and fear are likely to have
reduced capacities to attend to the child. Thus, in addition to fear of
harm coming to the parents, attachment anxiety is increased by uncertainty
about the parentÕs ability to respond to the childÕs distress and the lack of
open communication with both parents.Ó
Violence and its effect on attachment
As suggested by the data, the state of mind of the parent,
regarding attachment, will have a direct effect of the attachment status of the
child with both mothers and fathers. In the Attachment Theory update
training, you will learn that the most robust predictor of the attachment of
the child is the attachment status of the parent. If the parent is
insecurely attached or has unresolved trauma from her or his own past, this
will directly effect that parentÕs ability to read the signals of the child and
respond in an appropriate manner. Therefore, the child is affected by
numerous routes - directly by the offending parent and indirectly through the
victimized parent. Is insecure
attachment at life sentence? No, both children and adults, through
appropriate intervention, can move from insecurity to Òearned secuity.Ó
If you have questions about how violence affects child
attachmentÉ
Why do victims stay in violent relationships?
á
The
most common cited reasons, that are reality-based, are economics, fear,
balancing the rewards and costs of leaving, lack of protection from the courts
and lack of support from friends and family. However, even when these
factors are addressed women stay and return to their abusers. Why is
this?
á
Strube
and Barbour, (1983) found when victims were asked why they were involved with
partner at the beginning of therapy: 18% left partner if they mentioned
economics (vs 71% who didnÕt mention economics) , and, 35% left partner who
mentioned love (vs 71% who didnÕt mention love) .
á
In
another study of shelter residents the researchers found that only 13% say they
are planning to return to their abuser, but within two months of leaving the
shelter, 60% returned to their abuser.
á
Attachment
bonds are strong, regardless of specific characteristics of the attachment
figure. Infants and adults will turn toward abusive attachment figures for
comforting and protection.
á
Dutton
found 53% of battered women had a pre-occupied attachment status (as opposed to
10% of the general population) and only 7% were securely attached (as opposed
to 60% of the general population).
á
Morgan
found women who were pre-occupied were more committed to their relationships
and experienced more rewards than women who were more secure/less
anxious. In other workd, anxious people are more likely to follow their
hearts rather than heads.
á
Don
Dutton developed a theory called Traumatic Bonding that helps to understand why
victims have trouble leaving their partner. He point to periodic
reinforcement (like a gambler and the slot machine) and power imbalance that
both contribute to greater dependency and fear of leaving.
á
Another
theory, that we will go over in greater detail later, is the notion of
unresolved trauma. When victims put distressing thoughts, feelings or
memories of trauma out of their consciousness, their anxiety about their
situation is more likely to get sublimated into caretaking, substance abuse or
depressive symptoms and therefore ultimately interfere with their ability to
leave.
Why do women stay in abusive relationships?
Women who have been abused or witnessed violence as children
who are insecurely attached due to early parenting experiences will use
maladaptive coping mechanisms when responding to attachment distress (eg.,
abuse). Victims who are pre-occupied (over 50% of abused women in one
sample) are likely to use dependency, pleasing and trying to get the abuser to
respond to their distress as a means to coping with attachment distress.
All of these defenses serve to keep the victim ÒstuckÓ and Òfocused onÓ their
abuser, rather than looking to protect herself and her children.
Disorganized or unresolved victims of abuse, utilize
dissociation to escape the negative thoughts, feelings and memories of abuse
and therefore do not have these available to them to help motivate change.
Therefore why women have trouble leaving is really a complex
interaction of biological, psychological, relational and social dynamics.
Reducing an answer economics or lack of police protection,though significant,
are not suffient to understand why so many victims place themselves and their
children in danger. Interventions need to be geared to address all these
levels of analysis.
If you have questions about why victims stay in abusive
relationshipsÉ..
Assessment Instruments
Structured assessment tools
Many clinicians rely too heavily on the clinical interview
to complete their assessment process. Utilizing psychometric tests and
structured assessment tools can provide valuable information that may be
overlooked during the clinical interview. Here are a list of tools that
have been found useful in assessing perpetrators and victims of domestic
violence.
Personality and Diagnostic Screening
The MCMI-III is the most common test used in researching typologies of
perpetrators. The MMPI and Rorschach have also been used in research with this
population but not as often. The MMPI is useful for Axis I diagnoses
whereas the MCMI is useful in assessing Axis II diagnoses.
Diagnosis specific tests such as the Trauma Symptom
Inventory commonly
used with victims and perpetrators and the Hare Psychopathy Checklist are commonly used with
perpetrators.
Substance abuse screens such as the Michigan Alcohol
Screening Test
should be included in an assessment process.
The Structured Clinical Interview for the DSM-IV (SCID) is also a useful structured
interview to help confirm your clinical observations.
Domestic violence assessments
Conflict Tactics Scales (v. 2) developed by Murray Straus is the most common
violence assessment tool in research projects. It is freely available on his
web site at the University of New Hampshire.
The Propensity for Abuse Scale was developed by Don Dutton and has
been validated in a number of empirical studies. This scale is available
in his book, The Abusive Personality.
Richard Tolman developed the Psychological Maltreatment
Toward Women Inventory and like the Conflict Tactics Scales, is becoming the industry standard
for assessing non-physical abuse by researchers. This scale is available in his
article listed in the reading list.
The Kingston Screening Instrument for Domestic Violence
(K-SID) (Gelles & Tolman; 1998) shows some promise as to being a
useful tool, but it is not currently available.
The Anger Management Scale (Stith & Hamby) focuses on how
clients regulate their anger and can be a useful tool in both evaluation and
treatment.
The Domestic Violence Inventory and Risk Assessment software (Sonkin, 1999) was
developed for clinicians to provide consistency and organization to their
assessment process. It is a very comprehensive behavioral
assessment. This scale can be viewed at: http://www.daniel-sonkin.com/software.html.
The Spouse Abuse Risk Assessment (SARA) developed by Randal Kroop
and his colleagues is a risk assessment program that has empirical validity and
is currently being used by both researchers, clinicians and criminal justice
personal.
If you have any questions about structured assessment
toolsÉ.
Écontact Dr. Sonkin via email.
Risk Assessment
Prediction of violence remains a controversial concept in
the field of psychology. Research indicates that we are likely to be
wrong as often as we are right about predicting violent behavior. Most
researchers believe that the best predictor of future behavior is past
behavior. For the most part this may be true - but not always.
Researchers have tried to develop methods of predicting future behavior without
a lot of success. But nevertheless, some type of risk assessment is
important when working with violent individuals.
á
We are
often asked (whether we like it or not) by the court to give opinions about
future dangerousness.
á
Clients,
and partners in particular, often want to know about prognosis and the
possibilities of future violence.
á
When a
lethal incident does occur and a liability suit arises, the clinician is often
asked to explain how he/she took measures to reduce the risk of future
violence.
á
A
significant number of batterers do re-offend while in treatment; therefore,
identifying Òhigh-riskÓ cases may be clinically prudent.
Domestic Violence in Sonoma County (Rosenberg, M; 2000)
ÒPartly as a result of a terrible domestic violence homicide
and partly in reaction to the growing concern over the way domestic violence
cases had been handled, the County of Sonoma developed a coordinated criminal
justice and community response to the problem of domestic violence, which
included a specifically designated court to oversee misdemeanor cases, a
domestic violence unit within the adult probation department, and community
service programs that provide mandated group intervention for men and women
convicted of domestic violence. All misdemeanor cases of domestic violence were
heard and followed in front of the same judge. At that time Sonoma County was
one of the few places in the country that had a domestic violence unit in their
probation department.Ó
Dr. Rosenberg was hired as a consultant to monitor the
certification and re-certification process for service providers of mandated
group intervention programs described in California law, and to conduct a
general outcome study on probationers who have gone through the domestic violence
court system. In preparation for designing the outcome study, interviews were
conducted with probation officers in the domestic violence unit to determine
the types of information they wanted to understand about their clients.
One of the most frequently voiced concerns involved working
with probationers who demanded a great deal of attention and decision making as
a result of their problematic behavior.
The study was designed to determine the factors that would predict which
clients were likely to be labeled Òhigh maintenanceÓ. In other words which
client would demand greater attention from the probation staff, due to acting
out prior to and during treatment, including re-offenses.
Outcome of Sonoma study
High maintenance probationers had:
á
higher
numbers of prior domestic violence offenses
á
more
serious histories of drug abuse
á
higher
total SARA scores and,
á
lower
number of severe violent tactics used against the victim in the incident
precipitating arrest.
Low maintenance probationers had:
á
less
prior domestic violence incidents
á
absent
or low prior drug usage
á
lower
total SARA scores and,
á
higher
numbers of severe violent tactics used in the index incident
Rosenberg was also interested in whether treatment outcome
could be predicted.
Program completers:
á
were
those with lower numbers of prior domestic violence offenses
á
were
not homeless during probation
á
were
married
á
had
low or no problems prior to beginning their program and after arrest.
Program non-completers
á
had higher
numbers of prior domestic violence offenses
á
were homelessness
at some point during probation
á
were unmarried
á
had higher
numbers of problems prior to beginning their programs and after arrest.
Both the high maintenance and program non-completers were
clients with the more unstable life-style, drugs problems and more extensive
history of domestic violence.
This study suggests that a thorough pre-treatment assessment
is necessary to identity those clients who may need more attention, services
and structure to enhance their experience of treatment.
Risk Assessment
Richard Heyman of the State University of New York in
Stonybrook, recently conducted an extensive review of the literature on the
risk of domestic violence. In summary he found that, age, SES, history of child
abuse, and psychological variables all contribute to increased risk for partner
physical aggression. For many of the variables the effect sizes ranged widely
from study to study, with the exception of personality pathology and other
forms of psychopathology. Having a diagnosable personality disorder or other
mental illness is associated with greatly increased risk for partner physical
aggression.
Conditional model of violence prediction
Mulvey and Lidz proposed a conditional model of violence
prediction, where context plays an important role in the manifestation of
violence. Rather than simply looking at client characteristics and
predicting based on those qualities, they see a client as possibly doing some
type of act of violence if certain situations or factors persist or present
themselves. For example a particular batterer may become violent under certain
individual circumstances (e.g., under the influence or alcohol or not using
medications or not attending treatment), interpersonal circumstances (e.g., with
an aggressive partner or a partner who is under the influence of drugs) and
environmental factors (associating with peers accepting of violence or other
social or occupational stressors).
Clinical suggestions
So rather than framing risk assessment in categorical terms
(at risk or not at risk), it would be important for clinicians to describe the
likely context in which violence is likely to occur given your assessment of
that particular client. Mulvey and Lidz recommend considering individual
biological/psychological factors (e.g., history of violence, substance
use/abuse, need for medication, psychiatric disorder and the presence of
symptoms), victims factors (e.g., availability, provocation, substance
use/abuse) and social or environmental factors (e.g., peer support for
violence, economic or occupational stressors).
For example:
Mr. Jones is likely to reoffend if he relapses back into
cocaine use, stops taking his antidepressant medication and stopy attending
therapy and his 12-step program (individual factors). He is currently
separated from his wife who has an addiction to methamphetamine and has a
history of physical aggression as well (victim factors). Should they
start seeing each other, I believe it may be difficult for him to regulate his
emotions given the volatility of their relationship. Lastly, Mr.. Jones
has quite a few friends who supplied him with cocaine and his continued
interaction with them may compromise his recovery, which could lead to
additional acts of violence (social or environmental factors).
Risk Assessment Instruments
The Spousal Assault Risk Assessment (SARA)
As mentioned earlier the SARA is not a psychological
test, but can be used as an assessment guide to ensure that pertinent
information is considered and weighed. Risk factors are rated absent,
sub-threshold, or present. Based on the rating the final assessment the SARA
scores tell you whether there is imminent violence toward a spouse or other, or
the client is high, medium or low risk for violence.
Propensity Towards Abusiveness Scale (Dutton)
Dutton states that the PAS` can predict with 82.2% accuracy
who is likely to commit violence based on the psychological characteristics
assessed by this scale. The scale taps into background factors such as:
parental treatment, attachment style, anger response, Trauma symptoms, and
stability of self concept. This
scale can predict both physical and emotional abuse.
Danger Assessment Scale (Campbell)
Was developed by Jacqueline Campbell, she describes this
scale as aÉ Òform of statistical prediction, contrasted with clinical
prediction, because it is based on prior research and has some preliminary
evidence of reliability and validityÓ
The scale is based on ÒwomenÕs perception of the danger of being killed
by their partners.Ó However, the relationship of fear of the partner to actual
danger is unknown. This scale is available on the internet (see the
references).
Psychopathy Checklist (Hare)
á
Designed
for male forensic populations
á
Structured
interview and set of ratings based on the interview and corroborationÕs based
on case history reviews, institutional files, interviews with family members
and employers and on criminal and psychiatric records.
á
PC - R
(20 items) (2 scales)
o
Affective
(glibness, lack of empathy and pathological lying)
o
Social
Deviance ( antisocial behavior)
á
PC -
Screening version (12 items)
á
A
robust predictor of violent behavior in general, with many validity studies
including domestic violence perpetrators.
á
Predictive
of re-offending for domestic violence perpetrators.
Risk Checklist - Violence Inventory (Sonkin)
No empirical data and is not meant to have predictive
validity, but rather a comprehensive structured interview for clinicians
treating domestic violence perpetrators. Based on BrowneÕs (1987) risk
factors in her study of abused women who killed their batterer. Covers
many areas described in the dangerousness literature. Covers the
following content areas.
Sonkin Risk Assessment
á
Frequency
of physical violence in past two years
á
Frequency
of sexual violence in past two years
á
Severity
of violence
á
Threats
á
Frequency
of intoxication
á
Frequency
of alcohol use
á
Frequency
of drug use
á
Proximity
of victim and offender
á
Psychiatric
Diagnosis (DSM-IV)
á
Severity
of psychosocial stressors
á
Global
Assessment of Functioning Scale
á
Prior
criminal history/activity
á
Violence
towards others (check all that apply)
á
Child
abuse
á
VictimÕs
Involvement With Others:
á
Attitudes
towards violence
á
Weapons
accessible (eg. law enforcement)
á
Specialized
training in violence
á
Perpetrator
physically abused a child
á
Perpetrator
sexually abused a child
á
Perpetrator
witnessed violence as a child
á
Child
custody proceedings in progress
á
Other
divorce proceedings in progress
á
Other
legal proceedings in progress
á
Animal
cruelty or torture
Ways of Reducing Risk
á
Separation
of the victim and offender with either the victim in a safe house or shelter or
the perpetrator in jail is the safest situation. Short of that, there are
no guarantees of safety.
á
Stay-away
orders, restraining orders can be useful but only if the perpetrator is
intimidated by the courts and the police enforce the orders.
á
Criminal
sanctions are effective, however, many perpetrators continue to use violence in
spite of this.
á
Social
services can be useful in protecting children from abusive parents or parents
who refuse to protect their children from abusive spouses.
á
Treatment
for perpetrators can reduce the risk for continued violence. Evaluators
should not confuse education programs that treat people in large groups with
therapeutic programs that provided assessment based treatment either in group
or individually.
á
Treatment
for victims can also reduce risk. Many victims need treatment to resolve recent
trauma. Additionally, a large majority of victims have moderate to severe
psychiatric disorders stemming from prior trauma and childhood abuse.
Without treatment, these individuals will not be able to make safe choices for
themselves or their children.
á
Addressing
psychoactive substance use/abuse with both victims and perpetrators is critical
to reducing risk. This is consistent risk factor in the dangerousness
literature.
á
Medication
can be effective with both victims and perpetrators in helping to regulate
dysphoric affect associated with affective disorders and unresolved trauma.
á
In
extreme cases, hospitalization can be an effective method of managing risk to
self or others.
If you have any questions about risk assessmentÉ
Psychopharmacology and Domestic Violence
á
No
specific drug treats domestic violence.
á
However
psychotropic medication can be utilized to treat concurrent diagnoses
(depression, anxiety, etc).
á
In
addition, one can also treat particular symptoms related to violence.
o
PTSD
symptoms
o
Obsessive
and compulsive symptoms
o
Anxiety
o
Depression
Serotonin Selective Reuptake Inhibitors (SSRIs) have been
used with people who have violence problems (e.g., Paxil - the most sedating;
Luvox - good for obsessional symptoms).
Norepinephrine Reuptake Inhibitors (NRIs) (e.g., Wellbutrin)
may be good for people with adult ADD and similar syndromes (However, this
medication can also be agitating - which is problematic with people who have
trouble managing irritable emotions.)
Tri-cyclics: (e.g., Trazodone) can be useful because of its
sedating effect. However this class of drugs can have problematic side-effects.
Benzodiazepines: there are many negative side effects and
therefore, these are not utilized as often. There are newer non-benzodiazepine anti-anxiety medications
(e.g,. Buspar and Vistaril) that can be useful in treating anxiety and tension
symptoms.
SSRIs can also be useful in treating anxiety as well.
Although there are no drugs that treat PTSD per se, a number
of psychotropic medications can be utilized to address the various symptoms:
á
Flashbacks:
SSRIs
á
Hyper-arousal:
Antidepressants & anxiolytics
á
Transient
psychosis: Low dose anti-psychotics
á
Depression:
Antidepressants
á
Panic
attacks: Antidepressants, high potency anxiolytics
Recommendations
á
Use
the most benign intervention when beginning treatment.
á
Select
the medication that most closely addresses the primary diagnosable
disorder/symptom.
á
Have
some quantifiable means of assessing efficacy and side effects.
á
Institute
drug trials systematically by applying one intervention, assessing impact and
monitoring therapeutic levels.
á
Meet
on regular basis / good communication between therapist and prescribing
physician.
If you have questions about psychopharmacology and domestic
violenceÉ
Psychobiology of domestic violence
Alan Rosenbaum at the University of Illinois found
clinically significant prior head injury in:
á
53% of
male batterers as compared to
á
25% of
maritally discordant men and
á
16% of
maritally satisfied men
Along with these patterns, batterers also exhibited deficits
in:
á
Learning,
particularly for verbal information
á
Memory,
particularly for verbal information
á
Verbal
ability
á
Vocabulary
knowledge
á
n
Exhibited high levels of emotional distress
What do these results mean?
á
Always
take a history for prior head injury.
á
If
indicated, consider neuropsychological assessment to determine specific
deficiencies.
á
Consider
medication and cognitive rehabilitation in extreme cases.
á
Consider
how you use educational techniques in your treatment considering the
difficulties many clients may experience with learning and memory for verbal
information. In addition, consider their limited vocabulary when utilizing
writing assignments and verbal presentations in-group settings.
Neurobiology of violence
These data supports the notion that for some clients,
improving executive control function, such as response flexibility (thinking
about the options and weighing the pros and cons to various alternatives) is
key to helping gain control over their violent and aggressive behaviors. These
findings are in line with the typology research suggesting that a significant
issue for many perpetrators is controlling impulses and managing dysphoric
affect. This is also consistent with attachment theory conceptualizations
of domestic violence, as I will discuss later.
To date, there is no strong evidence that suggests that
violence is genetically based. Rather, study after study suggests that
itÕs the primary caretaking relationships of childhood which will ultimately
determine the organization of the brain which in turn leads to a propensity
towards violence. However, the pathways to violence are varied.
Although we are born with billions of neurons most of the
connections are immature and therefore are sensitive to experience. Early
experiences of violence organized the brain in such a way that it is primed to
response in a dysregulated or aggressive fashion. Neurons that fire together, survive
and wire together, which suggests that violence hardwires the propensity of
violence in the developing mind of the child.
The famous Minnesota Mother-Child Interaction Project
illustrated that even the types of the violence are transmitted over the
generation. They found that..
á
Physical
abused abused children - were more physically aggressive by early childhood;
á
Sexual
abused children were prone to sexual acting out;
á
Psychological
abused children were utilized more verbal acting out;
á
And
neglected children became disorganized and socially inept.
There are a number of theories that are not mutually
exclusive. These include the lack development of frontal lobes, a
breakdown of corpus callosum, the ratio of brainstem/limbic system to cortical
activity, the toxic effect of cortisol on the hippocampus, decreased
levels of serotonin and increase levels of noradrenaline - all suggest that
violence in childhood has a profound effect on the developing brain.
Yet we know that a significant percentage of abused children
donÕt become violent later in life. The pathways to violence are
complicated. Early experiences with violence and abuse that compromise
the healthy development of the brain that can in turn lead to problems that
exacerbate the early conditions: problems in school, drug and alcohol problems,
social problems and gravitating toward peers who support the use of violence.
And yet, we know that certain experiences can mitigate the
negative effects of violence in childhood. For example, having access to
a positive family-like experience, having a positive adult role model, having
higher intelligence or special abilities - these can all help to reduce the
possibility that violence will be an eventual outcome. And of course,
early intervention in the form of psychotherapy can mitigate the deleterious
effects of trauma.
The bottom line - violence is not a forgone conclusion or
outcome of early childhood victimization experiences, when positive experiences
are incorporated into the childÕs life story. Child custody evaluators
are in the unique position to help to change the destiny of the next
generation, through facilitating those positive experiences, and most
importantly assisting parents in taking on an important role in that process.
If you have questions about the neurobiology of violenceÉ.
É.contact Dr.
Sonkin by email.
Outcome Studies
An
examination of the outcome literature shows a range of 40-60% desistence rate
of physical violence 2 years post treatment based on victim reports. Some
studies show as high as 80% with treatment.
What
does this mean? Perhaps we need to reconsider educational interventions as a
sole approach to working with individuals with moderate to severe psychological
disorders.
If you have questions about treatment outcome..
Additional readingÉ
Click on the link below to view the reading list for this
presentation on the web.
http://www.danielsonkin.com/custody/additionalreading.htm
Or download the reading list (MSWord document by clicking on
the link below.
http://www.danielsonkin.com/custody/additionalreading.doc
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