 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on domestic violence. Over the course of the next hour or so, we're going to review the extent of the problem, identify risk factors for violence, review practice guidelines for working with survivors of domestic violence, identify primary, secondary, and tertiary interventions, and explore the components of an effective routine domestic violence screening program. And for those of you who are new, just to reiterate, I don't generally test on statistics because that's not going to help you in your practice. So the statistics are really just here in order to help you kind of understand the scope of the problem. 2.4 million women are battered each year. We really don't have good statistics on what percentage of men are battered each year. So a lot of this will seem kind of slanted, and it is because a lot of the research or a lot of the data isn't out there that we would look at because men can be battered too, and it's important to remember that. There's a 20 to 30% lifetime risk for a woman to be battered, and 1,500 women are murdered per year by their partners. Let that one sink in. 20 to 30% of women seen in medical settings may be abused victims. Well, that makes sense if they have a 20 to 30% lifetime risk, then 20 to 30% of them showing up in a medical facility probably have the, maybe abuse victims. They may not be presenting for abuse-related injuries, but if they're going to the doctor, we want to be able to screen. There's a 5 to 6% prevalence of elder mistreatment. 1.8 million elders every year are mistreated. There's 1,100 childhood deaths from abuse each year, 140,000 childhood injuries from abuse each year, and these are just the ones that they can truly link to domestic violence or child abuse. 1.7 million reports of child abuse each year, 250,000 to 450,000 cases of child sexual abuse, and 16% of adult women report a history of sexual abuse by a family member. Okay, so that's kind of pretty devastating and depressing statistics that we're looking at, and like I said, they're not even truly complete, but it's important to be aware because that means, especially if you're running a trauma-informed program, we need to be sensitive to that when people come in. We also need to screen for domestic violence that's current. Trauma-informed will help address people who have current domestic violence issues as well as maybe a history of domestic violence issues, but domestic violence screening can really help identify people who may be in a position right now that is dangerous. Economic costs of domestic violence come from acute medical care for injuries or neglect and their complications. Think about simple things, if you will. If somebody gets punched in the face and they lose a tooth or lose teeth and then that gets infected, that can be something that happens. When people, especially if they get hit in the face and they lose teeth, that has an impact on their self-esteem. There may be mental health and substance abuse care required for victims, perpetrators, and families. Victims, you know, obviously we can see where mental health might come into play. Victims may abuse substances in order to deal with the pain, physical pain like opiates, or in order just to deal with living in that environment, like benzodiazepines or alcohol. Perpetrators, there is a high correlation between the use of alcohol and domestic violence. So perpetrators may need to have access to substance abuse services, as well as mental health. I mean, we don't know what is fueling, what is the underlying reason that this person may be drinking heavily and have anger management issues. And then families, because children who witness domestic violence are traumatized from it. Parents, friends, caregivers who are significant others who are involved in these people's lives are going to potentially experience a sense of helplessness, hopelessness, depression, anxiety, anger, you name it, if they know what's going on. So there's a possibility that the entire family and probability that the entire family is going to be impacted. And there also may be inappropriate medical care for unrecognized mental health problems. So people who are depressed, they're low energy, they're fatigued, they can't seem to go to work, they're presenting at their doctor's office for some sort of medication to help them get going instead of addressing the depression issues. They don't really recognize the impact that the domestic violence is having on their life and leading to their depression. They feel like it's a physiological thing. So we always want to look at the root cause, whether it's physical or psychological or both. Criminal justice costs, intervening in domestic violence, arrests for domestic violence, prosecution and incarceration. You know, it's expensive to keep somebody in a jail, at least the jail that I worked at for, what was that, 15 years ago, you know, it was somewhere around $250 a day just to feed, clothe and house each prisoner. So that gets expensive really quickly. Legal system, you know, the people may, who are in the domestic violent, domestically violent relationship may separate, divorce, there are likely going to be custody disputes, protection orders, all kinds of stuff that require the use or presence of a judge, maybe attorneys. So there's lots of money here. Social welfare organizations are going to have costs from running emergency shelters, providing housing and foster care. When children are removed from the home because of domestic violence, even if nobody goes to jail, then we're incurring foster care costs. So there's money being spent there. And a lot of times there's absenteeism to work or poor productivity. If you've got somebody who was in a violent altercation the night before and has bruises in visible areas, they may not go to work. If they'd have bruises or whatever in non-visible areas, they may go to work but their productivity may be low. Now, remember that domestic violence is not just physical. It can be sexual and it can be emotional. So if the person is experiencing emotional abuse at home, you're not going to see any bruises. You're just going to see somebody who is really distressed and really depressed potentially, may have high levels of anxiety. So we want to look at, again, what's causing these symptoms in that person. Practice guidelines. We want to implement routine universal screenings. That means we're not singling out people by age, by ethnicity, by gender. We want to screen in all healthcare settings and remember that men can be battered and women can be batterers. So we don't want to be close-minded with this. And the screening needs to happen for all people. I need to change that. It's not just females anymore. All people, 12 years of age and older because there is dating violence that goes on. There are children who are abused. Now, obviously, younger children can be abused too but that's a different class. We want to look at what's going on. We want to provide skills to foster an environment that facilitates disclosure. So we want to make sure that our nurses and our techs and whoever meets with the person to get their general information, the first contact, we want to make sure that it's a welcoming environment. We want to make sure that whoever asks the question, whether it's a clinician or a technician, knows how to ask it in a compassionate way. They know how to respond if the person says, yes, it's a problem. And for physical domestic violence, there tends to be less of an issue with this as there is with emotional domestic violence or sexual domestic violence where the person receiving the report may have some reactions to it, either disbelief or disbelief is generally the one that comes up. So we want to make sure that people doing the screening understand all the different types of domestic violence and how to respond. What do you say to this person? What's the next step? How do you make sure that the person is safe? What do you need to do if there are kids involved? I mean, there's all kinds of stuff that comes up if the person says, yes, I'm in a dangerous situation. Whoever's doing this assessment needs to know what to document and know their legal obligations. Elder abuse reporting, child abuse reporting, even if the child is not being abused, if they're witnessing domestic violence, in most states that's a reportable issue. So you need to know what your state requires in terms of reporting. And one of the things that I found over the years that I've been practicing is if I have a question in my mind about whether it's reportable or not, and this worked really well in Florida where I was doing more clinical practice, we'd call the abuse hotline and I'd say, okay, this is the situation I have, no names are given yet. Is this something that you will take a report on? And the person that I'm talking to, and I have their badge number, so to speak, will either say, yes, that meets the threshold that we need to take a report or no, thanks for calling, but you can probably handle that. So that was good at helping us feel like it was okay to call and ask, if you're on the boundary, is this something that needs to be reported? So you're getting information and feedback. We need to make sure that we screen everybody and respond to the needs of all people, not just women, taking into account differences based on diversity. Some ethnicities believe that the family needs to stay together at all costs. Some religions believe that the family needs to stay together at all costs. We don't want to automatically say, well, you need to move out or you need to leave that situation. We don't know what they need. We are going to ask them, what is it that they need in this situation? Screening is a big first step when behavioral health providers are not integrated with primary care because you've got the right hand not knowing what the left hand is doing. So if we can get primary care providers to start screening and we screen in behavioral health care, then no matter which door the person comes in, they're going to get screened and then we can work hopefully in a multidisciplinary way. Because hopefully the medical provider will say, you know what? You probably need to talk to a counselor. And the counselor will say, you know what? You probably need to just get a once-over by the doctor and make sure that everything's okay. So those are all things that are helpful. Use reflective practice to examine how your own beliefs, values, and experiences influence the practice of screening. And there are, you know, we all have our own beliefs and experiences and biases and whatever. So it's important for you to really have a good understanding personally of what your feeling is about abusers, about victims, about children who are in or, you know, parents who have children who witness domestic violence and deal with any of your own issues. So that doesn't come out and seem off-putting to a person that you're screening. It's also helpful to have mandatory educational programs in the workplace designed to increase knowledge and skills and foster awareness and sensitivity about abuse. Trauma-informed care would say that even your desk clerk needs to be sensitive and consistent and available emotionally to people who come in and check in because that's the first contact. We also want to make sure that our waiting room environment is supportive and not traumatizing. We want to make sure that the curricula that we present incorporate content on abuse in a systemic manner. So we're not just providing little glimpses here and there and whatever. We want to help people understand this is what it is. This is why it's a problem. This is the wheel of violence. This is what you're screening for yada-yada. We want to develop policies and procedures supporting routine universal screening and initial response. Put it in your policy and procedure manual, your P&P, and make sure that every staff member is trained on that so they know what to do. They know what the signs are that may indicate that the person might be experiencing domestic violence. Work with the community at a systems level to improve collaboration and integration of services between sectors. And this is one of the things that Heather was referring to earlier when you have medical providers and behavioral health that aren't on the same page. We need to try to improve interaction. One thing that I have found is helpful and when working with other providers, and I will just be general with that, sometimes it's hard to get them on the phone. So if you can get a release of information signed and you can either fax or somehow securely get the case report or integrated summary or whatever you want to call it, over to that other provider, obviously, again, you've already gotten written release of information. And then request that they provide you some sort of feedback in writing so they can fax it back. That way they're not trying to call you because a lot of providers will not call you back. Just let's be real. And I wish it weren't the case, but it happens. You can also have the client. You can give the client the write-up that you want the medical provider to have. And hopefully on the bottom, you put something for the medical provider to respond to. So then they can bring it back to you. That's one way to initiate collaboration when you've got independent practitioners working with a client. Practice implementation requires adequate planning, resources, and administrative support. So if you start doing this assessment, if you start doing these universal screenings, you're going to find people who are experiencing domestic violence. Well, that's going to increase your caseload but you can't just say, oh, okay. Well, good to know. And let it drop. You need to be able to refer out to wraparound resources, shelters, medical care, legal services, et cetera, or somewhere that handles those. You need to potentially be able to provide, if you're obviously a behavior health provider, groups in order to help people who are struggling with this issue. If you're finding people who are batterers, you may need to have some sort of a batterers intervention program. So you need to know ahead of time, once we start doing this screening and opening this can of worms, we need to be able to see it through to the end. There needs to be appropriate facilitation. So whoever facilitates these groups needs to be aware of the intricacies of domestic violence. It's not just simple anger management. So the domestic violence facilitator needs to be well informed. There needs to be an assessment of organizational readiness and barriers. For example, if you've got batterers as well as victims, sitting in the same waiting room, that could be really uncomfortable. If you've got people coming in for a batterers intervention group, then you want to ideally have them come in in a different place or at a different time than people who are coming in for a survivors group. Even if it's not their spouse, it could feel uncomfortable and it could feel very threatening to a person who has been victimized. You want to have involvement of all members, from your CEO to your risk manager, big time risk manager to your clinicians and, again, even front desk staff. Dedication of a qualified single point of contact. There should be a domestic violence expert, if you will, at your facility. This is the person who knows what the resources are. This is the person who can facilitate getting the person the resources that they need. And this is the person who probably facilitates the groups as well. So they're super informed. Just like a lot of places have a single point of contact for HIV education and testing, we need to have a single point of contact for domestic violence. There needs to be ongoing opportunities for discussion and education. Not only what it is and how do we do it, but also debriefing and how do you feel and are we, after talking with people who have experienced domestic violence or committed domestic violence, are we providing the services that they need? We want to have an open dialogue with line staff to make sure that our program is helping, not hurting. And there needs to be opportunities for reflection to make sure that we prevent burnout. So woman abuse, and this is defined by the Registered Nurses Association of Ontario, is the intentional and systematic use of tactics to establish and maintain power and control over the thoughts, beliefs, and conduct of a woman through the inducement of fear and or dependency. Now you can replace woman with person in this and domestic violence is the intentional and systematic use of tactics to establish and maintain power and control. Tactics can include emotional tactics, belittling somebody, criticizing them, telling them they'll never survive, or telling them that nobody else is going to be with them. They will kill them first. Financial tactics, the abuser may control all the finances and maybe give the victim an allowance if they're lucky. Physical and sexual abuse, self-explanatory, intimidation, isolation. This is another aspect of domestic violence where the perpetrator will typically keep the victim or victims from socializing. We're only going to be a family. I don't want you going out with that person and it can show a lot of, the perpetrator will show a lot of jealousy, suspiciousness whenever the person is out of their sight basically. They may use threats or use the children against the victim and in many cases they use pets as well. I'll kill Fluffy if you don't behave. They can also use social status and privilege. If it's a higher SES or power family, the power and the loss of money, you're not going to be anything without me. You'll never be able to afford to put a roof over your head. You're dependent on me socially, financially, and as power goes. What do we do? Primary prevention prevents the disorders before they occur. We want to include activities such as educating patients about domestic violence. Even if they're not experiencing it, make sure everybody knows what domestic violence is. If it happens to them, they would be able to identify it and reach out for help. Teach parents about appropriate discipline. Some parents were disciplined harshly and they may discipline harshly. Effective parenting and discipline education can go a long way. Educate children about respect and appropriate assertiveness. Not saying that children ever bring it on themselves. They don't deserve it. But in order to help children avoid pushing buttons and being antagonistic, helping them understand some of these things. Recognize and refer patients at risk for perpetrating abuse. So if you're working with somebody that you think may have an anger management issue or you think may have some abandonment issues that's leading them to be controlling, then we may want to make a referral for an assessment. We want to assess potentially overstressed caregivers, whether it's a caregiver of an elder or a caregiver of a child. Advise middle-aged parents about the need to plan for future care and needs of dependent impaired adult children. This will make sure that when the older parent passes on that the dependent adult child is in a safe place and doesn't end up going somewhere where they may be abused. Make routine inquiries about any violence in the home, the presence of stressors, and the availability of firearms. Secondary prevention involves efforts as making the patients aware of our interest in hearing about the abuse. Secondary prevention is happening, but we want to keep it from getting worse. So we want to screen for all forms of victimization and psychiatric disorders. If depression and anxiety start showing up, low self-esteem, things that you might expect as a result of trauma or domestic violence, especially if they show up suddenly, we want to take a look at where those are coming from. Make available information about community resources and safety planning. Now there are a lot of caveats with computers especially because computers, you have to clear your cash and it can save information where you don't want it saved. So it's important for people who are in a domestically violent situation to know how to safely find information and access the resources they need. Tertiary prevention says, okay, it's happened. Ideally we want to keep it from getting worse, but we also want to prevent it from causing other problems like job loss and death. So we want to make sure that care is provided for injuries received by victims. We want to identify and refer for associated mental health disorders. Think about being in that situation. It can be terrifying. It can be demoralizing. It can make somebody feel hopeless and helpless and depressed. So there's a lot of mood issues that can come out of it. And have monitor and have an ongoing care plan for abuse. Notify child welfare if necessary, if a parent is being abused and children are observing. If children are being abused, it can go any way. But sometimes child welfare will need to be notified. In many states, there's also the requirement for notification if an elder is being neglected or abused. And sometimes you have to report to other entities and that depends on your license. Advocacy involves support and encouragement for individual patients. Let's let them know that this isn't your fault. And let's help you get the resources that you need. And we don't want to discriminate against abusers and say, well, it's your fault. You need to go to this class. We want to help the abuser feel accepted and understood and supported in their recovery, not blamed. And that can be really tricky for some people. Advocacy involves efforts to achieve broader changes that will reduce the morbidity and mortality from family violence. So that can mean making sure that there are respite care centers, making sure that there are domestic violence shelters that always have beds. That can mean making sure that we're talking about what's going on, making sure that law enforcement is well educated about domestic violence and how to handle it. And it's a challenge for law enforcement. It really is because a lot of times they'll go out to a domestically violent call. It's hard to tell who the aggressor was and neither one wants to press charges. And so they're stuck in this weird limbo situation. So we want to make sure that we're sympathetic when law enforcement may not do what we had hoped they would do. We want to offer support for victim advocacy groups. Make sure that there's community support for these groups. Make sure that there's financial support from, you know, grants from the county, whatever, to support these advocacy groups. And make sure that we publicize them and have people understand the value of them so we can get volunteers to help support these advocacy groups. And we want to support efforts to reduce social factors which promote violence. Now, we're not just talking about domestic violence here, but let's think about, you know, you have a family at home. What types of factors might cause somebody to be on edge and might cause somebody to explode or produce or prompt trigger a domestic violence episode? You know, if you had a bad day at work and the person, the perpetrator feels helpless at work and they come home and the people at home bear the entire wrath of the day because the perpetrator couldn't express him or herself well at the office than everybody else is kind of in the path when they come home. Financial stressors tend to be a big trigger for anger, anxiety and potentially violence. Drinking, like I said, is a disinhibitor and it's associated with a lot of domestic violence episodes. Clues we want to look for. Characteristics seen in all traumatized people and we'll say all, but, you know, we don't want to just say, it can be some, but they can be hyper-vigilant. They easily startle, they're guarded, they don't want to be touched. They jump at every single, you know, knock at the door or they're constantly checking their phone and it looks like they're very worried if anything's running late. Now, there are people who get irritable because things are running late but there's also people who get scared because they know that their significant other is going to just lose their ever-loving stuff and if they're late and they're unaccounted for. They may re-experience aspects of the trauma, such as unwanted images of the trauma or nightmares. If our clients start talking about not being able to sleep or waking up a lot in the night, we want to ask about nightmares. Are they having them? And if they are, you know, tell me about them a little bit. So let me understand what the nightmares are, what might have triggered them to start. Sometimes it's historical trauma, sometimes it is current domestic violence, they don't feel safe, but this is one place that we want to look at. And emotional numbing. You know, pretty obvious when somebody goes from being gregarious to just being, they're there, it's kind of like they're a empty body walking around. We want to make sure that any of these signs we can identify and start screening for domestic violence. It may not be domestic violence. There could be something else going on that is traumatizing the person or making them feel unsafe. But we need to start somewhere. Other characteristics or clues. Self-neglect, malnutrition, dehydration, and in children failure to thrive. If the person's quits taking care of themselves. Could be clinical depression. Could be clinical depression brought on by domestic violence. Depression, anxiety, panic attacks, sleep disorders, substance use, aggression towards self and others. Now you can have perpetrators, you think of them as being aggressive. Victims can also be aggressive sometimes. Sometimes when they're not in that situation, they can be aggressive to try to get their control back. Sometimes when they're in that situation, they can be aggressive because they're trying to assert their boundaries and maybe not doing it very well because that other person is not hearing them. So there can be aggression. There can be dissociative states, somaticizing disorders where they start having a lot of general pain, suicide attempts, compulsive sexual behaviors, in children lying, stealing, truancy, and poor adherence to medical recommendations. So basically not taking care of yourself and trying to push people away because it's not safe. I need you to stay away from me because other people aren't safe. It's basically the message that is often communicated non-verbally by a lot of clients who are struggling with domestic violence. The symptoms of traumatized individuals often represent attempts to master their trauma, which means they're trying to get control of the situation so they don't feel victimized. They feel like survivors, but that's hard to do sometimes, a lot of times. Children may work toward resolving their trauma through repetition of the struggle with authority figures. They're trying to get someplace where they've got to say or the use of play and behavioral reenactment. Adults often work toward resolution in intimate relationships, in dealings with their own children, and in therapy. So they will recreate certain characteristics of the situation potentially in order to try to master it this time. And it's subconscious. I mean, people aren't going, all right, I had a really crappy childhood and there was a lot of domestic violence. Let me see if I can make that happen now. We don't do that. But because that was a way of behaving and a way the person habituated to, if you will, then some aspects of that may translate into future intimate relationships and they may have to, you know, back up and try to figure out, okay, you know, that's even when I was young, I knew that wasn't the best way to handle things. And I'm doing it now. How can I choose something better? Clues to elder abuse include expressions of frustration by family members who are overwhelmed with caretaking, have unrealistic expectations of the elder, resent the dependence of the elder, or are angered by problematic behaviors of the impaired elder, such as wandering or taking all their clothes out of the closet. There are, we have a couple of classes on all CEUs that deal with working with the cognitively impaired and working with people with dementia, which can be helpful because dealing with this, dealing with an elder can be challenging, especially if they are starting to experience some level of dementia or Alzheimer's, or if they're just overwhelming in their presence. Neglect or frail or impaired elders by family members who are hostile, under, under involved or exploitive. So we want to look at the elder. Are they frail in some way? Have they suddenly, has their quality of health suddenly gone down? That could mean that the elder can't make their own food, so they're starving. That could mean that they're having their food withheld. That could mean a lot of things, but we want to look at the causes for what's going on. Is there neglect? Or, you know, when my grandmother got into her mid-80s, she just wasn't hungry. And I mean, she ate, but she didn't eat a lot. She, you know, she just kind of withered a little bit. And as she got closer to crossing the bridge, she became progressively more frail. And some of that is an age-related thing, but not all of it. You shouldn't see a sudden change in anything. There can be gross expressions of violence toward the elder. And we need to make sure that when we're talking to the caregivers that we're listening for insufficient knowledge. If they don't understand how to deal with somebody with dementia, if they don't understand how to communicate, if they don't have the access to resources such as adult diapers that they need, those are all the things that we need to listen for, because those are all things that could trigger frustration and ultimately domestic violence. Mental health indicators of elder abuse include mood and anxiety disorders, substance abuse, and somatiform disorders. So being, just being aware of when elders present with problems, it may not be just normal aging, many times it is. But we do want to be sensitive to the fact that sometimes it's not. Risk factors for child abuse, parental depression or mental illness, substance abuse, chronic physical illness, physical abuse of one parent by the other parent, poor adherence to medical recommendations for children or erratic office visits. You know, that is one of those risk factors, but it's also one of those clues if the kids are not getting to the doctor when they're supposed to be missing appointments. If there's marked aggression among siblings, it can be a risk factor. It can also be a clue. If there's extreme overprotectiveness by one parent, this more falls into the clue category, but it can also be a risk factor. If one parent is wanting to dominate the relationship with the child, then there can be power struggles, if you will. And parental overinvestment in proving for a child who is in providing for a child who is physically ill. You know, we're talking about munch housings by proxy here, potentially. So we do want to look at that. It does exist. These are all things that we want to be aware of. Problems in adult survivors, chronic head, face, back or pelvic pain can be from sexual abuse, can be from physical abuse, head pain and neck pain and upper back pain can also be from stress and that can be from emotional abuse. Gastrointestinal distress can be physiological or psychologically caused. Musculoskeletal complaints, fibromyalgia, those sorts of things can be stress induced. Asthma and respiratory ailments, obesity and eating disorders. Obesity and eating disorders can really happen if the person has been deprived of food or if the person has been made to feel like their worth lies within their body. So they become terribly afraid of being fat because if they become fat, then they don't think they'll be lovable anymore. Insomnia, sexual dysfunction and pseudo neurologic symptoms such as dizziness. All of these things can happen. Especially if you've got physical abuse, a lot of the pseudo neurologic symptoms can happen because of repeated brain injuries. Just thinking when we go through what could be causing this. PTSD triggers. So you've got somebody who experienced domestic violence and maybe in the past and then now they are in a safe situation and they think they're past it but all of a sudden the PTSD gets triggered and they start becoming hyper-vigilant and having the nightmares. What causes it? Pregnancy or birth of a child or labor can trigger PTSD especially in people who've been sexually abused. The illness or death of a parent or perpetrator kind of opens those wounds because there was never and I'm probably never and I'm sorry. There was never any closure most likely. Divorce of parents can trigger PTSD. If they see that as why didn't you divorce when the abuse was happening? Why did you insist that I stay subjected to the abuse? That can trigger PTSD. The age of the patient recalls onset of abuse. So for example if the abuse happened to me when I was 10 then when my daughter becomes 10 it may trigger PTSD in me because I'm seeing myself and her going oh my gosh I hope she's safe. Key anniversary dates or holidays. Family get-togethers or reunions. Illness or injury of a child even if it's not intentional. If a child comes home or is at school and breaks their arm and the parent had been abused and had multiple broken bones it can trigger PTSD. Hospitalizations or medical work-ups typically are invasive and unpleasant anyway so somebody who's been exposed to violence and had their power taken away may feel very vulnerable and traumatized. Any situation that mirrors a relationship with the abuser can trigger it. Home relocation especially to where the abuse occurred. So if they moved away and they are trying to reestablish connections for some reason or they're moving back home for some reason it can trigger PTSD. Viewing movies or television shows with abuse content. There is a lot of that now. Oh my gosh between physical abuse and sexual abuse it's really prevalent even on just regular TV especially in your crime shows like what is it? Criminal Minds and CSI and those sorts of things. So that can trigger PTSD for some people. General anesthesia that results in muscle paralysis can make people feel helpless and overly vulnerable. Insertion of catheters and needles again this mainly applies to people who've been sexually abused but it leaves you feeling vulnerable. Any sort of confinement such as an MRI or restraints, restraints and seclusion anything that makes the person unable to protect themselves can trigger PTSD. And finally if the practitioner resembles the patient's abuser in some way and it could just be your gender or your hair color or whatever it is. So it's important to understand if there are transference reactions going on. Universal Screening refers to the characteristics of the group to be screened and occurs when nurses and clinicians ask every person over a specified age about their experience of abuse. And again this should be expanded to not just be women but male and female people over the age of 12. Routine screening refers to the frequency with which screening is carried out. It needs to be performed on a regular basis regardless of whether signs of abuse were present. Indicator based screening refers to screening when people observe one or more indicators that suggest the person may have been abused and subsequently we want to question the person about these indicators. If there's multiple healed fractures we're going to want to ask about it. If the person has a black eye we're going to want to ask about it. The initial response. There's a series of responses that are very helpful. First we want to acknowledge it. When the person says it happens we don't want to minimize it or say well could you maybe misunderstand or was it really that bad? No. We want to acknowledge it and validate their experience. We want to assess their immediate safety which means right now is your abuser in the waiting room? Are you going home to your abuser? What are we talking about in terms of safety? What options do you have that you're willing to explore? Refer to violence against women's services or domestic violence services at the person's request. A lot of domestic violence shelters are set up exclusively for women. A lot of domestic violence shelters are set up to handle exclusively women. If you've got a male who has been a victim of domestic violence it's going to be a little bit more difficult to find resources. You want to think about that in your organizational planning ahead of time. Then you need to document the interaction. Make sure that you document your safety planning, your safety assessment and any referrals you made. Benefits of routine universal screening. It increases opportunities for the disclosure of abuse and for us to identify abuse. It helps us link the health consequences to the abuse so the person can see oh yeah I'm having all these problems and part of it could be the environment that I'm in. We can provide early intervention instead of waiting for the person to be hospitalized. We can hopefully intervene early. That also influences the impact psychologically on the person so they're not enduring emotional abuse for two, three, six years. Hopefully we're getting in there sooner. We can avoid stigmatization by asking all people about abuse. We reduce the sense of isolation that abused people experience if we ask about it and we're just open about it and this is something we're going to talk about. We afford opportunities to assist children of abused people. If we're talking to a child who tells us about domestic violence then we can intervene. If we're talking to a parent who is experiencing domestic violence and we can also provide services in order to help protect the children and break that transgenerational pattern as y'all are pointing out. We want to give a strong message that abuse is wrong. There's nothing that you can do that should ever justify being demeaned, belittled, hurt in any way. Inform people about the violence, domestic violence services available in your area and it will help foster healthy communities. Universal screening is educational and puts it out there. It makes it something we can talk about instead of something that's supposed to be hidden under the covers. Screening questions need to be incorporated into routine health history and intake processes at doctor's offices. This helps clinicians become more aware when the person goes to the doctor and considered the immediate safety of the person. Questions need to be asked face to face in private and never in the presence of the person's partner or other family members including children. So we want to make sure that the person doesn't feel self-conscious or afraid. In cases where language is a barrier only trained cultural interpreters are used. We want to make sure that the interpreter understands any cultural uniqueness that may be present in a domestic violence situation. When we ask the question we want to explain that all women are being asked or all people are being asked about abuse because violence is so prevalent in our society. And then we want to tailor our approach to that person. We don't want to be overly gushing if that's not appropriate. It's like they're in pre-contemplation. They say I don't have a problem. We can just provide a little bit of education and let it go with that. If somebody indicates that they may have experienced it in the past then obviously we're going to go down a different road versus the road we go down if they say they're currently experiencing it. We want to inform people that they can expect to be screened every time a health history is taken and continue to send that message that violence is unacceptable. When the person says yes we want to believe them and this is really a problem if a man says yes a lot of times they're not believed or they're minimized so they clam up or they won't even say yes. So it's really important that whenever somebody says yes I'm a victim of domestic violence we believe it. We want to name the abuse and identify what the person is experiencing as abuse. Assess their immediate health needs and their immediate safety. Explore their immediate concerns and needs. If they've got children at home that's going to be one of those concerns. If they've got pets at home that's going to be a concern. They may be concerned about their safety going to work. They may be concerned about how to get a restraining order. What are your concerns right now? Determine a plan of action and with the release of information refer to appropriate resources. Make sure to have a contact list of domestic violence services available that you can give people. Like I said you're probably going to have two different lists. One for male survivors and one for female survivors. There is going to be some information that will overlap. But it's definitely helpful to have those specialized services. If the person says no but you suspect yes. Discuss what you've observed and explain why you continue to be concerned about the person's health and safety. Offer educational information about the health effects and prevalence of abuse. Highlight referral services. Maybe even give the person a handout. Document the person's responses. And share general information about domestic violence. And maybe it's impact. Maybe the person isn't willing to do something for themselves. Maybe they feel too oppressed at this point. But they have children at home. And maybe they do want to take steps to prevent their children from experiencing secondary victimization. Culturally diverse people may be reluctant to answer questions about and disclose abuse due to isolation from their community of support. General mistrust due to racism, sexism and classism. Religious factors language and communication barriers. And just a lack of culturally sensitive services. We need to know what domestic violence means in that culture. We need to know what behaviors are common in that culture. And interpret it as such. Documentation. Your record needs to include a safety check. So we identified what we did to make sure the person was safe and had a safe place to go. Direct quotation of what the person describes. Direct observations made by us about their nonverbal presentation about any physical bruises or anything we might see. And referrals discussed and made and information given. Referral services include more detailed documentation. They need relevant health history. They need the history of abuse including the first, worst and most recent incident. Where and when the abuse took place. The name and relationship of the abuser. Detailed description of injuries if taken. Any photos. All health care provided and information and or referrals or resources provided to the person. So when we are making referrals if we are making or calling the abuse hotline or if we are making a referral to law enforcement they are going to ask these questions. We need to have these questions answered and available to them. And sometimes we may not have asked all those questions yet because we don't want to double traumatize the person. I have been in situations where I have sat with the detective or the responding officer while they have asked the questions and I have prepared the person for the next time. So they only had to answer it once. And then we both got our documentation done. Organizational development for domestic violence. We want to have an assessment of organizational readiness and barriers to education. We want to involve all members who are going to contribute to the implementation process. Remember to dedicate that qualified individual to provide support needed for education and implementation. So one person or the point of contact for clients, but they are also the point of contact for everybody else in the facility. If they see that there is a problem or they think there might be a problem or need advice on what to do about something, they are the go-to person. There need to be ongoing opportunities for discussion and opportunities for reflection on personal and organizational experience in implementing the guidelines. So the first few times that you do the universal screenings, it may feel weird. You may get weird reactions from people because they are not used to being asked that. So they may be like, why are you asking this? Or they may be resistant. And we want to normalize that reaction. I know this seems odd that I am asking you this or whatever the person feels is appropriate to say. And make sure that people feel comfortable asking the questions and implementing the procedures. Otherwise, even if it's in your PMP manual it ain't going to happen. So we want to make sure that they feel prepared and comfortable. Violence in the home not only impacts the direct victim but all members of the family and not just the people that are living right in there. You know, you've got grandparents and parents and extended family who are going to learn about the abuse and going to have effects from it. Violence comes in many forms including physical, sexual, emotional and financial. Culturally responsive routine screening of all people over the age of 12 is recommended. And agencies must have in place a protocol for documenting screenings and handling client responses. Again, we can't just do the screening and go, well, good to know. See ya. We have to have, you know, if they say yes, what do we do? If they say no, what do we do? And if there's no problem, we still ask again next year when they come in for their evaluation. Other resources. There are manuals for domestic violence at these two places that you can click on the links. There are lots of resources out there. These just happen to be two that I used in the preparation of this presentation. So I saw a bunch of comments come up here. I wasn't able to read all of them. Okay, so how do we begin to work with people? Oops. Where'd it go? How do we begin to work with people who've been historically abused and carry this trauma acting out in anger, abuse and addictions? And it's important and when you look at a trauma informed perspective you're going to recognize or become more cognizant of the fact that a lot of people carry intergenerational trauma. A lot of people carry intergenerational patterns of behaving. If they were told to go out to the tree and get a switch so they could get a weapon they're probably going to do the same thing for their kids. So we want to look at these patterns of behavior and what the impact was and alternative ways of acting and reacting and also help them figure out how did you feel when that happened to you. And it can be helpful to work through these transgenerational patterns with the victim and the perpetrator. Now a lot of times you're not going to do that together but you may end up working through it. Both of them need to work through these processes. The perpetrator needs to understand where it's coming from and alternate behaviors. The victim needs to understand where it came from and get her power back or his power back. Kelly pointed out that it's important to repeat education and name the abuse even when it's subtle and identify relationship dynamics that can be abusive. And Lori points out something very important that a lot of times in families where there is domestic violence to the outside world the family looks perfect. They look very happy, they look very well adjusted. The domestic violence happens behind closed doors. So if you do home visits you're going to get a better feel for the mood and the dynamics around the house. Then you're going to get in the office where they just have to hold it together and present that facade for an hour. So it's always helpful if you can do home visits to do home visits and get a better feeling for what's going on. Especially you know if you're working with children or if children are involved it can give you a lot of insight into what's going on. I appreciate all the interaction in the chat room today. Are there any questions? I guess one other thing I'll bring up since we were just talking about home visits. Home visits themselves, you need to have a protocol for safety. Home visits where you're going and you expect that there may be some sort of violence or domestic violence it's important that your policy and procedure manual has a very clear safety protocol which can involve having two people go to the residence or whatever the case may be but it can be considered an invasion or intrusive on the part of the abuser who could get angry and act out with the provider when they're in their home. Alrighty everybody have an amazing weekend and I hope to see you on Tuesday. To participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox. 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