January/February 2016 Issue
Mental Health Monitor: Universal Trauma-Informed Education — Addressing Intimate Partner Violence
Events associated with domestic violence, intimate partner violence (IPV), and sexual coercion are widely recognized to be particularly traumatic and associated with a sequelae of problems that are likely to negatively affect the health and well-being of victims of abuse over the life course. Providers of health care services, including clinical social workers in a variety of practice settings, are often well aware of the relationship between IPV and poor health outcomes, but are challenged to find a "point of entry," or a reason to talk with clients that connects the client's trauma history to her presenting concern in a way that supports and empowers the client toward a positive change. A universal, trauma-informed education intervention, an innovative approach supported by research-driven clinical practice guidelines, offers a solution.
Effects of IPV on Physical and Mental Health
Additionally, there is clear and strong evidence that experiencing IPV increases the risk of multiple mental health conditions, including PTSD, depression, anxiety, other mood disorders, substance abuse disorders, eating disorders, sleep disorders, as well as deliberate self-harm and suicidality. Experiencing multiple types of abuse (eg, physical, sexual, psychological) increases the risk of developing mental health symptoms. Studies consistently find higher rates of PTSD and depression, as evidenced by the following findings:
• Women who have experienced IPV are three times as likely to meet criteria for PTSD as those who had no such experience.
The cumulative effects of multiple traumatic experiences magnify the impacts of trauma. As cited in the Journal of Adolescent Health, most sexual assault survivors (80%) experience their first assault before the age of 24 years (McCauley, 2015). Another study found that sexual victimization in adolescence appears to increase the risk in adulthood, noting that respondents who had an experience of rape or attempted rape in their adolescent years were 13.7% more likely to experience rape or attempted rape during their first year of college (Lalor & McElvaney, 2010). Trauma related to IPV is often highly complex, with negative mental health consequences stemming from the interactions of multiple system factors. For example, physical violence in adolescent dating relationships is "positively associated with a broad range of childhood adversities, including but not limited to childhood sexual abuse, interparental violence, and parent mental illness" (Miller et al., 2011). In a trauma-informed perspective, it is important to be aware of the possibility of a more complicated and extensive trauma history than an initial report conveys.
Shifting the Paradigm of 'Screening'
Elizabeth Miller, MD, PhD, chief of adolescent and young adult medicine at the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center, and an expert on sexual violence prevention, explains the challenges of applying a public health model of screening to IPV. "'Screening' in public health refers to the identification of asymptomatic disease (generally before symptoms manifest) through the use of a test of set of prescribed questions that allow identification, early diagnosis, and subsequent treatment of the disease. When this screening paradigm is superimposed on interpersonal violence, the emphasis becomes case identification." She continues, "Such a disease-oriented paradigm may not be particularly relevant for survivors, many of whom are manifesting a range of health consequences from chronic exposure to violence, thus are not truly 'asymptomatic' nor 'early' in the course of IPV/SA [sexual assault] in their lives" (Miller & Decker, 2016).
Miller finds that "commonly used screening questions such as, 'Are you feeling safe in your relationship?' or, 'Are you safe at home?' do not promote helping women make the connection between the violence they have experienced and their health." She elaborates that common formulations of the screening question such as, "Have you ever been hit, kicked, slapped, choked, or forced to have sex against your will?" prompt providers into an investigative role as opposed to a present-oriented, empathic stance in which the provider can join with the patient to understand "where she is and what supports and services she needs" (Miller & Decker).
She adds "these type of screening questions can be confusing to survivors who may have a complicated trauma histories which don't fit neatly into a checklist. It is less important for a provider to ascertain details of the woman's experience—e.g., was force or threat used?—than to understand what kind of support she might be receptive to at this point in time."
In contrast to the "checklist" approach to screening, Miller and her collaborators have been researching the effectiveness of a universal, trauma-informed education intervention for more than a decade. Her research, which has been funded by several federal agencies, tests the effectiveness of clinical guidelines in family planning clinics, adolescent health centers, and college health centers. Studies have shown a variety of positive attitudinal impacts among subjects who received the intervention, and most significantly, a decrease in sexual victimization as reported in postintervention follow-up surveys.
Clinical Guidelines for Universal, Trauma-Informed Education
Miller offers the following examples of language she may use to preface universal education:
• "So many of our patients have had experiences with [IPV] that I've started talking to all my patients so they know how to get help for themselves or help others."
The conveyance of universal information is facilitated though a wallet-sized pamphlet/card and has been tailored to various practice settings, including general health safety, American Indian/Alaska Native, college campus, home visitation, pediatric health, perinatal health, reproductive health, and teen health. In addition to the culturally specific content, the cards include local and national crisis hotline phone numbers. These clinical guidelines are available at www.healthcaresaboutipv.org.
Social workers need to be aware of the applicable state laws related to mandated reporting of child abuse, statutory rape, and injuries caused by weapons, as a result of violence or through nonaccidental means. Talking with clients about the limits of confidentiality as part of the informed consent process is necessary prior to any discussion of IPV.
Finally, Miller acknowledges the clinical skill implicit in implementing a universal, trauma-informed education intervention. "It is understandable for a provider to feel pressured by lack of time and overwhelmed to keep up with best practices, reporting requirements, and referral procedures. It is common for a patient to experience automatic and involuntary emotional arousal at the very mention of IPV. The value in using the universal, trauma-informed education intervention facilitated by cards is in providing multiple points of entry to starting a conversation. The message is, 'No matter what situation you are in, there's someone and some place that can help you.' And we go from there."
— Liza Greville, MA, LCSW, is in full-time clinical practice in rural Pennsylvania and a contributor to Social Work Today.