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January/February 2016 Issue

Mental Health Monitor: Universal Trauma-Informed Education — Addressing Intimate Partner Violence
By Liza Greville, MA, LCSW
Social Work Today
Vol. 16 No. 1 P. 34

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
According to a 2014 report from the National Center on Domestic Violence, Trauma & Mental Health summarizing 30 years of research, IPV is associated with a wide range of deleterious effects on physical and mental health. Victims of violence are subject to the immediate effects of injuries sustained as a result of IPV and the increased likelihood of sexually transmitted diseases including HIV. The chronic stress in women in violent relationships is demonstrated to compromise endocrine and immune functioning, thus increasing susceptibility to a variety of chronic health conditions.

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.
• Survivors of IPV have nearly double the risk for developing depressive symptoms, and three times the risk for developing major depressive disorder (compared with women who have not experienced IPV).
• Mothers reporting IPV are more likely to have a current diagnosis of depression than mothers who have not been abused by an intimate partner.
• Women who reported IPV at least once in their lifetime are nearly four times as likely to attempt suicide compared with women who have not been abused by a partner.

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'
In recognition of the relationship between IPV and health outcomes, the American College of Obstetricians and Gynecologists has recommended screening for IPV as routine practice in health care settings since the early '90s. In 2011 the Institute of Medicine followed suit. The Affordable Care Act takes several measures to directly improve health care for victims of IPV, including coverage for routine screening for IPV and intervention services for women who screen positive.

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
The universal, trauma-informed education intervention represents a paradigm shift from the traditional public health model of routine screening. As opposed to identifying cases as the in-road to intervention, Miller's goal is to create "survivor-centered, trauma-informed spaces." These settings promote education and normalize conversations about violence with all clients, facilitate disclosure for victims of IPV, and meet disclosure with empathy, competence, and appropriate referrals. Creating and nurturing such spaces depends on many factors, with the foremost being the intervention delivered by the health care provider. Without specifically asking for disclosure of IPV, this approach often yields disclosure by providing a context that gives patients a natural segue in conversation to connect their own experience with the information provided. The intervention unfolds as the provider makes appropriate referrals and delivers a harm-reduction message about decreasing future risk of abuse. Safety planning is always the central component of any intervention with a client at risk for IPV.

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."
• "Oftentimes, other young women tell me that changes in their moods have to do with ways their partner might be treating them."
• "You may not need this information now, but perhaps you have a friend or family member whom you could help by sharing this information?"

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.

Lalor, K., & McElvaney, R. (2010). Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs. Trauma, Violence & Abuse, 11(4), 159-177.
McCauley, H. (2015). College sexual assault: A call for trauma-informed prevention. Journal of Adolescent Health, 56(6), 584-585.
Miller, E., Breslau, J., Chung, W-J, Green, J. G., McLaughlin, K. A., & Kessler, R. C. (2011). Adverse childhood experiences and risk of physical violence in adolescent dating relationships. Journal of Epidemiology and Community Health, 65(11), 1006-1013.
Miller, E., & Decker, M.R. (2016). Innovative health care responses to violence against women. In Renzetti, C.M., Edleson, J.L., & Bergen, R.K. (Eds.) Sourcebook on violence against women. 3rd edition. Thousand Oaks, CA: SAGE.