Domestic Violence: A Clinical Perspective

1. Domestic Violence:A Clinical Perspective Presented By: Chuck Diviney, MC, LPC, NCC, CCMHC Statistics Theory and Research Diagnostics / Characteristics Treatment Relationship With Clients Domestic Violence / Elder Abuse

2. DV Basics and Statistics What is Domestic Violence? Physical, emotional, mental, sexual abuse Statistics 1 in 3 Utah women are physically abused Utah: 26% higher homicide rate Children 6X greater chance of DV relationships Statistics similar across cultural lines 25%-33% of all relationships Leaving is the most dangerous time

3. Theory and Research Domestic Violence Research: Kernberg- A psychotic or borderline level of personality organization is a corollary of most homicidal attachments.

4. Theory and Research Domestic Violence Research: Gondolf- In a study of domestic violence batterers, no Axis I pathology emerged as typical for [common to] batterers. The characteristic that was found in most all batterers was narcissism.

5. Theory and Research Narcissistic Traits Surface: Grandiose Need to feel special/different Critical of others Controlling

6. Theory and Research Narcissistic Traits Core Personality: Emptiness Shame Fear of abandonment Extreme Vulnerability

7. Theory and Research Narcissistic Traits Defense Mechanisms: Rationalization Denial Grandiosity Splitting Projection Idealize and/or Devalue

8. Theory and Research Domestic Violence Research: Dutton- In his study, he found that 85% of men referred to his treatment program had a diagnosable personality disorder. He also found that approximately 40% had antisocial personality characteristics.

9. Theory and Research DV Batterer Classification (one model): Family-Only Batterer Dysphoric/Borderline Batterer Generally Violent/Antisocial Batterer

10. Diagnostics/Characteristics Cluster B Personality Disorders (DSMIV-TR) Developmental Continuum Histrionic> Borderline> Narcissistic> Antisocial (less severe ? ? ? ? ? ? more severe) The farther to the right, the worse the pathology in terms of attachment, object-relations, and prognosis for change

11. Diagnostics/Characteristics Histrionic Personality: Pattern of excessive emotionality Attention seeking Constant need for approval Self-centeredness/self-preoccupation Sexual Seductiveness DV: Very emotionally and psychologically abusive; little physical abuse (very mild)

12. Diagnostics/Characteristics Histrionic Personality (cont.) Risk Assessment Questions: #10 Alcohol / Drug problems? #12 Mental Health Issues? #15 Abuse as a child? (mild to moderate) #16 Separations? #18 Suicide/Homicide? #19 Stalking?

13. Diagnostics/Characteristics Borderline Personality: Deflated false self and fragmented ego Labile/impaired emotional regulation Unstable, intense interpersonal relationships Extreme idealization and devaluation Use of thinking errors extreme (all/nothing) Low frustration tolerance DV: Very emotionally and psychologically abusive; mild to moderate physical abuse; emotionally labile and unpredictable; homicidal/suicidal threats

14. Diagnostics/Characteristics Borderline Personality (cont.): Risk Assessment Questions: #10 Alcohol / Drug problems? #12 Mental Health Issues? #15 Abuse as a child? (moderate) #16 Separations? #18 Suicide/Homicide? #19 Stalking? *Higher level of intensity vs. HPD

15. Diagnostics/Characteristics Narcissistic Personality: Pervasive pattern of grandiosity / �image� Lack of empathy Hypersensitive to evaluation by others Inflated false self Emptiness and shame at core of personality Others seen as extension of self DV: Dismantle victims emotionally; complete control of activity; manipulative; moderate physical abuse, more likely emotional / psychological abuse

16. Narcissistic Personality (cont.) Risk Assessment Questions: #1 Control of money, activity, socialization? #8 Image outside of the home? #15 Abuse as child? (moderate to severe) #16 Separation? #18 Suicide/Homicide? #19 Stalking? *Higher level of intensity vs. HPD and BPD Diagnostics/Characteristics

17. Diagnostics/Characteristics Antisocial Personality: Criminal activity/legal history extensive Behavior begins in adolescence (conduct) Extreme impulsivity Calm in crisis situations Lack emotional responsiveness / empathy No attachment (unless need driven) DV: Terrorizing; extreme physical abuse; not likely to change with intervention; most dangerous of personality disorders

18. Diagnostics/Characteristics Antisocial Personality (cont.): Risk Assessment Questions: #1 Control of money, activity, socialization? #2 Abuse of children? #3 Assault outside of family? #4 Weapons? #5 Cruel to animals/pets? #10 Alcohol/Drug issues? #13 Criminal record/history?

19. Diagnostics/Characteristics Antisocial Personality (cont.): Risk Assessment Questions (cont.) #15 Abuse as a child? (severe) #16 Separated? #17 Forced into sexual act? #18 Suicide/Homicide? #19 Stalking? *Most severe of personality disorders and least likely to change

20. Diagnostics/Characteristics Other Risk Assessment Factors: #1: Control of money, activity, and socialization- �yes� response more likely to represent DV (as opposed to poor communication/anger management issues) #6: Increase in severity/frequency- typical to all personality disorder types/DV relationships.

21. Diagnostics/Characteristics Other Risk Assessment Factors: SERIOUS RED FLAGS! #3 Abuse outside of the home? #4 Weapons? #5 Cruelty to animals/pets? #10 Drugs/Alcohol? #16 Recent/pending separation? #18 Suicide/Homicide threats?

22. Diagnostics/Characteristics

23. Diagnostics/Characteristics

24. Diagnostics/Characteristics

25. Diagnostics/Characteristics Thinking Errors Used throughout the cycle Frequent use/daily living patterns Irrational thinking Perpetrator�s way to �connect the dots� EXAMPLES Justification, All or Nothing (B/W), Lying, Victim Stance, Blaming, Minimizing, Denying, Power Thrusting, Build Up

26. Diagnostics/Characteristics Mental Health Disorders (Axis I) Depression Anxiety Bipolar Schizophrenia (paranoid)

27. Diagnostics/Characteristics Victim Types: Classical: lacks phys/psych �power� Pseudo-Classical: some psych �power�, e.g., sets up the violence/chooses when DV occurs Mutually Violent: no pattern establishing either party as �the victim�

28. Diagnostics/Characteristics Post Traumatic Stress Disorder: Most common Axis I disorder for victims and children of DV Anxiety symptoms: panic, dissociation, fragmentation of bodily experience Increased risk of alcohol/drug use Poor impulse control Depression likely to follow

29. Diagnostics/Characteristics Dependent Personality Disorder: Dependent and submissive behavior Intense preoccupation with abandonment Extreme discomfort with being alone Anxiety and depression very common Unable to make decisions alone

30. Diagnostics/Characteristics Diagnoses with children: PTSD vs. ADHD Depression Anxiety Personality Disorders: 6X greater chance of being in DV relationships as an adult Oppositional Defiant/Conduct Disorder

31. Diagnostics/Characteristics Brain Scan: Victims of DV (children and adults) Frontal lobe development impaired (higher processing area of the brain) Hyperdevelopment of brainstem area (fight/flight)

32. Treatment Batterer/Perpetrator Treatment Phases of Treatment: Phase One- Elimination or change of dysfunctional or destructive behavior; containment; crisis intervention; safety planning Phase Two- Education; learning new skills Phase Three- Acquisition of personal insight

33. Treatment Crisis Management/Initial Intervention: Timeout Skills Safety Plan Stress Log Self-care

34. Treatment Rational Emotive Behavioral Therapy (REBT) Albert Ellis, Ph.D., 1954 Relationship between thoughts, behaviors, and emotions Teaching self-control Rational vs. Irrational thinking

35. Treatment Rational Emotive Behavioral Therapy (REBT)

36. Treatment Rational Emotive Behavioral Therapy (REBT) A + B ? C Activating + Belief ? Emotional/ Event Behavioral Consequence + D ? E + Dispute ? New Consequence

37. Treatment Solution Focused Behavioral Therapy Scaling Plan For Progress Solution Generating/Focused Questions

38. Treatment The Personality Balance Wheel

39. Treatment Goals for treatment: Increase perpetrator accountability Prevent further violence Decrease recidivism Increase mental health functioning

40. Treatment PTSD: Secure, consistent, predictable environment Ordering activity/daily routine Body awareness/use of sensory perception Relaxation techniques �Goodbye� letter (letting go) Journal Creating social support Open discussion and processing Children: Play therapy

41. Treatment DV Treatment Guidelines: Perpetrator treatment = 16 weeks No court ordered treatment for victims No couple�s therapy, unless: 12 week minimum in treatment No continued risk of danger (comprehensive assessment completed) Safety plan in place Victim acknowledges desire for treatment Funds available Relapse to be expected (thinking vs. behaving)

42. Relationship With Clients ENGAGEMENT Focus on help for the entire family SUPPORT, EMPATHY, TRUST Advocacy, Education, Support vs. Decision Maker Rapport with client is 75% predictor of success

43. Relationship With Clients Nonverbal (specific to crisis intervention): Eye contact Matching Relaxation (�Take a couple of deep breaths�) Listening/allowing client to vent Empathy (�That must be difficult�) Being safe Avoiding attacks on partner

44. Relationship With Clients Crisis Intervention Skills Take control of the situation Determine the real client Emphasize strengths Mobilize social resources

45. Relationship With Clients Crisis Intervention Skills (continued): Lethality and Danger Assessment Look at the serious red flags Take people with you to help Identify a safe place and time to meet with the victim Safety plan

46. Relationship With Clients Risk of Danger Form Form that belongs to the victim Assessment of danger and lethality, as well as an awareness tool Use the chart of dangerous behaviors to help increase awareness Don�t blame the victim Listen

47. Relationship With Clients Safety Planning Ask the victim about what has been done Identify support system Identify safe places (don�t put the address) Plan for daily activities (work, groceries, etc.) �If they stay� vs. �If they leave� The role of the victim advocate, shelters, caseworkers: ADVOCACY

48. Relationship With Clients Approaching the counseling process*: Making contact Explain who you are/the counseling process Speak briefly Individualize your counseling When you don�t know what to say, SAY NOTHING *taken from Elements of Counseling (3rd ed), Meier and Davis, 1997

49. Relationship With Clients Avoid these: Positive thinking does not equal rational thinking Agreement does not equal empathy Change is not typically simple Make psychological assessments, not moral judgments Do not assume anything, clarify

50. Relationship With Clients Dealing with a Personality Disorder: Set firm boundaries with the client and FOLLOW THROUGH! Behavior logs Journal Strengths focused Don�t expect TOTAL change-modification is key Work with a team/avoid triangulation (communicate)

51. Relationship With Clients Know thyself! How did you decide to become a counselor? With what emotions are you uncomfortable? What amount of progress is acceptable? How will you deal with client feelings for you? How will you deal with your feelings for clients? Can you be flexible? What are your values? Any conflicts with clients?

52. Domestic Violence / Elder Abuse Three Potential Scenarios in Elder Abuse/Domestic Violence: Long-term relationship with early onset

54. Domestic Violence / Elder Abuse Three Potential Scenarios in Elder Abuse/Domestic Violence: Short-term relationship with early onset

56. Domestic Violence / Elder Abuse Three Potential Scenarios in Elder Abuse/Domestic Violence: Long-term relationship with late onset