Shahrzad Bazargan-Hejazi, PhD UCLA/CDU Medical Education Program November 6, 2012

1. Motivational Interviewing to Improve IPV Screening, Brief Intervention, and Referral for Treatment (SBIRT) Shahrzad Bazargan-Hejazi, PhD UCLA/CDU Medical Education Program November 6, 2012

2. IPV Training Objectives • Define signs, symptoms, consequences, and CA reporting policies of Interpersonal Violence (IPV). • Describe the essentials of the Motivational Interviewing (MI) approach. • Identify and describe steps in IPV-SBIRT • Rehearse IPV-SBIRT via role-playing.

3. Definition & Prevalence of IPV IPV refers to behavior within an intimate relationship that causes physical, sexual or psychological harm. IPV includes acts of: • Physical aggression • Sexual coercion • Psychological abuse • Controlling behaviors

4. Prevalence in the U.S. • Women Men • 35.6% lifetime 28.5% • 6.0% any year 5.0% • 17.0 % sexual 8.0% • 24.3% hit, kicked… 13.8% • 28.8% fearful 5.2% • A high % of IPV is not reported to police (~50%) Liebschutz JM, NEJM2013

5. Consequences of IPV The harm that IPV causes can last a lifetime and span generations, with serious adverse effects on: • Health, including: • Physical injury • Unwanted pregnancy • Abortion • Gynecological complications • Sexually transmitted infections (including HIV/AIDS) • Post-traumatic stress disorder • Depression • Parenting Skills • Child behavior • Education • Employment

6. Cost of IPV for the U.S $10.4 billion in 2012 42% higher cost of health care for IPV-experienced women

7. Risk Factors for Both IPV & Sexual Violence

8. The Ecological Model Source: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.

9. Typical Non-injury Signs of IPV • Neurological (headaches & neck pain, tingling & numbness) • Cardiopulmonary (chest pain, tachycardia, feeling of choking) • Pelvic symptoms (pelvic pain & UTI, vaginal pain & painful intercourse)

10. Physical Signs of IPV • Head, neck & facial scrapes, cuts & bruises, FRX and rope burns ,T.M. membrane rupture, loose and broken teeth • Abd & ext cuts, bruises & bite marks, and cigarette burns • Signs of old and new fractures and burns

11. Typical Behavior of the Abuser • Refuses to leave the patient • Abuser overly controlling, and may insist on answering questions for the patient • Its very important to take the history in private

12. IPV Reporting Procedures 1. Inform the patient of the health care provider’s duty to report. 2. Inform the patient of the likely responses by law enforcement, and what will happen to the report. 3. Make a telephone report to the local law enforcement agency where the incident occurred, immediately. 4. Complete a Suspected Intentional Injury Reporting Form a) Send within 48 hours of receiving information about the person to the law enforcement agency where the incident occurred. 5. When two or more HHSA employees suspect a domestic violence incident that requires a report, only one person needs to submit the report.

13. IPV Reporting Procedures (cont.) 6. All health care providers involved are equally responsible to see that the report is made and completed, according to State requirements. 7. The report must be kept confidential 8. A report must still be made even if the person has died, 9. Enter the following into the patient’s chart: a) Any comments by the patient regarding past domestic violence b) “Body Diagram Map” c) A copy of the Suspected Intentional Injury Reporting form. There will be a liability for failure to report.

14. What Do We Know about Management of IPV by Providers? • Health care providers commonly have an optimistic bias toward the vulnerability of their patients in regards to IPV.

15. IPV Training & Provider Practice • Empirical evidence shows that practitioners who receive IPV-related training are significantly more likely to screen for it. • Conversely, health practitioners who do not receive adequate training on how to recognize, treat, and refer IPV victims and perpetrators are less willing to conduct routine screening.

16. Existing Gap in IPV Training • Despite a national interest in IPV issues, many U.S. medical schools still do not provide adequate training for IPV screening and prevention. • Medical education and residency programs continuously look for mechanisms to teach IPV screening and identification, and measure their competencies for IPV screening and prevention.

17. Current Guideline Under Affordable Care Act (ACA) New guideline under the ACA requires insurance coverage to include IPV screening and counseling as part of eight essential health services for women at no additional cost to the patient. James L., Shaeffer S. : 2012: www.futureswithoutviolence.org

18. IPV-SBIRT in the Context of Motivational Interviewing (MI)

19. What is MI Definition: MI is an effective way of talking with people about change:

20. The Spirit of MI MI is a style of interviewing that is: • Patient-centered and collaborative approach • An invitation for partnership • Direct persuasion is not effective • We meet people where they are with change • We negotiate change with the patient • Supports/tolerates patient ambivalence • Readiness to change is not a trait • Evocative • It elicits behavior change from the patient • Non-judgmental listening rather than instilling • Responsibility of change is with the patient • Not coercive, but directive • Respectful of patient autonomy

21. Core Skills for MI: OARS • Open-Ended Questions • Affirmation • Reflective Listening • Summery

22. Open- Question • R U in pain? Vs. How do U feel? • Don’t you want to move to a safer place? Vs. What are the advantages of moving to a safer place? • How much alcohol do you drink a day Vs. What is the role of alcohol in your life?

23. Affirmations • Statements about anything positive that you notices about the patient: • Awards, Attempts, Achievements, Accomplishments • You really care about your family/child/work • You do feel responsible to take of yourself • It takes a lot of courage to do what you do • Build self confidence, self-efficacy

24. Reflective Listening • Understanding what the patient is thinking and feeling, then saying it back to the patient in a statement form and not question • I have been like this for as long as I know myself Reflection: So all of this seems normal to you • I don’t like my husband getting mad at me all the time Reflection: You want your husband to manage his anger • I don’t think that I have depression Reflection: You are not sure about the diagnosis of depression

25. Summaries Let see if I understand you right, you are worried about your husband rage, and you have been thinking that if you live closer to your parents you be safer. But there is a downside to it, you family might find out about this. But you are also worried about you children. I cannot live with fear of him getting mad at me all time!! I love him but he is moody, sometimes I might be safer if I move closer to my family I am worried about my childern I worried about my family finding about this

26. The Four Processes of MI • Engaging • Focusing • Evoking • Planning

27. 1. Engaging “The process of establishing a trusting and mutually respectful relationship” • Establishing rapport; Attuning; Aligning • Question-Answer Trap/assessing • Confrontation-Denial Trap • Expert Trap/telling how to fix a problem • Labeling Trap/ • Premature Focus Trap • Blaming Trap

28. 2. Focusing “An ongoing process of seeking and maintaining direction” • Setting an agenda • Patient’s goals and priorities • Your goals and priorities • Clear direction for ultimate change plan

29. 3. Evoking “ Eliciting a patient’s own motivation for change” • Eliciting change talk • Patient’s statements that favor movement in the direction of change • I want • I wish • The reasons are • I can • I will

30. How to Generating Change Talk D: Why do you want to make this change? A: How might you be able to do it? R: What is one good reason for making the change? N: How important is it, and why? (0-10) C: What do you intend to do? A: What are you ready or willing to do? T: What have you already done? Desire, Ability, Reasons, Needs, Commitment, Activation, Taking action

31. 4. Planning “Developing a specific change plan that your patient agrees with and is willing to implement” SMART • Specific • Measurable • Achievable • Relevant • Timed

32. Signs of Resistance to Change • Argument • Interrupt • Denial • Pessimism • Ignoring • Non-answer

33. Signs of Readiness to Change • Less resistance • Feeling welcome • Feeling comfortable • Feeling understood • Fewer questions about the problem • Provides self-motivating statements • More inquiry about change • Optimism/envisioning • Experimenting with change

34. The Main Goal of MI Retention Motivation Goal of MI Outcome Resistance

35. Steps in Conducting IPV-SBIRT • Establish rapport • Ask permission to discuss the subject • Explore pros and cons • Explore discrepancies between present condition and intended goal • Assess readiness to change • Negotiate a plan to change • Plan follow-up

36. Readiness Ruler • How ready are you to change this situation (abuse) for yourself? Not Ready (1-3) Unsure (4-7) Ready (8-10) 3 1 10 2 6 4 5 7 8 9 EXPRESS CONCERN, OFFER INFO. FOLLOW-UP EXPLORE PROS & CONS HELP PLAN, IDENTIFY RESO, CONVEY HOPE

37. Good News: A substantial number of counselors in the U.S. are being training in MI and report that they are “doing MI” in their sessions Bad News: A substantial number of physicians are not trained in MI Research demonstrates that most of those who say they are doing MI really are not Unless they record sessions that can later be rated, it is not possible to know if they are really doing MI or are adhering to MI rules Good News/Bad News

38. Take Home Message • IPV is prevalent • IPV is preventable • Health Care Providers Should Take action • IPV-SBIRT