7 IN DEALING WITH PARTNER VIOLENCE David Katerndahl, MD, MA Department of Family and Community Medicine University of Texas Health Science Center San Antonio, Texas
SPEAKER DISCLOSURE Dr. Katerndahl has disclosed that he has no actual or potential conflict of interest in relation to this topic.
MAGNITUDE OF THE PROBLEM Lifetime prevalence of rape, physical violence or stalking by intimate partner (2010) * 36% U.S. Women 35% Texas Women Texas (2013) 76,704 reported victims of Intimate Partner Violence (IPV) Estimated 1.1 million Texas Women were battered (HHSC) Lower Rio Grande Valley (2014) Reported incidents of Family Violence Edinburg = 943 McAllen = 539 * CDC, 2010 Harlingen = 520
MAGNITUDE OF THE PROBLEM Spousal Homicide Gun in Home → Increases Homicide Risk 500% 72% of Murder-Suicides involve Intimate Partners 200 Wome n Kille d By Pa rtne rs 150 100 50 0 2010 2011 2012 2013 2014 2015 T EXAS
HEALTH CONSEQUENCES OF IPV* *Miller & McCaw, 2019
LEARNING OBJECTIVES By the end of this educational activity, the learner should be better able to: 1. Recognize seven sources of primary care provider frustration in dealing with patients in violent relationships. 2. Set realistic expectations in dealing with partner violence. 3. Identify strategies for minimizing the impact of these frustrations.
LACK OF DISCLOSURE Focus Groups of 44 PCPs 1 Frustrated about nondisclosure by women BUT PCPs: Have unrealistic expectations about disclosure Ignore patient hints about IPV Qualitative Interviews With Mothers (n=40) 2 More comfortable answering IPV questions if children NOT present Hispanics less comfortable “What I share depends on how the (Doctor-Patient) relationship is going.” Victims want PCPs to ask about IPV 3,4 1 Zink, 2004 Qualitative interviews of 142 women 5 2 Zink, 2006 3 Zink, 2007 63% say they would disclose if PCP asked 4 Burge, 1996 5 Morse, 2012
LACK OF PCP RESPONSE Qualitative interviews of 142 Women* PCP Response: 71% of PCPs told her to just leave (frustrating for women) [PCP] “All those times that you kept going back, I told you not to go back, now you are on your own.” 22% neutral about advice 31% gave safety information (rarely made safety plan) Women’s feelings about PCP 15% - PCP NOT open to talking about IPV 26% - PCP NOT knowledgeable about abuse *Morse, 2012
LACK OF PCP RESPONSE Focus groups of 72 Women 1 Focus groups of 44 PCPs 2 What Women want from PCP: PCPs feel unable to respond Open-minded Barriers: Listens Lack of knowledge and skills Unhurried Lack of time Respects confidentiality Attitude – “Not my job!” 1 Usta, 2012 2 Zink, 2004
* Relationships are complex 1 “Taking sides” “[I felt] embarrassed and unprotected. I felt like [my doctor] defended my husband” 2 Mutual violence 2 9,643 daily reports of violence completed 3,813 (40%) reports of husband-perpetrated violence 2,209 (23%) reports of wife-perpetrated violence 85% of women involved 1 Zink, 2007 2 Katerndahl, 2014
* 2.5 2 1.5 Women 1 Men 0.5 0 Frequency of Days Average Severity on Violence Burden with Violence Days with Violence (frequency + severity) p<.001, all comparisons *Katerndahl, 2014
“Complex Dynamics” 1. PATTERNS OF DYNAMICS Periodic Dynamics Random Dynamics Chaotic Dynamics 2. NONLINEARITY = Output not proportional to input
Prevalence of Dynamic Patterns (N =135) * 70 59% 60 50 PREVALENCE (%) 40 30% 30 20 12% 10 0 Periodic Chaotic Random DYNAMIC PATTERN *Katerndahl, 2014
Distribution Of Nonlinearity Measurements * Disorder Information P C R P R w P C R p R w P = Periodic, C = Chaotic, R p = Pink Noise (Random), R w = White Noise (Random) *Katerndahl, 2014
Importance Of Nonlinearity * VIOLENCE Outcome Frequency Nonlinearity Optimal Or Severity Measures Nonlinearity Attitudinal/Behavioral Positive Coping Negative Coping + Positive Appraisal – + Negative Appraisal Hope / Support – – Clinical Symptoms / Dysfunction + Medical Utilization Readiness To Act + Mental Health Utilization + *Katerndahl, 2014
Relationships Among Prior-Day Predictors * Husband’s Hassles Alcohol Intake Marital H USBAND - Emotional Wife’s W IFE - P ERPETRATED P ERPETRATED Distance Upset Alcohol V IOLENCE V IOLENCE Intake + Feedback - Feedback *Katerndahl, 2014
Compared with Non-Victimized Women * Smaller Support Networks Number discussing important matters Number socializing with Support Exchange Less support received Proportionally less support received Fewer supportive contact in prior 3 months Support imbalance Fewer reciprocal relationships Support given > support received *Katerndahl, 2013
Cautious about seeking support Family, cultural and societal sanctions 1 Sense of isolation 1 Sense of shame Lack of perceived benefit Friends respond poorly (often in or witnessed violence) Do not know how to respond 2 Reaction perceived as unhelpful 3 Negative / mixed reaction can hinder taking action 4 1 Rose, 2000 2 Latta, 2009 3 Fanslow, 2010 4 Bosch, 2004
AUDIENCE POLLING QUESTION 1 Which of the following statements is truly about women’s decision-making concerning their violent relationship? 1. Most women seen in primary care have never taken any action before 2. Psychotherapy is generally rated as a positive experience 3. Forgiveness by women leads to bad outcomes 4. Taking legal action depends strongly upon her perceived need-for- action 5. Having children at home is not important to women’s decision- making
Decision-Making Measures* R EADINESS -T O -A CT P RIOR A CTION N EED -T O -A CT A CTION T AKEN OUTCOME TIME FRAME Prior Experience Past Readiness-For-Action Future Perceived Need-For-Action Immediate Action Taken DONE *Katerndahl, 2016
PRIOR EXPERIENCE: Action & Experience* HELP LEGAL ACTION LEAVING 60% 50% # 40% 30% 20% 10% # # 0% Action (%) Experience (mean) * Hispanics LESS # Hispanics MORE *Katerndahl, 2016
READINESS FOR ACTION* PRIOR ACTION TAKEN Only 28% of women have NEVER taken any action before 20% of women have taken at least 5 actions before READINESS-TO-ACT: *Katerndahl, 2016
READINESS versus ACTION (# of women) * BASELINE READINESS HELP-SEEKING LEGAL ACTION LEAVING Readiness Action Readiness Action Readiness Action (Returning) PRECONTEMPLATIVE (No Interest) 10 0 60 3 39 0 0 CONTEMPLATIVE (Someday - 6 Months) 38 1 28 4 49 0 3 PREPARATION (30 Days) 11 1 0 0 0 0 0 ACTION (Trying Now) 44 5 15 5 15 10 0 *Katerndahl, 2016
CATASTROPHIC DECISION-MAKING (Readiness) * Readiness→ Violence & Need→ NEED FOR DISTORTING FACTORS Help • More Forgiveness Legal Action • More Children Leaving • More Children • Less Hope & Positive Coping *Katerndahl, 2017
Nonlinearity Of Need-For-Action * APPROXIMATE ENTROPY LZ COMPLEXITY P C R R P C R R LEAVING LEGAL HELP P w P w P C R R P w P C R R P C R R P w P w *Katerndahl, 2016 P = Periodic, C = Chaotic, R p = Pink Noise (Random), R w = White Noise (Random)
INTERRELATIONSHIPS AMONG PRIOR-DAY PREDICTORS OF NEED* NEED TO NEED LEAVE FOR HELP Violence Keep Forgiveness Increasing Stalking Together Her Forgiveness Violence His Violence Violence Increasing + Perceived His Control Alcohol Ready Effect To Move On Children NEED On Children Safety FOR LEGAL Stress His Violence Financial Concern Keep Together Violence Increasing Positive His Perceived Negative Alcohol Control Children Safety *Katerndahl, 2016
TAKING ACTION (Seeking Help)* Prior Action Experience – Best Experience Prior-day Predictors Sense of control Same-day Correlates Need for help Stress *Katerndahl, 2016
TAKING ACTION (Legal Action) * Prior Action Experience – Any Experience Prior-day Predictors Concern: Child safety and effect of violence His stalking Same-day Correlates – NONE *Katerndahl, 2016
TAKING ACTION (Leaving [And Returning])* Prior Action Experience – Worst Experience As Barrier Prior-day Predictors Triggers Barriers Perception Violence Increasing Concern: Finances His Alcohol Intake His Violence Same-day Correlates Triggers Barriers Need To Leave Her Alcohol Intake Stress His Seeking Forgiveness RETURNING AFTER LEAVING Prior-day correlates His alcohol intake His stalking *Katerndahl, 2016
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