What Do Professionals Need to Know?
Model Domestic Violence Policy for Counties
Mental Health System
Numerous studies have shown high rates of victimization among those with a variety of psychiatric diagnoses, such as depression, some anxiety disorders, somatic complaints, eating disorders, substance abuse, suicide attempts, sleep disorders, and certain personality disorders. While many biological and psychosocial factors may facilitate the development of any such illnesses, victimization is a strong contributory factor.(37)
There are certain characteristic symptoms seen in many people following highly traumatic life events. Some women experience these symptoms as a result of the trauma associated with adult domestic violence. These symptoms may include hyper-vigilance, re-experiencing aspects of the trauma, and/or emotional numbing. These symptoms are normal psychological responses to stressful life events, much as fever, elevated white blood cell count, and activation of the immune system are normal reactions to infection and are the body's attempts to begin a reparative process.
Many victims experiencing the symptoms mentioned, find that these symptoms spontaneously remit when they become safe from further harm from their abusive partners. In order to appropriately diagnose and treat women presenting with these symptoms, therefore, mental health providers must identify if clients are being abused and develop treatment plans that integrate safety-related concerns.
Men who are abusive use emotional, psychological, economic, sexual, and physical abuse to control their intimate partners. In general, abusers act from a set of attitudes and beliefs about how men and women should relate in intimate relationships. Domestic violence does not result from personal or moral deficits, childhood trauma, diseases, diminished intellect, addiction, mental illness, other persons' behaviors, or external events. Responses to abusers' violent behaviors that focus on these issues, therefore, simply give abusers support for the excuses they offer to explain their abusive behavior and undermine their ability to achieve insight about their capacity to stop their abuse against their partners.
In addition to incorporating the recommendations outlined in the Guiding Principles and the Employers sections into their responses to domestic violence, and being mindful of the potential need for individualized responses based on factors such as socio-economic status, race, ethnicity, sexual orientation, age, religious affiliation, physical and mental disabilities, immigrant status, education, employment status, urban vs. rural residency, and marital status, mental health providers should also integrate the following recommendations specific to the mental health system.
- VICTIM SAFETY AND SELF-DETERMINATION
- Private, routine screening for domestic violence should be conducted with all female clients to determine if they are being abused by their intimate partners.
- Mental health providers should routinely screen all child clients for the presence of adult domestic violence and for concurrent child abuse and neglect.
- For clients identified as victims, mental health providers should elicit and document complete health histories, including trauma histories. With the victim's consent, this should include obtaining copies of relevant medical records from other sources. Providers should maintain thorough, objective, and accurate case records.
- When domestic violence is identified, mental health providers should collaborate with the victim in evaluating the impact of any recommended treatment strategies on her safety, develop mental health treatment plans that give priority to safety-related needs, and pro-actively assist victims in developing short and long-term safety plans.
- Mental health treatment providers should recognize that, at times, the legitimate survival and safety strategies employed by victims (such as resistance, non-compliance, and dishonesty) may conflict with mental health treatment strategies. Treatment strategies and activities should be continually reviewed and modified, as necessary, to reflect a victim's ongoing safety-related needs.
- Mental health providers should cultivate cooperative relationships with domestic violence service providers, provide victims with accurate information about available domestic violence residential and nonresidential services, and should actively assist victims in making the linkage with those services, if they so desire.
- Mental health providers should conduct initial, individual screenings for domestic violence before making referrals to or engaging couples or families in couples counseling, family therapy, or mediation; and should conduct ongoing screening and assessment for domestic violence with couples or families who are engaged in these services.
- In the event that an abuser and a victim are being treated or housed at the same site, and the victim has independent knowledge of her partner's participation in mental health treatment and raises it with the mental health provider as a safety-related concern, full consideration should be given to transferring one or the other client to a different site, in consultation with the victim.
- With the consent of the victim, mental health providers should inform all staff when a client has an order of protection and should keep a copy of the order of protection in a confidential on-site location.
- ABUSER ACCOUNTABILITY
- Routine screening for domestic violence should be conducted with all male clients to determine if they are perpetrating abuse in their intimate relationships.
- Mental health providers should reinforce abusers' sole responsibility for their violent and coercive behavior as the issue emerges in any forum, including individual and group counseling sessions.
- If a court orders an abuser into mental health treatment as a response to the individual's violent and controlling behavior in an intimate relationship, the mental health provider should respectfully refer the case back to the court with a recommendation for the imposition of appropriate criminal or civil justice sanctions.
- Mental health providers should maintain thorough and accurate case records.
- In the case of a victim's partner coming on-site, mental health providers should activate appropriate in-house security measures. If the abuser refuses to leave, and/or engages in acts that threaten the safety of staff or clients and/or that violate an existing order of protection, the police should be called. Mental health treatment providers should consider the input of the victim in developing a response plan but also maintain a responsibility to respond quickly to the safety-related needs of staff and other clients.
- Mental health providers who have a legal duty to warn, should take appropriate steps to protect the intended victim when they have direct knowledge of a client's intent to do harm to that intended victim.
- SYSTEMS' RESPONSIBILITY
- Mental health providers should receive comprehensive and ongoing training on domestic violence and the ways in which victims and abusers may present to the mental health treatment system.
- With the appropriate releases of information, case management for victims should be coordinated, as appropriate, with domestic violence service programs, and the health care, mental health, child welfare, and legal systems.
- All mental health facilities should develop written policies and protocols in collaboration with domestic violence service programs that should be widely disseminated. To the fullest extent possible, staff of these facilities should be included in the development of these policies.
Universal screening of female clients for domestic violence should be part of all intakes, especially since conventional clinical questions may miss important indicators of abuse and battering. Most forms of domestic violence and abuse are chronic in nature and there are many factors that influence the nature of the clinical picture seen, such as the specific acts and temporal pattern of her partner's abuse, the victim's psychological make-up, the victim's developmental stage, and the availability of external resources. Direct assessment for domestic violence is essential to understanding the clinical presentation.
Frequently, the presenting problems of children are related to or a result of domestic violence, including a wide variety of somatic, behavioral, or emotional problems. Proper and early identification of domestic violence as a factor helps to ensure both appropriate diagnoses and treatment plans.
Information obtained from the victim, as well as any pertinent observations, should be carefully and fully entered into the client record. Any future or pending legal proceedings might very well draw on the information recorded in the case record. The failure to document the abuse may be used by the perpetrator to deny its existence, or the provider may be held liable for failing to recognize the abuse and respond to the victim's complaints. Client statements are best recorded through the use of direct quotations, when possible. Injuries should be either photographed, or detailed in careful schematic drawings. The fact of abuse and any sequelae noted should become part of the master problem list.
While thorough and accurate case recording is necessary, be alert to the potential harmful uses of the information in the case record, such as an abuser using a partner's mental health diagnosis as evidence of the victim's unfitness as a custodial parent.
The ability of victims to follow through on mental health treatment plans can be compromised by the actions of their abusive partners. Victims should not be expected to comply with mental health treatment plans that require them to do things that directly or indirectly endanger them. For example, a goal for a client in mental health treatment might be to increase their independence through becoming more assertive, setting clear limits and personal boundaries, and/or expanding their social networks. For victims, these behaviors may, in fact, precipitate increased violence from their abusive partners. Abusers are often resistant to their partners' attempts to seek help of any kind and may increase their use of violence and threats in order to reestablish control. The consequences of treatment plans should be evaluated with regard to immediate and long-term safety.
Victims with histories of psychiatric illness might have even greater difficulty in getting safe or planning to leave their violent partners. A victim might rightfully fear the abuser's threats of institutionalizing her and of losing custody of her children. She might not have outside support from family, friends, and other resources. Safety-planning and an expansive identification of options is critical. (See Guiding Principles, 1.d.)
In some cases, medication may be indicated and might support a woman's attempts to become safe. Some medications, such as psychotropic drugs, however, also have the potential to impair a woman's ability to assess risk and respond accordingly. Medications should be prescribed only after careful assessment by the professional of both a victim's medical needs and safety-related needs, and should be re-evaluated on a regular basis. Frequently, once a victim is safe, presenting symptoms dissipate without medication.
The safety-related concerns of victims do not necessarily remain constant. As a result, victims may attempt to protect themselves from the violent and coercive acts of their partners in ways that conflict with agreed upon recovery strategies. A victim's use of survival strategies related to safety should be supported and encouraged and not seen as a failure to comply with the mental health treatment plan, but as an indication that the treatment plan needs to be reviewed and modified.
Even when women are receiving treatment for mental health problems, domestic violence service providers can often lend additional support for women. For example, mental health providers can refer women to peer support group meetings, if desired and appropriate. Inpatient providers should routinely include referral to local domestic violence programs as a part of discharge planning.
Since many domestic violence service providers are not equipped to deal with victims experiencing serious emotional distress, mental health providers should also know what restrictions may exist on the provision of domestic violence services.
Providers should conduct a thorough assessment for domestic violence before engaging couples in family or conjoint counseling/therapy. These assessments should be conducted with each individual in private. In cases in which domestic violence is identified or suspected, these modalities should not be used. In cases in which the domestic violence is not identified in an initial screening, but is recognized or exposed later in the intervention process, providers should develop strategies for terminating the family or conjoint therapy without further endangering victims. (See Guiding Principles, 1.i.)
Client transfers in these circumstances may or may not be in a victim's best interests. Providers should confer with the victim to determine the safest course of action and take the steps necessary to respond to her safety-related needs. If it is a victim's judgment that a transfer of either partner may, in fact, increase her danger, the providers should investigate the feasibility of alternative measures to increase safety for the victim, such as limiting the abuser's access to the victim by scheduling appointments for both parties at different times, alerting security staff of the situation, arranging for security escorts when appropriate, etc.
It is helpful for staff of the mental health treatment program to be informed and/or have access to information regarding program clients who have orders of protection so that they will be prepared to take appropriate action regarding enforcement of the orders, if necessary. With a victim's consent, this information should be made available to all staff even if they do not have direct program responsibility for a particular client.
While mental health treatment is not recommended for responding to abusers' use of coercion and violence in their intimate relationships, screening male clients for domestic violence can be helpful. Awareness that a client is an abuser creates an opportunity for the mental health provider to provide information and education to the abuser about his abusive behavior (see 2.b. below). In addition, such awareness can assist a provider in developing a treatment plan for whatever the presenting mental health issue is, in a way that does not undermine an abuser's responsibility for his coercion and violence and that does not undermine a victim's safety.
Domestic violence is behavior over which abusers have control and should never be justified, excused, or minimized. Abusers, even those with mental health problems, should be held accountable for their battering and abusive behavior. Alcohol/other drug treatment, mental health treatment, or psychiatric care should not be used as a response to an abuser's violent behavior, although such care may be warranted as a response to other issues prior to or in addition to an appropriate criminal or civil justice response. Providers should be aware of the socio-cultural roots of domestic violence and not perceive their treatment of an abuser as a "cure" for his violence. Further, providers should not do anything in providing services to abusers that might compromise a victim's safety.
Perpetration of violence and coercion in an intimate relationship is not a mental health issue. Mental health providers can best support the goal of abuser accountability by refusing to accept cases in which abusers are court-ordered into mental health treatment as a response to their violent and controlling behavior.
The appropriate response of the courts in dealing with abusers is to impose sentences of incarceration, probation, restitution, or fine, or some combination of these. Where available, mandated participation in a Batterers Intervention Program may be part of such a coordinated sentence. Abusers should neither be referred to nor mandated to dispute mediation, mental health services, or substance abuse treatment as a response to the domestic violence. Providers in all of these systems should be referring the cases back to the court for appropriate adjudication.
Information obtained from the client, as well as specific observations, should be carefully and fully entered into the client record. Future or pending legal proceedings might very well draw on the information recorded in client records.
Abusers' threats should be taken very seriously and responded to swiftly and consistently. When there is firsthand knowledge of an abuser's threat to do harm, the victim and the police should be notified immediately, and the victim should be provided the local domestic violence service program hotline number and offered assistance with safety planning.
All mental health providers should be trained on the issue of domestic violence. The training should include an understanding of the dynamics of domestic violence, assessment tools, appropriate interview and intervention skills, and an adequate understanding of domestic violence resources, as outlined in the Guiding Principles, 3.a. In addition, mental health providers should also receive training that will help them identify the clinical clues and indicators of domestic violence in the mental health treatment setting. Training should be thorough and ongoing.
Case management and coordination is key to the success of victims in developing and implementing effective safety plans. It is essential that involved systems work together to ensure that mental health treatment and intervention goals support victims' attempts to be safe.
(37) American Medical Association, Diagnostic and Treatment Guidelines on Mental Health Effects of Family Violence, 1995.
