SUPPORTING SURVIVORS OF RELATIONSHIP VIOLENCE LIVING WITH SERIOUS MENTAL ILLNESS

Annie Peacock, MSW, LCSWA

Durham VA Medical Center

May 2nd, 2015

OBJECTIVES Increase competencies to identify and screen for

relationship violence when working with clients living with serious mental illness (SMI)

Learn strategies to better clinically intervene with survivors of relationship violence living with SMI

Identify specific treatment barriers faced by

survivors of relationship violence living with SMI

Gain strategies to empower survivors to understand the dynamics of abuse within their relationship and create safety for themselves within relationships

GROUP EXPERIENCES?

How comfortable do you as a provider feel in addressing the intersectionality of relationship violence and serious mental illness?

Extremely Confident Confident Not sure Not confident I have no idea what to do!

WHAT IS INTERPERSONAL VIOLENCE?

Interpersonal violence (IPV) is defined by the World Health Organization as any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship. Violence is considered the intentional use of physical force or power, threatened or actual, against another person that results in a high likelihood of injury and/or psychological harm or death.

World Health Organization, 2002

RELATIONSHIP VIOLENCE

Relationship violence is: a pattern of verbal, physical, emotional,

financial, psychological, and/or sexual abuse

within the context of a romantic relationship, during or after the relationship is over

When one partner uses abusive behaviors to assert power or maintain control over the other and there is an unequal distribution of power between partners

GROUP ACTIVITY: BRICK WALL

Take one of your post-it’s: Write a challenge you face or are concerned about facing when dealing with survivors of relationship violence who also have SMI.

Take your other post-it: Write a personal strength you have that helps you work effectively with survivors of relationship violence with mental illness.

Adapted from the Wisconsin Coalition Against Domestic Violence, 2004

PART I:DEFINING ABUSE AND CLINICAL CHALLENGES

RELATIONSHIP VIOLENCE AND SERIOUS MENTAL ILLNESS Women with disabilities are at an increased rate of all types of abuse

including physical, emotional, sexual and verbal abuse Austin, Lewis & Washington, 2014

82% of women diagnosed with serious mental illness reported a lifetime incident of physical abuse and 69% reported a lifetime incident of sexual abuse Rice, 2009

Sample of 5,326 women in NC found that women with disabilities were significantly more likely (1.5% vs .6% ) to have been sexually assaulted in the last year

Martin, Ray, Sotres-Alvarez, Kupper, Moracco, Dickens, Scandlin, & Gizlice, 2006

A review of 11 studies focused on serious mental illness and victimization found that women had a 13-19 fold increase in experiencing violence compared to women in the general population.

Du Mont & Forte, 2014

Study of men and women with SMI in two states found that 26% of men and 64% of women had been sexually asaulted at some point in their lives. 49% of men and 37% of women had been physically attacked with a weapon.

Goodman, Salyers, Mueser, Rosenberg, Swartz, Essock, Osher, Butterfield & Swanson, 2001

EXAMPLES OF RELATIONSHIP VIOLENCE

National Center on Domestic and Sexual Violence. Power and Control Wheels. Austin, TX. www.ncdav.org

GROUP ACTIVITY

Myths and Assumptions Exercise I need 12 volunteers With the people around you, discuss the

following questions: “What are societal assumptions and myths

about survivors of relationship violence with serious mental illness?” 

What myths or assumptions do you think survivors with mental illness have about providers?

Adapted from the Wisconsin Coalition Against Domestic Violence, 2004

BARRIERS SURVIVORS FACE WHEN DISCLOSING ABUSE

Group question:

Why might it be difficult for a survivor with SMI to leave a relationship?

BARRIERS SURVIVORS FACE WHEN DISCLOSING ABUSE  Stigma of mental illness

Internalized belief of being an acceptable victim of violence

Fear of not being believed  

Isolation

PovertyRice, 2009

Austin, Lewis and Washington, 2014

Alaska Network on Domestic Violence and Sexual Assault, 2011

BARRIERS SURVIVORS FACE WHEN DISCLOSING ABUSE

Lack of psychoeducation provided by clinicians

Mental Health symptoms seen as “disruptive”  

Impaired detail recall

Fear of institutionalization

Cycle of referrals  Rice, 2009

Austin, Lewis and Washington, 2014

Alaska Network on Domestic Violence and Sexual Assault, 2011

DIFFICULTY PROVIDERS FACE IN SUPPORTING SURVIVORS

Feeling forced to “vet” clients’ stories

Feeling overwhelmed at lack of resources for survivors with SMI

Seeing violence as inevitable to avoid burnout

Lack of knowledge about relationship violence

Balancing choice versus safety Rice, 2009

National Center on Domestic and Sexual Violence. Power and Control Wheels. Austin, TX. www.ncdav.org

WHAT KEEPS SURVIVORS IN ABUSIVE RELATIONSHIPS?

Connection Activity

13 volunteers

Come take a card and a piece of string. Read out who you are and the statement on your card.

Preston,2008

PART II:SUPPORTING SURVIVORS AS CLINICIANS

HOW TO ASK ABOUT RELATIONSHIP VIOLENCE

Ease into the conversation: Don’t rely on a formal screening tool

Iverson, Huang, Wells, Wright, Gerber, Wiltsey-Stirman, 2014

Be prepared to deal with paranoia:Express the reasons you are asking the

questionsEx: “I heard you say some things that sounded very scary. I want to check in to see if I can help.”

Communicate that you are trying to understand how they have come to understand the abuse

Offer hope that you might be able to figure out ways to increase safety

Sacks, 2015

POSSIBLE SCREENING QUESTIONS What, if anything would you like for me to know about your relationship? What, if

anything, should I know about you to make sure I can be the best social worker possible for you.

Does your partner ever call you crazy? How do you feel if that happens?

Does your partner ever give you too much or too little of your medication?

Does your partner ever say unkind things about your mental illness to other people?

Does your partner ever do things that make the symptoms of your mental illness worse, such as messing with your sleep at night or stopping you from going to see the doctor?

Does your partner ever tell you that you can’t talk to other people or keep you isolated from your family or friends?

Does your partner ever tell you that nobody will believe you if you talked about how they treated you?

Does your partner ever talk to your therapist or doctor without your permission and say things about you that you don’t feel are fair or accurate?

Does your partner ever tell you that he or she will have you committed if you disagree, try to leave or report them?

Does anyone have legal control over your money or decisions? What happens if you disagree with them about their decisions?

Adapted from Washington State Coalition Against Domestic Violence, 2010

BEST PRACTICES FOR PROVIDERS

Move past assumption that reducing SMI symptoms must be focus of treatment

Do not challenge hallucinations or delusions; Survivor safety is your number one priority

Do not be insincere

Help survivors navigate other systemsAlaska Network on Domestic Violence and Sexual Assault, 2011

Virginia Sexual and Domestic Violence Action Alliance, 2004

National Center on Domestic Violence, Trauma and Mental Health, 2012

BEST PRACTICES FOR PROVIDERS Reframe your understanding of psychotic or

symptomatic thought content!

Questions to ask: How does this symptomatic thought content make sense

to this survivor? What happened to trigger this response? How can I help

them find safer ways of coping that cause less grief? How can I help this person make the changes they want to

make to feel better about their relationship? How can hallucinations or other symptomatic thought

content help me connect with this survivor? What would this person need to cope and be safe

WITHOUT these symptoms?

Alaska Network on Domestic Violence and Sexual Assault, 2011

National Center on Domestic Violence, Trauma and Mental Health, 2012

WHAT HAS COGNITIVE PROCESSING THERAPY FOR DUAL PTSD/SMI DIAGNOSIS TAUGHT US?

 Psychotic thought content still helps us understand people’s perception of the world and stuck points

Providing validation for increased mental health symptoms

Always be asking yourself as a practitioner: what is this hallucination telling me about safety or how this person feels about themselves in the relationship?

Cognitive Behavior Thought for psychosis can also be used with other psychotic “stuck points” outside of relationship violence disclosure

Can be helpful to externalize particularly tough stuck points “You are having the thought that…” as a way to move towards action if survivor is very caught in psychotic thought content

Sacks, 2015

PART III:PROVIDING INTERVENTIONS AROUND RELATIONSHIP VIOLENCE FOR INDIVIDUALS WITH SMI

AREAS OF THINKING THAT CAN BE CHALLENGING FOR INDIVIDUALS LIVING WITH SMI

Domains measured by the Montreal Cognitive Assessment (The MOCA) Attention Abstraction/ problem solving Inhibition/ selective attention Fluency tasks Planning Immediate and delayed verbal and non-verbal

memory for facts and events Working memory Processing speed

Lapota, 2014

AREAS OF THINKING THAT ARE LESS CHALLENGING

Rates of forgetting

Recognition Memory (ability to recognize previously encountered events, objects, or people.)

Procedural memory (memory for doing things)

Working memory capacity- working memory has the ability to be improved upon.

Language (reading, spelling and vocabulary) Lapota, 2014

ADAPTATIONS FOR MEMORY DIFFICULTIES Write down info/psychoeducation about

relationship violence

Add details and examples

Have main takeaway points on the top of each page of psychoeducation provided

Repetition

Limit information provided per session

Provide cuesLapota, 2014

MODIFIED SAFETY PLAN

Safety and Wellness PlanThis plan is designed to help keep you safe! Remember to keep it in a safe place or with someone you trust.

Strategize: Secure extra money, important documents, medication, ID, children’s documents in a safe place or with someone you trust.

Other important documents for me to add:

I will keep them:

Develop: Develop a code with family or friends to signal for help (This could be a special word, text or call you make to someone.)

My code is:

Identify: Identify a safe neighbor to call, resources who can help.

People who can help me and their contact information:

MODIFIED SAFETY PLAN CONTINUED

Safety and Wellness PlanPlan: Plan an escape route from your house, where you will go if you leave, where you can hide valuablesMy escape route is:

Discuss: Discuss referral resources, local advocates, shelters, legal optionsThe most important resources and contact information for me are:

Avoid: Avoid rooms where weapons or dangerous objects are present (like the kitchen where knives are kept)I will avoid:

Tools: Take care of your mental health. Recognize vulnerability to emotions and substance use.Remember to HALT: Am I Hungry? Angry? Lonely? Tired? Take care of your mind and body!Use meditation, other tools you learned from therapy, or medications. Identify safe people to talk with who will support you.

My tools are:

Safe people who support me are:

Adapted from the Alaska Network on Domestic Violence and Sexual Assault, 2011

ADAPTATIONS FOR LANGUAGE DIFFICULTIES Repetition

Shorter but more frequent sessions

Visual handouts

Frequent Check-ins

Give time to respond

Cues can help to generate responses

Lapota, 2014

EXAMPLE: LANGUAGE DIFFICULTIESThe Merry-Go-Round of Violence

Violent incident

Apology PhaseCalm

Atmosphere of abuse

(Start here)

Tensions are building. You might feel like you are “walking on eggshells”

This could be a physically violent incident, could be you getting yelled at or humiliated

Your partner apologizes for the violence; they rationalize, minimize and deny the violence

Incident is “forgotten.” For the moment, no violence is happening

This cycle illustrates four stages that often occur when one person in a relationship is engaging in abusive behaviors.

ADAPTATIONS FOR DISORGANIZED SPEECH

Write down themes of violence disclosure on a board

Gently point out increased cognitive disorganization and the function it may be serving (avoidance); but also normalize this in context of abuse disclosure

Pay attention to what was being discussed before the disorganized speech started

Sacks, 2015

ADAPTATIONS FOR ABSTRACTION DIFFICULTIES

Provide specific examples

Role-play

Demonstrate the activity or skill or request you are making of a survivor

Lapota, 2014

ADAPTATIONS FOR EXECUTIVE DYSFUNCTION

Structure sessions Have an agenda written out, etc. Ask survivors

what they took away from each session.

Goals: Break down safety planning or other action steps to leave a relationship into smaller steps

Lapota, 2014

EXAMPLE FOR DIFFICULTY IN EXECUTIVE FUNCTIONING

Safety Plan Action LogThis week I will take the following actions on my safety plan:

1. 2. 3.

One thing I learned today is about how to stay safe in my relationship is:

One area of having a healthy relationship I want to learn more about next session/class is:

HOW TO HELP SOMEONE WHO IS NOT ORIENTED

If not oriented x 3 and/or if someone is homicidal, suicidal etc. you can still support their safety: When a survivor is not experiencing acute

symptoms, create Advanced Directive and Psychiatric Advanced Directive; update regularly

If doing WRAP planning, incorporate relationship safety into this plan

If you know the survivor well, obtain permission to notify inpatient staff who is able to safely visit, get information, etc.

For someone you have never met but have screened: Ask inpatient staff to screen when they become more

stable, or, if possible, follow up and screen yourself

QUESTIONS? Thank you!

WORKS CITEDAustin, B., Lewis, J., & Washington, R. (2014). Women with disabilities and interpersonal violence: a literature review. Journal of the National Society of Allied Health, 11(12). 42-55 

Alaska Network on Domestic Violence and Sexual Assault. (2011). Real Tools: Responding to Multi-Abuse Trauma. Juneau, AK: Edmund, D. & Bland, P.

Du Mont, J. & Forte, T. (2014). Intimate partner violence among women with mental health-related activity limitations: a canadian population based study. BMC Public Health, 14(51). Retrieved from: http://www.biomedcentral.com/1471-2458/14/51

Goodman, L. Salyers, M., Mueser, K…& Swanson, J. (2001). Recent victimization in women and men with severe mental illness: prevalence and correlates. Journal of Traumatic Stress, 14(4). 615-632. doi: 0894-9867/01/1000-061559.50/1

Iverson, K., Huang, K., Wells, S., Wright, J., Gerber, M., & Wiltsey-Stirman, S. (2014). Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration. Res Nurs Health. 37(4). 302-11. doi: 10.1002/nur.21602.

Lapota, Holly. (2014). Using Cognitive Screening Data in PSR Programming [Powerpoint slides].

Martin, S, Ray, N., Sotres-Alvarez, D., Kupper, Moracco, K., Dickens, P., Scandlin, D., & Gizlice, Z. (2006). Physical and sexual assault of women with disabilities. Violence Against Women, 12(9). 823-37. doi:10.1177/1077801206292672

National Center on Domestic and Sexual Violence. Power and Control Wheels. Austin, TX. www.ncdav.org

National Center on Domestic Violence, Trauma and Mental Health. (2012). Asking about and responding to survivors’ experiences of abuse related to mental health. Chicago: IL.

WORKS CITEDPowers, L., Hughes, R., Lund, E., & Wambach, M. (2009). Interpersonal violence and women with disabilities: a research update. VAWne: A project of the National Resource Center on Domestic Violence. http://www.vawnet.org. Preston, Tiombe. (2008). Working with Survivors of Sexual Violence: Issues of Mental Illness [Presentation Filming].

Rice, Elizabeth. (2009). Schizophrenia and violence: accepting and forsaking. Qualitative Health Research, 19(6). 840-849. DOI:10.1177/1049732309335390 Rice, Elizabeth. (2008). The invisibility of violence against women diagnosed with schizophrenia: a synthesis of perspectives. Advances in Nursing Science, 31(2). 9-21.

Sacks, Stephanie. (2015). Trauma Informed Care for People in Recovery from SMI [Powerpoint slides}].

Virginia Sexual Assault & Domestic Violence Action Alliance. (2004). Violence against women with disabilities: A study of sexual assault and domestic violence among women in Virginia who have mental illness and/or cognitive disabilities. Richmond, VA. www.vdsalliance.org.

Washington State Coalition Against Domestic Violence. (2010). Safety Planning for Domestic Violence Victims with Disabilities. Seattle, WA: Hoog, Cathy.

Washington State Coalition Against Domestic Violence. (2010). Screening Practices for Domestic Violence Victims with Disabilities. Seattle, WA: Hoog, Cathy.

Wisconsin Coalition Against Domestic Violence. (2004). Interactive training exercises on abuse later in life. Madison, WI: Brandl, B. & Spangler, D.