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Training Module for Applying Evidence-Based
Treatment to Families Experiencing Domestic
Violence

+ How Media Portrays
Domestic Violence

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National Coalition Against Domestic Violence
 One in every four women will experience domestic violence in her lifetime
 85% of domestic violence victims are women
 Females between 20-24 years of age are at greatest risk of nonfatal intimate partner violence
 Most cases of DV are never reported to the police
 The cost of intimate partner violence exceeds $5.8 billion each year
• $4.1 billion of which is for direct medical and mental health services

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 A systematic pattern of dominance and control within an intimate relationship
 The willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior perpetrated by an intimate partner against another

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 Affects individuals in every community, regardless of age, socioeconomic status, race, religion, nationality, or education background

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 Physical
• Pushes, shoves, slaps, hits, pulling hair, kicks, punches, restrains with force, choking, throwing objects, abandoning a partner in an unsafe place, using any item as a weapon
 Emotional/Psychological
• Ignoring feelings, withholding affection or approval, criticizing, calling a partner names, shouting, making decisions for the partner, controlling all actions, ridiculing beliefs or thoughts, manipulating, humiliating
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Sexual
Demeaning remarks about one’s gender, calling a person unwanted sexual names, forcing a partner to take off clothing, touch that makes one uncomfortable, objectification, insisting a partner dress more inappropriately, minimizing thoughts or feelings on sex, accusations of sexual activity with others

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*Having one or more of these does NOT automatically mean they are an abuser- things to keep in mind when beginning a relationship
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Questioning a partner’s behavior or motives
 Controlling who a partner speaks to, listens to
 Possessiveness
 Jealousy
 Lying, manipulating
 Secretiveness
 Imposition of his/her beliefs or opinions
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Belittling the partner’s opinions or beliefs
 Dislike or put downs of friends or family= isolation
 Is in a hurry to be romantically involved
 Unpredictable, erratic temper
 Physically aggressive towards others

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 Verbal mistreatment of others than in public (Dr. Jekyll/Mr.
Hyde)
 Blaming other for problems
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“Playful” use of force during sex
 Often is charming or charismatic/well liked in community
 Alcohol or drug use
 Invasion of privacy
 Reputation as womanizer/player
 Unreliable
 Cruelty towards animals or children
 Has different persona in private

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(Los Angeles County Board of Supervisors Domestic Violence Council, 2009)
 Myth #1: DV is just a momentary loss of temper
• Truth: True domestic violence is a conscious choice to exert power and control over someone using force. It is an ongoing technique.
 Myth #2: Domestic Violence only happens in poor families
• Truth: DV occurs throughout all levels of society. There is no evidence that suggests any community is free of violence.
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Myth #3: DV is just an occasional slap or punch that isn’t serious
• Truth: Victims are often seriously injured from acute battering.
 Myth #4: Heads of households have the right to control the people they support
• Truth: No person has the right to control another person or exert physical, emotional, or sexual force over another.

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(Los Angeles County Board of Supervisors Domestic Violence Council, 2009)
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Myth #5: The victim can always leave
Truth: It takes on average a woman 6-8 times to leave an abuser. Victims usually do not have a safe place to go and because of extensive history of relationship, victim has limited options
(money, friends, family, etc…). Sometimes it is safer for the victim to stay with the batterer for the time being than to try and escape. Creating a plan to leave can help victims stay safe and successfully keep away from the batterer.
o Over 75% of homicides cases involving DV occur when the woman has attempted to leave or has left her abuser (National Coalition Against Domestic Violence, 2011)
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Myth #6: If the batterer is truly sorry and promises to reform, the abuse is going to stop
Truth: Remorse and begging for forgiveness are usually part of the method batterers use to control victims (honeymoon phase). Batterers rarely stop battering without institutionalized intervention.
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Myth #7: If the violent episodes don’t happen very often, the situation is not that serious
Truth: Violence is always serious. Even if physical violence does not happen often (if ever), the threat of it remains a terrorizing means of control.
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Myth #8: Victims have the types of personalities that seek out and encourage abuse
Truth: There is no empirically supported evidence for this claim. Batterers are responsible for the abuse, not the victim.

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Concept from Wisconsin Coalition Against Domestic Violence

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 Anxiety
 Depression
 Posttraumatic Stress Disorder
 Isolation
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Inability to Trust
Fear of intimacy
Emotional detachment
Sleep disturbances
 Suicide Ideation  Flashbacks
 Low self-esteem  Dissociations
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Although fewer women in DV relationships have nonviolent partners and only experience psychological or emotional abuse, negative experiences not associated with overt violence can produce Posttraumatic Stress
Disorder
(Vitanza, Vogel, & Marshall, 1995)

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 Women experiencing more severe intimate partner violence (IPV) reported more physical health symptoms than those with less severe
IPV
(Woods, Hall, Campbell, & Angott, 2008)
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 IPV associated with physical problems including:
• Gynecologic problems
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Sexually transmitted diseases and infections
Central Nervous System problems
Back pain
Headaches
Fainting
Seizures
Hypertension
Abdominal Pain
Viral and bacterial infections
Chronic health problems

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 Higher levels of intimate partner violence were associated with more severe PTSD symptomology

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 A. The person has been exposed to a traumatic event in which both of the following were present:
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The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
The person’s response involved intense fear, helplessness, or horror.
 B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
• Recurrent or intrusive distressing recollections of the event, including images, thoughts, or perceptions
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Recurrent distressing dreams of the event
Acting or feeling as if the traumatic event were recurring (includes hallucinations, dissociative flashback episodes, sense of reliving the experience)
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

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C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect
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Sense of foreshortened future
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two
(or more) of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
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Difficulty concentrating
Hypervigilance
• Exaggerated startle response
E. Duration of the disturbance is more than 1 month
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

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Witnessing violence between one’s parents or caretakers is the strongest risk factor of transmitting violent behavior from one generation to the next
 Boys who witness domestic violence are twice as likely to abuse their own partners and children when they become adults
• According to Social Learning Theory

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 Children that witness violence in the home are more prone to:
• Aggressive or antisocial behavior
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Lower social competence
Poor academic performance
Less emotional health and wellbeing

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 Children witnesses
• Sometimes in line of fire
Wrong place, wrong time
Hiding (under bed, behind couch, top of stairs
Hear the blows and screams
See the wounds
See destruction of property

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 Risk factors for negative effects on children
• Severity
• Frequency
• Chronicity
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Numerous factors that play a role in children’s outcome of exposure to violence including:
• Temperament of child
• Resilience of child and parent
• Parenting has been identified as a key factor in affecting how a child experiences exposure to violence

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 Acknowledge that domestic violence has occurred
• Make speakable what is unspeakable
 Psychoeducation
 Acknowledge the consequences of violence on the family
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Identify each member’s response to violence
 Process thoughts and emotions generated by the violence
 People cannot fully heal from trauma if they are still in it
• Important to acknowledge the possibility of violence in the home and to prepare family for it

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Los Angeles County Board of Supervisors Domestic Violence Council, 2009
 Important phone numbers
 Friends and family
 Neighbors
 Places to go in emergencies
• Inside the home
• Outside the home
 Copies of important documents
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SS card
Birth certificates- adult & children
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Restraining/Protective Orders
Divorce Decree
Driver’s License/Car Registration or Pink Slip
 Items hidden in safe places
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Keys
Money

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“The availability of effective treatments, combined with pressures to reduce the length of psychotherapy, has encouraged many community agencies to begin adopting evidence-based practices”
 Goal of EBP: Use best, up-to-date research available to provide clinical care in order to diagnose and treat clients

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Similarities between practices used to treat family violence
 Primary focus of treatment is on decreasing negative symptoms associated with traumatic experience(s)
 Frequently incorporates the use of play
 Importance of involving non-offending parents or caretakers

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 Trauma re-exposure
 Psychoeducation
 Cognitive restructuring
 Emotion expression and regulation
 Social problem solving
 Safety planning

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 Created by Judith Cohen, Esther Deblinger, and Anthony Manarino
 Recognized nationally by the U.S. Department of Health and Human
Services as a model program
• Listed with the National Registry of Evidence Based Practices and
Programs as a scientifically supported intervention
(nrepp.samhsa.gov/index.asp)

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 Originally developed to treat PTSD symptoms in children and adolescents who experienced child sexual abuse
• Now adapted and evaluated to be used with youth who have experienced wide array of traumas including domestic violence, grief & loss, community violence, & natural disasters

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 Decrease posttraumatic stress reactions
 Build cognitive skills
 Gradual exposure to feared trauma memories
 Incorporate play with children
(Lang, Ford, & Fitzgerald, 2010)
• Play can be utilized to introduce many of the components and facilitate learning of skills

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 Psychoeducation and parenting
 Relaxation
 Affective regulation
 Cognitive coping
 Trauma narrative
 In-vivo exposure
 Conjoint parent-child sessions
 Enhancing safety and future development

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 Helping children and parents learn about trauma
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• Defining trauma
Effects of trauma
 Information dependent upon developmental level of child
 Focus on building rapport and trust, instilling hope
• Normalizing & validating reactions to trauma

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 Parenting strategies may include
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• use of praise reinforcement/reward systems selective attention contingency reinforcement time-out procedures active and reflective listening skills
 Assists clients in realizing that talking about trauma may cause distress but doing so in a manageable helpful way is necessary for a successful treatment outcome
(Rubin, 2012)
 Use of metaphors to explain why talking about trauma is important
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• cleaning out a wound gradually getting used to cold swimming pool water

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Relaxation Training
 Useful technique in handling stress and managing levels of emotional arousal
• Helpful for day-to-day stress as well as decreasing physiological hyperarousal that occurs in response to trauma reminders and while child develops future trauma narrative in sessions
(Briggs, Runyon, & Deblinger, 2011)
 Teach, practice, master
• Focused breathing
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• Visualization
Mindfulness
Meditation
Progressive muscle relaxation

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By: Kerry Lee MacClean
 Story to introduce concept of meditation and mindfullness
 Read story
 Create Mind Jars
 Teach deep breathing

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 Assist both children and parent in recognizing, identifying, appropriately expressing and effectively modulating emotions
 Build feelings vocabulary and awareness of intensities of emotions
 Connect and process specific emotions related to trauma

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 Learn connection between thoughts, feelings, and behaviors
• Teach cognitive triangle
 Recognize and understand the difference between helpful/accurate and unhelpful/inaccurate cognitions
 Create ability to generate thoughts that are more accurate or helpful than existing negative ones
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• Use thoughts and feelings from current behavior
Then relate information to thoughts related to the trauma
 Introduce techniques such as:
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• Positive self-talk
Thought-stopping

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 Goal is to break apart unpleasant associations between thoughts, reminders, or discussions of the trauma from overwhelming negative emotions
 Over course of sessions, child describes detail of trauma
• Writing or drawing a story, puppets, poem, song, book with chapters o Includes:
 first & last incidents of abuse
 how people found out
 worst part of the abuse o Woven through the story are thoughts and feelings about each section
 Cognitive processing: explore and correct cognitive distortions and errors in thinking

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 The written trauma narrative is reviewed with the child repeatedly to expose child to traumatic reminders
• Extinguish the child’s generalized fear and anxiety that is often associated with thinking or talking about the traumatic experiences (Briggs, Runyon, & Deblinger,
2011)
• Repeat same procedure with parents

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 Creating trauma narrative may be enough to overcome traumatic memories but not sufficient in helping children avoid inherently harmless stimuli that reminds them of trauma (Rubin, 2012)
• Connect fear of harmless stimuli to trauma
 Attempt to gradually overcome avoidance and improve daily functioning
 Little by little, gradually expose themselves to harmless stimuli beginning with something they can tolerate and implementing relaxation techniques when anxiety increases with exposure

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 Allow child to read trauma narrative to parent and allow parent to assist in coping techniques with child
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Previous to joint sessions, therapist and parents address parent’s worst fears and worries and are taught appropriate ways of responding to child’s narrative
 Therapist facilitates open communication about the trauma
• Promotes positive and open communication between child and parent

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 Child and caregiver learn skills that will add to and help to maintain the treatment gains that they have already made
(Rubin, 2012)
 Promote safety skills related to trauma experienced
• Safety plan
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• Ability to recognize internal and external cues to dangerous situations
Identifying people and places that provide safety

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 Treatment for trauma-exposed preschool age children
• Children under 5 are subject to higher rates of violence exposure in comparison to other age groups and suffer higher rates of injury and mortality after abuse and violence
(Grossman, 2000; as cited in Rubin, 2012)
 Listed in National Registry of Evidence-Based Programs and
Practices

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 Places value on child-mother relationship as therapeutic mechanism of change
• Attachment system is main organizer of children’s responses to danger and safety in first years of life
 Interventions target a change in maladaptive behaviors, support developmentally appropriate interactions, and guide child and mother in creating a joint narrative of the traumatic events while working towards their resolution
(Lieberman, Van Horn, & Ippen, 2005)

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 Promoting developmental progress through play, physical contact, & language
 Offering unstructured reflective developmental guidance
 Modeling appropriate protective behavior
 Interpreting feelings and actions
 Providing emotional support/empathic communication
 Offering crisis intervention, case management, and concrete assistance with problems of living

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Unique & Essential Aspects of CPP
 Play
 Child sensorimotor disorganization and disruption of biological rhythms
 Child fearful behavior
 Child reckless, self-endangering, and accident-prone behavior
 Child aggression toward a parent
 Child aggression toward peers, siblings, or others

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 Parental use of physical punishment
 Parental use of derogatory names, threats, or criticism of the child
 Relationship with the perpetrator/absent parent
 Ghost in the Nursery: The intergenerational transmission of psychopathology
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Angels in the Nursery: Benevolent influence in the parent’s past
 Saying Good-bye: Ending the session, terminating treatment

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“Don’t Hit My Mommy!: A Manual for Child-Parent Psychotherapy with Young Witnesses of Family Violence”
 Alicia F. Lieberman & Patricia Van Horn (2005)

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(identifying information has been changed)
Discuss in small groups
 Monica (28), 2 children: James (7), Victoria (4)
 Hispanic background, HS education, low SES, mom does not currently have a job, children and mother living with maternal grandparents
 Married for 8 years, husband is a mechanic, currently separated, husband incarcerated
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Children witnessed Monica be hit, pushed, verbally degraded, pulled by hair, etc…
 James (7) showing anger towards mom, pushing & hitting, biting & slapping
 Victoria (4) throwing temper tantrums, excessive crying, detached from others
 Mom having PTSD symptoms such as hypervigilence, trouble sleeping, flashbacks & nightmares
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What are some questions or concerns you would have at the beginning of this case?
What would be some treatment goals you would apply to this case? Specific interventions?
Any other information…

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Please fill out evaluation