Thursday, May 6, 2010

Clinician Interventions for Sexual Violence - Lindsay Barus

Sexual Violence is a pervasive public health problem in the United States for women of all ages, but pregnant adolescents are particularly susceptible. Of the 236,980 women who were victims of sexual assault (SA) in the United States in 2007, 55,110 were assaulted by an intimate partner,(1) although this statistic is likely under-representative given that SA by an intimate partner is less likely to be reported compared with SA by a non-intimate partner.(2) Data based on the National Women’s Study suggests that 5% of sexual assaults of reproductive-aged females (15-44 years) result in pregnancy;(3)theoretically, this would result in ~2,756 pregnancies each year assuming that women assaulted by intimate partners were of reproductive age.
SA by intimate partners usually co-occurs in the context of physical intimate partner violence (IPV)(4). 1 out of every 5 adolescent females report incidences of dating violence (5) and studies have shown a positive correlation between dating violence, sexual risk-taking and teen pregnancy.(6, 7) Research studies estimate the occurrence of various forms of IPV during teen pregnancy to range from 16% to 37%, (7-9) compared with 14% to 15.9% for women age 20 and older.(6, 8) IPV during pregnancy causes serious health risks to adolescents including vaginal bleeding, pre-term delivery, and low birth weight infants;(10) inadequate prenatal care utilization, poor nutrition and alcohol abuse.(11)
While a large amount of research regarding the prevalence of IPV in pregnant adult women has been conducted, there is a notable absence in the literature of studies focusing on the adolescent population. Although the American College of Obstetricians and Gynecologists recommends universal IPV screening, yet only an estimated 10-12% of physicians routinely incorporate it into their practice.(12) Physicians often don’t assess pregnant teens for IPV because they (falsely) assume 1) that teens safely reside with family members, and 2) adolescent intimate relationships are not as serious as those of adults. Even when physicians do assess for teen IPV, they often neglect to explain to teens the rationale behind their questioning and what they will do with any information they learn. This invariably stems from the fact that they themselves often do not know what to do with reports of IPV given by patients. Physicians often cite lack of formal training and institutional support as reasons why they remain immobile when faced with IPV in the clinical setting.
A recent study of medical school education in the U.S. found that only 50% of 4th-year students ever discuss IPV and less than half of those students think that IPV will be relevant to their future clinical practice.(13) If students are not taught the importance of IPV screening and are not given adequate time to practice their technique, how can they be expected to be screen patients when they become physicians? This is clearly evidenced by the findings of a study showing that only 1 in 3 14-20 year olds presenting to urban area adolescent health clinics were questioned by residents concerning IPV, even though most report they would have been amenable.(14)
In response to the opinions of physicians who describe lack of training, discomfort, and lack of an adequate social support system as the main obstacles in routinely screening patients for IPV, many hospitals are implementing training programs for physicians.(15) The Health Information and Education division of the California Family Health Council (CFHC) has proposed an IPV training curriculum for healthcare professionals entitled “Breaking the Cycle of Teen Intimate Partner Violence.” The goals of this curriculum are to educate adults regarding the prevalence of teen IPV, adolescent psychosocial development, and teach strategies for IPV screening and intervention. The intended goals of the program are admirable; however, the program ignores environmental factors unique to teen IPV, making screening difficult and intervention nearly impossible. The program claims to promote “resiliency” as one of its main goals, yet fails to encourage self-efficacy. Furthermore, by labeling potential survivors and survivors as “at risk” and “victims” respectively, the program may instill anger and shame in teens also defeating the idea of self-efficacy. The methods by which proponents hope to educate healthcare professionals about teen IPV are misguided, and in some cases may even be detrimental.
Environmental Factors Unique to Teen IPV
Studies show prevalence of IPV amongst adolescents compared to adult women.(12, 16, 17) Unfortunately, age, education level, and lack of social skills compound the risk of IPV for teens. Physiologically, adolescents appear identical to adults; however, in terms of cognitive development, this is grossly inaccurate. Using fMRI, it has been shown that maturation of the dorsal anterior cingulate cortex and the lateral prefrontal cortex (the areas of the brain responsible for control) is incomplete during adolescence. When combined with increased sensitivity in the ventral medial prefrontal cortex and the ventral striatum (comprising the “reward” pathway) this explains the propensity of teens towards risk-taking behavior.(18, 19)Educational level has also been cited as an individual risk factor for IPV, with more than half of post-partum females experiencing IPV having attained less than a high-school level education.(17)
In addition to being risk factors for IPV, these same factors (age, social status, education level) also hinder interventions. Pregnant adolescents experiencing IPV face additional risk factors due to their lack of social and legal autonomy. Estrangement from family and friends (due to the circumstances of the pregnancy) tends to result in inadequate support systems. Loss of family support further compounds their level of risk, because they are usually reliant upon family for housing and financial support. In these cases, they are often forced to rely on the violent partner for food and shelter. Escaping from an abusive partner is considerably more difficult for teens—many domestic violence shelters are unwilling to take minors, especially those with children. Furthermore, teenagers are generally less knowledgeable navigating the legal system than their adult counterparts and are often distrustful of healthcare practitioners, social workers, and other adults in positions to help.(8, 20) This is especially true considering that many pregnant teens have not forged meaningful relationships with a trusted adult and often fail to disclose abuse to clinicians for fear of not being believed, blamed, fear of losing their child to Child Protective Services, or fear of violent retribution from an abusive partner.(21)
Urie Bronfenbrenner’s Ecological Systems theory posits that both the individual processes occurring within a given environment and the interaction between processes must be considered in order to fully comprehend a situation.(22) Therefore, in order to successfully intervene in cases of teen IPV, one must take into account the environment of the adolescent. Many adolescents struggle with low self-esteem. While low self-esteem is not a predictor of pregnancy,(23) it is a risk factor for teen IPV.(16, 24)In addition to being an individual risk factor, Ecological Systems Theory would also suggest that the interaction between low-self esteem, risk-taking behavior, and peer influences is also significant when attempting to intervene in cases of teen IPV.
A successful intervention strategy must include components aimed at improving teens’ self-esteem. The teen should be told that she is a good, strong, intelligent young woman, and the violence she is experiencing is NOT her fault. Encouraging the teen to participate in a support group would likely help her develop a strong social support group and provide positive peer influences, which would ultimately decrease risk-taking behavior.(19)
Promoting Self-Efficacy
One of the objectives of the IPV screening/intervention curriculum proposed by the CFHC is promotion of self-efficacy among teen survivors. Albert Bandura believed that belief in one’s own ability to succeed at a given task was imperative to successful completion of that task.(25)Yet many adolescents have difficulty viewing a situation temporally--they only observe the immediacy of their own reality. They believe that they are powerless to escape an abusive relationship; this lack of self-efficacy can be prophetic. The problem with the CFHC curriculum is that it does not provide clinicians with a step-wise screening and intervention system. Teens have difficulty envisioning future events. Therefore, clinicians not only need to take a systematic approach to screening and intervention, they also need a model that allows for thought processes that are sometimes stable, but at other times dynamic.
James Prochaska and Carlo DiClemente’s TransTheoretical Model (TTM) takes into account that behavior change is a process. Utilization of this behavior model allows teens to develop timetables suited to her individual needs and regain the sense of control that is taken from her by an abusive partner. During the Pre-Contemplation stage, a teen may feel that the abuse is either not a problem or that she is helpless to stop the abuse.(26) It is during this stage that physician screening for IPV is key. While the teen may not recognize that she is being abused, the physician will. The curriculum should instruct clinicians to ask direct questions assessing the teen’s physical, sexual, and emotional health using plain language. Education is also key during this stage. The clinician should be instructed to discuss components of a healthy relationship with an intimate partner. At this stage the teen will not be ready to commit to any type of change; however, the clinician can tell the teen her options and make sure that she knows she has a trusted adult to confide in when she is ready.
Once a trusting relationship has been built between the teen and clinician, allowing for honest debate regarding the pros and cons of escaping the abusive relationship, the curriculum should prepare clinicians for stage two: Contemplation. The teen will realize that it is in the best interest of both herself and her child to leave the relationship even though she may be very reluctant to do so. That is alright—at this point the physician can discuss with the teen the steps she might take in the future, but no definite timeline needs to be implemented.
When the teen is ready to commit to a definitive plan and timetable, the Preparation stage begins. At this point, it is imperative that the clinician has the support of colleagues and outside resources. While all clinicians should be trained to assess, discuss, and intervene in instances of teen IPV and SA, a single person is rarely able to manage the variety of medical, social, and legal care a teen victim of IPV needs. The curriculum should discuss the importance of working together to develop a plan of action prioritizing personal safety. In order for that Action stage (stage 4) to be reached, it must be agreed upon by the teen, physician and the support group that the teen’s actions do indeed constitute positive, healthy behavior changes aimed at preventing further risk of abuse.
Maintenance (stage 5) can be conducted throughout prenatal, postnatal, and well-baby visits. It is essential that clinicians be taught to continually discuss IPV with the teen and be constantly vigilant regarding signs that she is feeling tempted to return to the abusive partner. Teens may have trouble asserting their independence to abusive partners or asking friends or other adults for help. In situations such as these, it may be beneficial to role-play assertiveness with the teenager.(9) At the same time, the previously established social support network should be helping the teen to become more self-confident in her ability to keep both herself and her child safe and more self-reliant upon her own instincts and judgments.(26) When the teen no longer feels compelled to rely on the abusive partner for social, emotional, or financial support, she has reached Termination (stage 6).
The Dangers of Labeling
During the screening portion of the CFHC curriculum, clinicians are instructed to “targeting clients determined to be at risk or victims” but this carries many problems. First is the problem inherent with labeling itself. Labeling Theory posits that an individual’s behavior is influenced by how they are judged and “labeled” by society (especially peers). Research has shown that once adolescents are subjugated to social groups by labeling, they often adopt the behavior associated with that label.(27)
Therefore, if a teen is labeled as a “victim”, there is a danger that she may begin to believe that she is helpless to escape her abusive situation. This may lead to even lower levels of self-esteem, which further increases her risk of IPV. (16, 24) Secondly, the curriculum fails to define “at risk” and fails to warn clinicians of the danger of stereotyping. In a study of pregnant Latinas and IPV, the authors found the correlation between women falling into traditional “at risk” screening groups and positive IPV screens to be low.(28) If IPV screens among these women provided false positives, it is entirely possible that the screens also missed many women who were currently suffering from abuse.
To remedy this problem, the curriculum should instruct clinicians to recognize risk factors according to validated, detailed screening instruments such as the10-item Family Stress Checklist (FSC) or the 19-action Conflict Tactics Scale (CTS).(17) Furthermore, the term “survivor” should be used rather than “victim”. According to Labeling Theory, a teen labeled as a survivor will adopt these behaviors, leading to greater self-efficacy. This, in turn, will hopefully lead to a better overall outcome for the teen and her child.
Studies have shown that clinician training programs for teen IPV screening and intervention increase the identification of survivors, as well as improve comfort and screening practices of residents.(29, 30) However, it is crucial training helps clinicians to build a therapeutic relationship
with IPV survivors that empowers and educates patients and does not demand disclosure.(24)Therefore, in order to improve CFHC’s proposed IPV training curriculum “Breaking the Cycle of Teen Intimate Partner Violence,” the following amendments should be implemented: incorporation of environmental factors unique to teen IPV, promotion of self-efficacy, and replacement of negative labels such as “victim” with more positive labels such as “survivor”. Lack of clinician education regarding screening and interventions for teen IPV constitutes a serious public health problem but if educational curricula grounded in social behavioral theories are implemented, the situation is far from hopeless.
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