Northern Europe

Case 20

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Effectiveness of a Domestic Violence Perpetrator Programme (DVPP)

Note:  

Respect is a national Domestic Violence charity working with the perpetrators
DVPP: Domestic Violence Perpetrator Programme
ISS: Independent Support Service associated with the DVPP

Objectives

  1.  To show the effectiveness of a DVPP in stopping domestic violence at its source, by changing behaviour and managing the risk of perpetrators.
  2. To show the impact on children of domestic violence.

 

Narrative

A family safely together

Jason rang the Respect helpline following an incident of violence where he had grabbed his partner Elly by the hair and thrown her to the floor, causing bruising to her face and a sprained wrist. This was not the first time Jason had been violent but it was the first time Elly had been visibly injured.

The Phoneline workers spent some time talking with him about what had happened and then referred him to a local DVPP. Elly was initially reluctant for Jason to involve outside agencies. She felt that she and Jason had a good family and a good way of life. They both had successful jobs and two children together. She felt ashamed at admitting that she was a victim of domestic violence as she always imagined this was something that happened to other people. Nonetheless, when ISS contacted her, she agreed to regular updates about Jason’s progress.

On the programme, Jason quickly learned to be non-violent, but he struggled to be non-controlling.

Jason was asked to conduct a re-enactment exercise in the group. With the guidance of DVPP workers, he re-enacted the worst incident of violence he had committed, step by step, stopping just before he used violence. Until this exercise he had always maintained that the children had never been aware of the abuse. However, during the re-enactment he had to account for the children’s whereabouts and it quickly became obvious to him and the group that the two children were aware and very distressed by him hurting their mother.

This was an important contributory factor in getting Jason to end his verbal and emotional abuse. He had already developed an increased awareness of his own stresses. Further awareness of the effects of his behaviour upon the children as witnesses to violence helped positively motivate Jason to remain non-abusive. This was confirmed by the ISS contact with Elly and by the end of the programme Jason had achieved a sustained period of non-violent and non-abusive behaviour. Elly felt that she and the children were safe to continue living with him, knowing that the ISS was there, should things change.

Learning points

  1. Women are often reluctant to disclose abuse, because they are ashamed. Having children and not wishing to ‘rock the boat’ is another reason to remain silent.
  2. Domestic violence and abuse is more commonly associated with poverty or hardship , but    can occur in any social class.
  3. Knowing that children are aware of their father’s abuse of their mother is a very important factor in changing the perpetrator’s behaviour. Many men are not aware of the distress they are causing their children.
  4. Children from families where domestic violence has occurred are more likely to become perpetrators themselves
  5. Without the DVPP/ISS it is  more likely that domestic violence will continue, perhaps leading to more serious violence, greater impact on the children, police call-outs, and involvement of the criminal justice system and health services.  Recurrence of domestic violence with a new partner is a real risk.

 

Acknowledgments: This case has been adapted from cases from the UK charity
Respect, with their kind permission.

 

Case 19

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A typical case of the elderly domestic violence in Finland

Objectives

  1. To illustrate the family dynamics in a case of elder abuse.
  2. To show how financial problems and alcohol abuse by the caregiver can trigger abuse, one of the more common forms of elder abuse
  3. To illustrate the value of a multidisciplinary team in the assessment and care of an abused person.

Narrative case:

A 79 year old woman, living with her son in a 2-room apartment, came to the day clinic [1]. The patient said that she fell over her rollator and bruised herself the previous evening. She had difficulties breathing, pain all over her body and was sad, shaking, meanwhile making no eye contact during talking [2]. She started to cry on a number of occasions during the conversation and examination. The doctor, a specialist in geriatric medicine, examined the patient and was surprised by the number of bruises and hematomas on her body and left cheek and orbit, where later a fracture of the cheek bone was diagnosed. There were also some bruises on both forearms. On x-ray examination, multiple old rib fractures were found. From previous documentation it was found she was examined earlier due to a falling problem, with no orthostatic reaction and she did not appear to be using prescribed  blood pressure lowering drugs. The patient denied alcohol consumption. Domestic violence is suspected by the examining doctor.

During treatment, the patient was found to be suffering from malnutrition and weighed only 45 kg with a plasma albumin well below normal. She refused to eat and expressed wishes of wanting to die [3]. Her cognitive status was defined by tests as mild cognitive impairment [4]. When carefully asked about what happened on the night prior to hospital admission, she confirmed that her son abused her and he had come home drunk late at night. She says that the relationship with her 49 year old son had deteriorated lately due to his alcoholism. Her son is often out of the house. He has been unemployed [5] for quite some time and threateningly demanded that she shared her small pension with him. Lately, the patient had on a number of occasions refused to give her money away because she was afraid [6] her son would simply drink more. Whilst telling this fact,the patient started to cry bitterly. Later in conversation, it came out that for about two years her son physically abused his mother regularly.

This case was discussed by a team, consisting of the medical doctor, nurses, social worker, physiotherapist and functional therapist [7]. A guardian for the patient’s economic interests was organized. The patient received supportive psychotherapy to deal with the problem and the social worker organized separate living facilities for the mother and son (mother was able to stay in her own home). Additionally weekly contact with other elderly people was organized by the city council and the local church. Our patient also has regular (three times weekly) visits by the nurse from the local health centre in order to support her to be able to stay and function at home (regular medicine usage, buying together products from the local store, etc). As the patient experienced strong fear reactions towards her son, a temporary restraining order was put in place  [8].

 

Learning points:

[1] The WHO has identified various risk factors connected with elderly abuse such as  shared living which was the case here. The apartment in this case was quite small and there is likely to have been  a lack of privacy for both the patient and her son.

[2] EASI, the Elder Abuse Suspicion Index (see appendix) lists various signs that may indicate abuse such as poor eye contact, a withdrawn nature and malnourishment. Most patients refuse to report the abuse; they are ashamed or are afraid of the perpetrator. Another problem is that in hospitals the patient usually does not know the physicians and the lack of trust also prevents them from telling the truth.

[3] Elder abuse does not only cause physical injuries, but can also lead to depression. Patients see no possibility of escape. The patient is depressed and rejects food and wishes to die.

[4] A weak elderly patient or patients with illnesses as well as mental problems are more likely to experience abuse.

[5] Here we see the typical case of elderly women abuse: threats and physical violence based on economical abuse, which gets worse with time. The son has financial problems and is unemployed which might lower his self-esteem. Caring for his mother might be too much for him.

[6] The son is alcohol dependent, which might be triggered by his current unemployment and the worsening financial situation. As the abuse worsens the situation, he is caught in a vicious circle now depending on his mother`s pension which she refuses to share. Dependence on someone is also considered as a risk factor leading to elderly abuse.

[7] This is an excellent example of a positive outcome – a team of various specialists discuss the problem and find a solution, thereby ending the circle of violence. Not only physicians but a multi professional team including a social worker and a legal guardian for the patient’s economic interests to find the best possible solution.

[8] The problems are solved but it is important to consider whether the patient was able to live on her own which might not always be the case. The WHO says that a good network of physicians, nurses and social workers is necessary to tackle the problem of elderly abuse as well as self-help groups for victims, safe houses and shelters.

 

To summarize: this case demonstrates these issues:

 

  1. The loss of an older person’s independence can result in a vulnerability that makes them more at risk of abuse.
  2. Social factors such as unemployment or financial stress are other factors in abuse scenarios.
  3. In some situations, the abuse can be so severe that family breakdown occurs.
  4. Alcohol abuse can be a factor in elder abuse, as in other forms of Domestic Violence.

 

Background information:

Finnish population studies tells us that 40% of women 15 age and older become victims of physical or sexual violence. Forty percent of women who live in a long relationship are abused by the spouse (Heiskanen & Piispa 1998).

 

Family abuse is existing in all social groups and the research on the reasons for it, is undeveloped. Risks for family abuse usually are: mutual dependence on each other, living together, social isolation. Economic difficulties and borderline poverty increase the burden on the family in general, weaken female position in the family and damage men ego.

 

In Finland about 50 women die yearly because of the violence directed to them and 2/3 of those die as victims of the domestic violence. Sufferers of the domestic violence, who commit suicide, are left out of these statistics. Restraining order procedure was adopted in Finland in 1999.

 

Elderly women can be subjects to psychological, physical, sexual and economical abuse. In 70 % of the cases abuser is child or spouse. The most common type of abuse of the elderly woman is economical. Special form of abuse is refusal of the family member to help or to treat elderly when elderly is totally incapable to take care of herself. To leave without help when help is needed is an abuse. Victims of the domestic violence use more health system services than other population, but elderly usually are cautious to break the taboo. They experience physical and communicational difficulties in approaching health system, but often shame, guilt and even protection of the family member are on the way.

 

Here we see typical case of the elderly women abuse, threat and physical violence based on economical abuse, which got worse with time. Situation was prolonged and got out of hands because elderly women had physical and psychological weakness, did not want to disclose problems with her son, was ashamed of his alcoholism, and somehow, felt responsible for his behavior.

 

References:

 

  1. Heiskanen, M. and Piipsa, M. Faith, Hope and Battering: A Survey of Men’s violence to Women in Finland, Helsinki, Statistics Finland

 

Case 12

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Children are at serious risk in households where there is domestic violence

Objectives

  1. To show how children who live in households where there is domestic violence are seriously at risk and need child protection.
  2. To illustrate how parents can manipulate health care professionals and deliberately set out to deceive them
  3. To demonstrate the need for all agencies involved with children to share information and to ensure it is formally documented.

Narrative Case

This case is about Daniel a 4 year old boy and his 27-year-old-mother Ms. Luscak, who has had four different partners and did not seem able to detect abusive relationships or learn from past experiences [1]. This was made worse by her alcohol misuse [2] and occasional violence towards her partners. Originally from Poland she spoke little English [3].

Daniel had 2 siblings, a 7 year old sister Anna by her first partner, and a 1 year old brother Adam by her fourth partner, Mr. A.  On 27 different occasions, the police were called to domestic violence incidents often complicated by both parents being drunk [4]. On 2 occasions Daniel’s mum took overdoses with the intention of committing suicide [5]. She suffered a number of serious incidents with partners including attempted strangulation, being threatened with a knife, suffering a hand fracture and rape allegations. When asked to press charges she withdrew her statements [6]. On numerous occasions the children were judged not to be at risk and left with the parents with sometimes children’s social care not being informed [7]. The family moved house on a number of occasions due to inability to pay the rent [8].

When pregnant with Adam, Mr. A urged Ms. Luscak to have a termination. She missed 4 antenatal appointments. At one stage she was hospitalised and Mr. A took the drip out of her arm and she self discharged. Ms. L phoned the midwife and told her there was  domestic violence, despite previously denying this fact to healthcare professionals [9].

In January 2011 Daniel had a spiral fracture to the left arm [10] reported as due to jumping off the settee with his sister the previous day. Bruises on his shoulder and lower tummy were said by his mother to be due to falling off his bike regularly. Meetings of health care professionals took place but the long history of domestic violence was not considered.[8] In September 2011, Daniel started school. There were frequent absences as for his sister Anna. On a number of occasions different members of staff noticed injuries including black bruises around the eyes, blood spots on the face, severe marks on the nose, spot bruises on the neck and forehead bruising.  They also became concerned as Daniel was getting markedly thinner and always seemed hungry, taking food from lunchboxes and rubbish bins. [11 ]His sister Anna was told by Ms L to say that Daniel had this pattern of behaviour at home, ate more food than she did and was constantly falling over. Daniel had poor English and although a cooperative boy was shy and reserved and did not talk to the teachers.

Daniel saw a Paediatrician in February 2012 who was unaware of the school’s concerns.  His mother was very convincing that Daniel had an eating disorder and fell over a lot. Tests for medical conditions were initiated.  Three weeks later Daniel died. At post-mortem he was found to have high sodium levels and over 40 injuries including an acute subdural haematoma and an older smaller one.  His mother and stepfather have been convicted of Daniel’s murder and his 2 siblings are in foster care. Daniel had been subject to the most appalling abuse including being starved at home, fed salt to make him sick if school said he had taken food, put in cold baths nearly drowning on one occasion, locked in a box room with the handle taken off the door, had a soiled mattress and urine soaked carpet. He had physical punishments given by his stepfather of situps for 1 hour, standing in the corner, squats and running on the spot which were planned in advance. He had no toys.[12] His sister Anna had tried to protect him as much as possible including physically. She confirmed that Daniel had been hit “many,many times” by the stepfather.

 

Learning Points

[1] Children in households with domestic violence are at serious risk and must be thought about carefully. There is a strong association between witnessing DV and severe PTSD symptoms: withdrawal, clinging, regressive behaviour, hyperactivity, aggression, difficulties in concentration (Kilpatrick et al, 1997).  Child witnesses are much more likely to grow up to be either victims (females) or perpetrators (males).

[2] This is a typical pattern in DV: alcohol and/or drug abuse leads to fighting and then reconciliation.  Often the man feels overcome with remorse after beating the woman and there are pleas for forgiveness, promises to reform, lovemaking and then further cycles. The perpetrator is often very loving and repentant following a violent outburst and this intensifies the partner’s attachment to him.

[3] Abuse of children is more prevalent in socially isolated or disadvantaged families, with alcohol and drug abuse and with domestic violence. This case has all these risk factors including the mother speaking little English.

[4] Every minute in the UK, the police receive a call from the public for assistance for domestic violence. This leads to police receiving an estimated 1,300 calls each day or over 570,000 each year.  However, only 23-35% of incidents of domestic violence are reported to the police.

[5]  Domestic violence commonly results in self-harm and attempted suicide.  Abused women are five times more likely to attempt suicide and one third of all female suicide attempts can be attributed to current or past experience of domestic violence.

[6] The low rate of conviction in cases of domestic violence can be attributed to the victim’s inability or unwillingness to give evidence (Cretney and Davis 1995).

[7] Interagency communication is vital and children’s social care should always be informed. In all the landmark cases in recent years in the UK, there has been lack of communication between agencies (Lord Laming 2003).

[8] Moving house several times is a typical pattern seen and the mother may lose all her possessions

[9] Domestic violence increases during a pregnancy and is the commonest cause of injury in pregnant women. Men often feel threatened by the prospect of having a child – economically they have little to offer and emotionally it means one more person to be cared for. This intensifies the man’s feelings of worthlessness and he defends against this by being more angry and violent. Bacchus (2004) reported 23% of women receiving care on antenatal and postnatal wards had a lifetime experience of domestic violence, and 3% had experienced violence in the current pregnancy.

[10] The possibility of abuse needs to be considered with spiral fractures and a judgment made as to whether the suggested mechanism of injury is plausible. In this case the issue was not considering other red flags i.e. the bruises on the abdomen which are unusual and for which there needs to be a clear explanation and the history of domestic violence.

[11] This eating behaviour is grossly abnormal and needed communicating to health care professional eg school nurse or general practitioner. Again there is lack of communication between different professionals.

[12] Health care professionals need to be able to “think the unthinkable” – this is a catalogue of abuse which if this was not a real case many would think was not possible

Background information

Background information on domestic violence

This is defined as abuse between persons in an intimate relationship, independent of gender, sexuality or marital status.  The term usually excludes abuse of children and the elderly.

Prevalence:

  • One incident of domestic violence is reported to the police every minute in the UK
  • On average, 2 women a week are killed by a current or former male partner.
  • 23% of women experience DV in their relationships at some time.
  • 45% female homicide victims are murdered by their partners. (Australian Bureau of Statistics: Women’s safety survey, 1996.) Women presenting to ER (Australian study)
  • 49% had experienced DV, 40% in the last 12/12.
  • 25% had a history of childhood abuse plus adult DV (Roberts et al, 1998).

 

Background of risks to children of domestic violence

Unicef figures estimate that globally the number of children exposed to domestic violence is 133-275 million. This varies by country: Developed countries 4.6-11.3million,

SubSaharan Africa 34.9-38.2 million and South Asia 40.7 – 88 million. At least 750,000 children a year witness domestic violence (Department of Health UK). Estimates vary from 30%-66% children are abused either physically or sexually by the same perpetrator. Children are completely dependent on adults and all children witnessing domestic violence are being emotionally abused

Children react in various ways to living with a violent person. Age, race, sex, culture, stage of development, and individual personality affect response. Children can be affected by tension, witnessing arguments, distressing behaviour or assaults. They may get caught in the middle of an incident, sometimes trying to make the violence stop; they may be in another room but be able to hear the abuse or see their mother’s physical injuries following an incident of violence; or they may be forced to take part in verbally abusing the victim. They experience a range of emotions including that they are to blame, anger, guilt, being alone, frightened, powerless, or confused. They may have ambivalent feelings, both towards the abuser, and towards the non-abusing parent.

Effects of domestic violence on children include:

    • Anxiety and depression
    • Difficulty sleeping.
    • Nightmares or flashbacks.
    • Physical symptoms such as headaches and abdominal pain
    • Enuresis
    • Temper tantrums
    • Behave as though they are much younger
    • School problems including truanting, sometimes staying at home to protect their mother
    • Aggression
    • Withdrawal from other people due to internalizing the distress
    • Lowered sense of self-worth
    • Start to use alcohol or drugs.
    • Self-harm eg overdoses or cutting themselves.
    • Develop an eating disorder.
    • Affecting social relationships – they may feel unable to or are prevented in bringing friends to the house

 

References

  1. Bacchus L, Mezey G, Bewley S, Hawort A, (2004) Prevalence of domestic violence when midwives routinely enquire in pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 111; 441-5.
  2. Cretney A, Davis G. (1995) Punishing violence. Routledge, London  
  3. Family Rights Group: www.frg.org.uk
  4. Lord Laming (2003). The Victoria Climbié Inquiry https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf
  5. Mind ‘How to parent when you’re in crisis’. http://www.mind.org.uk
  6. Mullender, A. and Morley, R. ‘Children living with domestic violence’ (London: Whiting and Birch).
  7. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from http://www.rcpsych.ac.uk/info/young.htm).
  8. NSPCC Children living with domestic abuse
  9. http://www.nspcc.org.uk/help-and-advice/worried-about-a-child/online-advice/domestic-violence/domestic-violence_wda86312.html
  10. Parentline Plus.  Support for parents under stress www.parentlineplus.org.uk
  11. Radford L, Aitken R,  Miller P, Ellis J, Roberts J, Firkic A. Meeting the needs of children living with domestic violence in London Research report. 2011 http://www.nspcc.org.uk/Inform/research/findings/domestic_violence_london_pdf_wdf85830.pdf
  12. Royal College of Psychiatrists (2004) ‘Mental health and growing up, 3rd edition: Domestic violence: Its effects on children’ Available from http://www.rcpsych.ac.uk/info/young.htm
  13. Save the Children and  Women’s Aid services.  Safe Learning – an insight into children’s experiences of domestic violence and how these may affect their learning, 2006
  14. Serious case review: Daniel Pelka http://www.coventrylscb.org.uk/dpelka.html
  15. The Hideout website
  16. http://www.thehideout.org.uk/under10/adults/effectonchildren/default.aspa
  17. UNICEF: behind Closed Doors the impact of domestic violence on children
  18. http://www.unicef.org/protection/files/BehindClosedDoors.pdf
  19. Women’s aid organization  – Statistics on Domestic Violence http://www.womensaid.org.uk/domestic_violence_topic.asp?section=0001000100220036sionTitle=statistics
  20. Women’s aid organization – Children and domestic violence http://www.womensaid.org.uk/domestic-violence-survivors-handbook.asp?section=000100010008000100380001.