Comprehensive Services

The connections and linkages between the causes and consequences of different forms of family violence have prompted some agencies and communities to develop coordinated strategies in treatment and prevention. Comprehensive service efforts can be administrative conveniences designed to integrate fragmented program activities, or they can represent systematic efforts to integrate diverse units into a coherent strategy focused on the treatment and prevention of selected forms of family violence. The desire for integrated, comprehensive, community-based programs that integrate services from health, social service, and legal settings has stimulated a variety of models and approaches that deserve careful analysis. The combination of services, however, creates a major methodological challenge in determining the effectiveness of a comprehensive approach, for it may be difficult to establish adequate measures for comparing the effects of the separate components of programs that involve multiple agency participation.

Three comprehensive programs were presented in the workshop, two of which were based in local criminal justice systems and the third located in a major urban hospital setting. The two criminal justice systems are focused on domestic violence interventions, while the hospital program seeks to use child abuse reports as an early screening device in identifying possible cases of domestic violence. These efforts suggest that there are multiple opportunities for system integration efforts to enhance responses by institutional systems to complex issues of human behavior.



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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP Comprehensive Services The connections and linkages between the causes and consequences of different forms of family violence have prompted some agencies and communities to develop coordinated strategies in treatment and prevention. Comprehensive service efforts can be administrative conveniences designed to integrate fragmented program activities, or they can represent systematic efforts to integrate diverse units into a coherent strategy focused on the treatment and prevention of selected forms of family violence. The desire for integrated, comprehensive, community-based programs that integrate services from health, social service, and legal settings has stimulated a variety of models and approaches that deserve careful analysis. The combination of services, however, creates a major methodological challenge in determining the effectiveness of a comprehensive approach, for it may be difficult to establish adequate measures for comparing the effects of the separate components of programs that involve multiple agency participation. Three comprehensive programs were presented in the workshop, two of which were based in local criminal justice systems and the third located in a major urban hospital setting. The two criminal justice systems are focused on domestic violence interventions, while the hospital program seeks to use child abuse reports as an early screening device in identifying possible cases of domestic violence. These efforts suggest that there are multiple opportunities for system integration efforts to enhance responses by institutional systems to complex issues of human behavior.

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP THE DULUTH DOMESTIC ABUSE INTERVENTION PROJECT Mary E. Asmus The City of Duluth, Minnesota, has developed a coordinated community response to domestic violence over the past 14 years. The Duluth Domestic Abuse Intervention Project (DAIP) has two primary goals: (1) to bring together various components of the justice and human service systems in the city of Duluth to intervene in domestic violence situations and to protect victims from further violence, and (2) to hold both individual perpetrators and the community itself accountable for the violence that historically has been acceptable in families. The Duluth project has been built upon three basic assumptions. First, it is the responsibility of the community, not the victim, to stop the battering in domestic violence. The victim is not responsible for bringing on the violence, and the larger community has a responsibility to intervene in domestic violence situations. Second, victims of domestic violence come from all parts of society, age, race, and class distinctions. Both “nice” and “not nice” women are beaten by their partners. As a result, victim-blaming practices are a form of collusion with the batterer and do not promote the confrontation of the violence itself. Third, a community cannot effectively intervene against domestic violence without understanding the power dynamics that accompany the violence. Individuals in a violent relationship are not equally powerful, autonomous beings who operate independently of each other. The power differentials between men and women that result from the historic right of men to punish and chastise women are recognized as important elements in the development of a strategy for intervention and prevention. THEORETICAL FRAMEWORK These assumptions and goals underlying the efforts of the Duluth DAIP have led to the development of a theoretical framework that guides the activities of the project. Seven activities have been identified as essential elements in the operation of an intervention program: A theoretical foundation for understanding domestic violence is necessary to understand the problem of domestic violence. Legal and mental health systems cannot be repaired without addressing fundamental errors in thinking about domestic violence

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP itself. System practitioners in community programs need to substitute a different theoretical foundation for victim-blaming practices, or the result may be a more efficient, but misguided, system of services. An intervention project should develop policies, procedures, and guidelines for the best practices in each agency. Basic protective measures should be the focus of policy development, and they should address considerations such as the necessity of shifting the burden of responsibility for stopping the violence from the victim to the community; preserving victim autonomy and self-determination; and eliminating broad discrimination while establishing policies that allow agencies to respond effectively to individual cases. A monitoring function is a necessary part of an intervention strategy. Case monitoring facilitates networking and information sharing among agencies in the community, a process that allows fragmented systems to have greater access to important information about particular cases. Case monitoring should hold both abusers and practitioners accountable to battered women and to community norms and standards. A coordinated community response facilitates the operation of multiple agencies as a unified system rather than as individual entities. Communication among therapists, probation officers, and prosecutors is one example of a coordinated response. An intervention program needs to provide basic services for women, including safe housing, financial assistance, legal advocacy, and educational groups. These basic services are fundamental to the development of all other activities, and they determine what policies and procedures are appropriate for women in a particular community. Thus, if a shelter did not exist in a community, then a law enforcement policy of mandatory arrests may not provide protection for women. Intervention with offenders requires the effective confrontation of abusers in a manner that is protective of victims. The program should acknowledge that most abusers are the products of a community 's values and address the broader context of practices that may encourage abusive behavior. Evaluation is a final essential activity of an intervention project. Evaluation studies need to assess the impact of the intervention on battered women, the impact of battered women on the larger community, and the extent to which the intervention has improved the safety of women within a particular community. Evaluations should also consider whether the system has challenged the historic right of men to batter women and whether deterrents have been created for individual batterers as well as a general deterrent to domestic violence in the community. OUTCOME MEASURES Outcome measures in the DAIP are viewed from the perspective of how women experience the system that they turn to for help. The emphasis of the DAIP evaluation effort is on the totality of efforts in the community to address domestic violence rather

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP than quantitative measurements of specific but sometimes disjointed activities (Novak and Galaway, 1983; Shepard, 1987, 1988, 1990). The project team explores whether violence against women has been reduced in the community, whether individual women have acquired a greater sense of autonomy, and whether deterrents have been created for individual batterers. DAIP evaluation studies have a continual focus on obtaining input from battered women in the community. Research has also been conducted to determine which abusers are recidivists in Duluth and which abusers are most likely to re-offend. These studies suggest that the men most likely to re-offend exhibit characteristics of alcoholism, severe childhood abuse, and a history of general crime. Through anonymous questionnaires, victims are asked to critique their experience with various practitioners in the system and to evaluate the effect of the overall intervention on their personal safety. The analysis of these questionnaires is analyzed with women who have used the shelter and other services in Duluth. NEW INITIATIVES The Duluth project is now developing a new tracking system with a grant from the Centers for Disease Control and Prevention (CDC) that will allow practitioners to have immediate access to updated case information with reports from other service programs. The information will be centralized within the community-based group, the DAIP, and will be accessible to practitioners on a need-to-know basis. The tracking system will be tested to see if it can be replicated or adapted in other cities. The CDC grant will support additional systemic changes in order to heighten the level of emergency response to particular women who are in situations of increasing danger, because of either increased severity or frequency of violence. This approach will highlight cases at risk for serious assault or homicide if intervention efforts do not occur. The emergency response program will supplement existing efforts to secure broad compliance with basic policies and procedures in the community's legal and mental health systems, including mandatory arrest by police, aggressive prosecution, increased sanctions for offenders, and a movement away from couples counseling toward a group treatment process for men who batter. DAIP is an institutionalized community advocacy model--a community holding itself accountable for intervention in domestic violence. The program is a nonprofit corporation that receives no funds from the city or county government, although agencies of the criminal justice and mental health systems participate in its activities. The leadership of the Duluth project has come from a community-based group, and this approach provides a creative tension in the system of services. The history and structure of the program has encouraged practitioners to debate and discuss whether enough was being done, how the system might be improved, and whether all aspects of the system have implemented the policies that have been developed. In contrast to a task-force model (comprised of agency representatives with minimal participation of advocates), the Duluth project is characterized by an approach where members of the

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP community, including battered women, hold the system and community accountable for the protection of battered women. Project staff are concerned that in many communities, in the rush to do something about domestic violence, the voices of the victims may be silenced. Task forces and coordinating councils may not include battered women, and if they do, the women may be add-ons to agency members. FUTURE CHALLENGES One of the most challenging difficulties in providing interventions involves the backlash that has arisen in the area of domestic violence. Programs have been criticized because they appear to be biased toward women and victims. The development of mens' rights organizations and the national mood on this issue contribute to this backlash. Research data that suggests that women are as violent as men has contributed to the resistance to program initiatives. As a result, system practitioners and the larger community are often reluctant to view domestic violence in terms of gender and power relationships that exist between men and women. A second challenge in developing intervention efforts concerns the nature of domestic violence itself. The key goal is to protect battered women and hold abusers accountable for their actions, not simply to develop more efficient systems of service delivery. For this reason, battered women and battered women's advocates need to be involved in developing and evaluating programs and policies in this field. The major challenge for practitioners and communities is to develop practices of substance, not merely of form. REFERENCES Novak, S., and B. Galaway 1983 Domestic Abuse Intervention Project Final Report. Domestic Abuse Intervention Project, Duluth, Minn. Shepard, M. 1987 Intervention with Men Who Batter. Paper presented at the third national Conference for Family Violence Researchers, Durham, N.H. 1988 Evaluation of the Educational Curriculum-Power and Control: Tactics of Men Who Batter. Domestic Violence Intervention Project, Duluth, Minn. 1990 Predicting Batterer Recidivism Five Years After Community Intervention . Domestic Violence Intervention Project, Duluth, Minn.

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP DOMESTIC VIOLENCE RESPONSE TEAM Mimi Rose The Family Violence and Sexual Assault Unit in the District Attorney 's Office in Philadelphia is responsible for the prosecution of child abuse, domestic violence between intimate partners and family members, and adult sexual assault. The unit is staffed by 15 prosecutors; 3 victim advocates who provide information, court accompaniment, multiagency coordination social service, housing and mental health referrals for adult and child victims and witnesses; 3 police officers who do follow-up investigation and handle reports of witness intimidation; a domestic violence counselor from a local advocacy agency housed in our unit; undergraduate and law students who volunteer their efforts; and a family therapist and forensic child psychiatrist who consult pro bono when requested. The unit was developed to retain the significant benefits of specialized prosecution. Prior to 1990 the Philadelphia District Attorney's Office had discrete specialized units for child abuse, domestic violence, and adult sexual assault. It became apparent that separate intervention systems to protect children and to protect their caregivers was an unrealistic and sometimes dangerous configuration. The present structure of the unit reflects the reality that child sexual assault is often one incident of a pattern of long-standing abuse within some families. Three basic principles guide the unit's work. First, criminal justice response to family violence must be proactive as well as reactive. The amount of resources allocated to a prosecution cannot always be determined by the charges filed. Rather than being satisfied by a successful prosecution of a domestic violence homicide, we need to also aggressively intervene in less serious episodes of violence, especially misdemeanor crimes where there are risk factors that should alert us to an increased likelihood of continued violence. Second, a multidisciplinary approach works best. Collaboration and coordination between prosecutors, victim advocates, social service, and medical and mental health providers is essential. Cross-training, multidisciplinary protocols, and a service referral network must be ongoing efforts. We have come to recognize that the prosecution of family violence may not be the most important intervention. Going to court may be tertiary to other needs better served by other agencies. By recognizing the limitations as well as the possibilities of the criminal justice system, we can seek out alliances and resources to enhance our efforts. Finally, prosecution of family violence must be user friendly. People who have been hurt by violence must be given information, support, and the opportunity to be

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP meaningful participants in a case that affects their lives. As prosecutors, our decisions must be informed not only by the needs of our system but by the needs of the victims. The goal of winning a case, so central to our criminal justice response, must be redefined. We win when the quality of life for children and their caregivers is enhanced by involvement in our system. When families are safer, we win.

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP PROJECT AWAKE Jennifer Robertson The AWAKE Project (Advocacy for Women and Kids in Emergencies) assumes that victims of child abuse cannot be protected and aided unless their mothers are too. The program intervenes with mothers of abused children in order to prevent future incidents of child abuse and to improve the welfare of the mothers as well. The framework of the AWAKE Project is based on the belief that child abuse and woman abuse cannot be viewed as separate issues since, in at least one study, the overlap of the two is calculated to be 59.4 percent (Newberger et al., 1989). Conflicts over custody and visitation issues, intertwined with family violence issues, are often long and bitter, since issues of woman abuse can influence custody and visitation decisions. The AWAKE Project began offering comprehensive services late in 1986 to ensure that Children's Hospital is a safe place for victims of family violence to disclose abuse. The program provides hospital staff from a variety of disciplines with training on family violence in order to assist them in recognizing the subtle signs and symptoms in women and children which may lead to subsequent identification of victims and referrals for AWAKE intervention services. The project offers crisis and long-term intervention services to support, validate, and empower women at risk of domestic violence. The objective is to facilitate changes in service systems to lessen the prevalence of unwarranted separations of mothers and children which in many instances only serve to revictimize both. The goal is to assist women and children in order for them to remain together and safe whenever possible. AWAKE offers immediate risk assessment and safety planning; one-on-one counseling by phone and in person; a weekly walk-in support group; a six-week educational group; and telephone outreach to every woman referred to the program. The project offers a 10- to 12-week group session for children ages 6-10 who have witnessed or experienced violence each year. A principal goal of AWAKE is to initiate and maintain interdisciplinary collaborations and community linkages. AWAKE staff members participate in committees within Children's Hospital such as weekly Child Protection team meetings and are also active members of several community and statewide advisory boards. These activities result in resource accessibility which provides optimal service plan development and protection for abused children and also their mothers when necessary. In addition, AWAKE staff serve as advocates on behalf of all battered women and children with the medical, legal, and criminal justice communities throughout

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP Massachusetts. Collaboration with shelters and district attorneys is standard practice. Staff members participate in roundtable discussions in several courthouses; provide case consultation to agencies contracted to conduct in-home evaluations when child abuse is reported; and are frequent presenters in medical, legal, and criminal justice training sessions. In 1993 AWAKE initiated and continues to facilitate a Health Care Providers Meeting on Domestic Violence every 6 weeks with participants from over 30 health care facilities in Massachusetts and one each from Rhode Island and Maine. One particular challenge associated with working with abused women and children in a healthcare environment is the development of specialized security procedures to maximize victim protection. In many cases, acts of violence by abusive partners occur during in-patient hospitalizations of children. AWAKE staff members attend rounds/case conferences and assist unit personnel in developing safety plans that may include visitation schedules; 24-hour security presence on the unit; the barring of the abusive parent; the moving of the medical chart to a secured location; and in many instances the changing of rooms, floors, and the elimination of the name from the reception desk and unit lists. Mothers are consulted in making such security decisions, and no changes or exclusions are implemented without their knowledge and, in most cases, their agreement. One study of AWAKE cases from 1987 to 1988, which was performed by Kersti Yllo, a professor of sociology at Wheaton College, found that only one case resulted in the removal of a child from the mother by a child protection agency. In the same study, 85 percent of the mothers were no longer being abused after 16 months. Although 60 percent of the children had been physically abused and 24 percent sexually abused, abuse of the children had ceased in 76 percent of the cases. During 1994, AWAKE served 481 women and 723 children. Preliminary analysis of this client base indicates that after AWAKE intervention, only 12 percent of the women remained with their abusive partners, although more than half still experience varying levels of control and violence, usually associated with visitations and court proceedings. About 87 percent of the women had experienced physical violence; 40 percent disclosed sexual violence; and 100 percent reported repetitive psychological maltreatment. From this clientele, only two mothers lost custody of their children to child protection agencies, but in both instances the child was returned within 90 days. In determining project effectiveness, AWAKE monitors hospital staff and community provider awareness of service availability and referral protocols; visibility and accessibility to hospital staff, community providers, and abused women; perceptions of awareness, growth, and empowerment in women, which increase their own and their children 's safety; and the ability to prevent unnecessary separation of children from their mothers. Preliminary reports suggest that early identification of abused women in a pediatric medical setting can be effective and provides an atmosphere of safety for the women and their children. If family violence intervention services are offered to mothers in conjunction with medical, mental health, and supportive services for their children, the protective and positive impact can be immense.

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP In December 1994, AWAKE expanded its services by placing a trilingual/bicultural advocate in a community health center based in a low-income housing development in an area ravaged by poverty, street and family violence, and linguistic isolation. The goals are the same as stated earlier, with an additional goal to lower infant mortality and low-weight births through early identification and intervention with pregnant and also currently parenting women. AWAKE's future plans include the development of more extensive evaluative research of program services. AWAKE also seeks to stimulate educational centers to develop intake protocols that would promote early identification of child and adult victims of domestic violence in day care, nursery, elementary, and even graduate school levels. Yet fiscal realities may limit opportunities for program growth and the level of service ability. REFERENCE Newberger, E.H., E. DeVos, and L. McKibben 1989 Victimization of mothers of abused children: A controlled study. Pediatrics 84(3):531-5 .

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP DISCUSSION HIGHLIGHTS The assessment of comprehensive service programs within local and state agencies is challenged by the lack of documentation regarding the basic processes, strategies, assumptions, and conceptual frameworks that are embedded in such efforts. Many comprehensive programs have provided insufficient information regarding their basic program design, characteristics of their client base, data collection efforts, and process components. In the absence of such information, researchers are unable to evaluate the relevant outcomes for such programs or to assess their relative effectiveness compared to categorical efforts within health, social service, or legal settings. What is particularly needed at this time is better documentation regarding the types of interagency coordination problems that are presented by comprehensive service efforts and assessments of the relative effectiveness of information-sharing within comprehensive service programs in various institutional settings. Although many different service systems can contribute to a comprehensive response to the problems presented by family violence cases, each agency is often too busy with its own responsibilities to develop a coordinating strategy for others. For maximum effectiveness, it is often necessary to identify an independent coordinator whose sole task is to facilitate the necessary connections that are essential to comprehensive services. Responses to multigenerational issues are especially complex, such as when women who are victims of domestic violence also abuse their children, or when issues of domestic violence require judicial consideration in determining custodial and visitation rights for the offending parent. In some cases, women behave abusively to shield their children from the violence of a man who is abusing both the woman and her children. In some jurisdictions, prosecutors discuss treatment options with social services and, if mitigating circumstances are present, they may support the need for options that facilitate at-home intervention rather than removal of the children. The size of the community may be a significant factor in shaping the nature of comprehensive interventions. Community sanctions such as those in Duluth, where 1 in every 17 men has been through Domestic Abuse Intervention Project classes, may be more effective in a small city than a large one. Small community size may inhibit effective community responses, however, when victims are unwilling to report abuse because of fear of stigma or shame. Participants examined the conflicts involved in policies such as mandatory

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SERVICE PROVIDER PERSPECTIVES ON FAMILY VIOLENCE INTERVENTIONS: PROCEEDINGS OF A WORKSHOP reporting, mandatory arrest guidelines, prosecution strategies, and sentencing guidelines. Although mandatory policies may encourage victim reportings and system responses, they can be dangerous if they reduce the role of discretionary judgment in responding to the needs and wishes of victims and the professionals who serve them. Mandatory arrest policies may help protect some battered women who would otherwise be reluctant to violate the traditions of privacy and confidentiality that characterize health care, research, and other fields of professional practice. Participants noted that such policies require definitions of probable cause so that reporting officials can recognize signs of warning, rather than relying on individual discretion. If such resources are not available, mandatory reports may do more harm than good. Another detriment associated with mandatory reporting and arrest policies is the limited availability of services. If sufficient services are not in place to meet the needs of battered women and children, then reporting requirements create a tremendous burden on caseworkers and others. The result can be a response system than tends to emphasize case investigation rather than service delivery. Participants observed that guidance from victims of family violence was very important, especially in dealing with battered women who are frustrated by the responses from agency representatives. Some systems that have limited resources and that are resistant to change have relied on family violence advocates as a means of holding divided and fragmented systems accountable for the wise use of resources in helping battered women and their children.