Athealth Interview with Carole Warshaw, MD
Carole Warshaw, MD, Director
National Center on Domestic Violence, Trauma & Mental Health (NCDVTMH)
Athealth: Dr. Warshaw, please begin by telling our readers what led you to specialize in Domestic Violence (DV) and Intimate Partner Violence (IPV).
Dr. Warshaw: I had been working on issues related to violence against women and women’s health since the 1970s, but during the early 1980s when I was working as an ER attending at Cook County Hospital a few articles on Domestic Violence (DV) in the ER were published and, being one of the few women attendings (on staff) at the time, the ED director asked me to present them for our journal club. One of them was the groundbreaking 1979 article on Medicine and Patriarchal Violence: The Social Construction of a Private Event (Evan Stark, Anne Flitcraft and William Frazier (1979) -which looked at how the structure of medical encounters contributed to women’s ongoing entrapment in abusive relationships. Their research highlighted a very disturbing pattern - one in which women would come to the Emergency Room for an isolated injury which when not recognized and responded to appropriately would lead to repeat visits for multiple injuries and eventually the longer-term health and mental health sequelae of domestic violence. Becoming a “repeat visitor” with “vague” unexplained problems led to the woman herself being viewed as the problem, rather than a system that wasn’t able to recognize what she was experiencing. At each stage, the failure to ask about abuse, to respond in a caring non-judgmental way, to talk with patients about their priorities, concerns and safety, or to offer resources and support further increased their isolation and entrapment and gave a clear message that what was happening wasn’t important and that help was not available. They made a compelling argument that as health care providers we were actually contributing perpetuation of domestic violence and also made clear the important role that health care providers can and should play in addressing this issue.
Thus, my initial work focused on improving the health care system response to domestic violence, including trying to understand why health care providers were not asking about domestic violence or other types of traumatic experiences and often were not able to “see” or respond appropriately, even when there were obvious signs of injury. It was clear that despite widespread recognition of domestic violence as a public health problem, many clinicians still had difficulty integrating routine intervention into their day-to-day practice. In part, this was due to the fact that domestic violence raised a distinct set of challenges for both providers and the institutions that shape clinical practice. Domestic violence is a complex social problem rather than a biomedical one, and addressing it means asking us as clinicians to step beyond a traditional medical paradigm to confront the personal feelings and social beliefs that shape our responses to patients and to work in partnership with community organizations committed to ending domestic violence. In addition, addressing domestic violence raised important challenges to the health care system itself — to its theoretical models, to the nature of medical training, and to structure of clinical practice. However, growing attention to the issue also generated important opportunities for changing the ways health care providers and systems responded to domestic violence.
By 1999, when we first started focusing more specifically on the intersection trauma, mental health and domestic violence, the physical consequences of domestic violence had been well documented. Yet acknowledging the mental health and substance abuse effects of DV was still controversial. While many people were aware of the impact that victimization could have on the emotional well-being of domestic violence survivors and their children, DV survivors and advocates were concerned about how these mental health and substance abuse effects were being used against survivors by their abusive partners and by the systems where they sought help. In fact, two recent studies on mental health and substance use coercion administered by the National Domestic Violence Hotline highlight the scope of this problem. An alarming percentage of hotline callers reported a current or former partner had deliberately done things to undermine their sanity, sobriety, and recovery; control their access to treatment; and/or use mental health or substance use issues to sabotage their efforts to obtain custody or protective orders (Warshaw, Lyon, Bland, Phillips & Hooper, 2014)[i].A lack of knowledge about domestic violence and the stigma associated with mental health and substance abuse increased abusers’ control over their lives and placed survivors and their children in further jeopardy. For example, if as clinicians we are not trained to address the social factors that entrap people in abusive relationships, this can result in mistakenly interpreting survival strategies as disorders, overlooking the advocacy needs of survivors (e.g., safe housing, legal assistance, safety planning), and not understanding the risks a psychiatric diagnosis can pose for custody battles with an abusive partner. Similarly, we often use a family member to provide collateral information during psychiatric crises, without safely ascertaining whether the informant is, in fact, the abusive partner. Obtaining information from potential abusers or those who may be allied with them or allowing abusers into the treatment or discharge planning process can be dangerous for a person who is being victimized by an intimate partner.
Athealth: Explain the mission of the National Center on Domestic Violence, Trauma & Mental Health.
Dr. Warshaw: NCDVTMH is a national, technical assistance, resource center supported by the U.S. Department of Health and Human Services; Administration on Children, Youth and Families; Family Violence Prevention & Services Program. Our mission is to improve program and system capacity to serve DV survivors and their children, who are experiencing a range of trauma, mental health, and substance abuse-related needs and to develop culturally relevant approaches to DV and other lifetime trauma.And, we offer a lot of information and resources on our website that should be useful to people who are interested in these issues - www.nationalcenterdvtraumamh.org
Athealth: Discuss how you will use the terms domestic violence (DV) and intimate partner violence (IPV) in this interview.
Dr. Warshaw: While the term intimate partner violence (IPV) is sometimes used to refer to physical violence between partners and the term domestic violence (DV) has sometimes been seen to encompass any violence that occurs between family members, in general (and in this interview) these terms are used interchangeably to refer to an ongoing pattern of coercive control perpetrated by one partner over another, or when one partner in an intimate relationship uses a range of tactics (including physical violence, sexual violence, threats of violence, psychological abuse, economic abuse, use of children, coercion related to reproduction, mental health or substance use, immigration statues, sexual orientation or gender identity, or parenting, etc.) to dominate and control the other partner.
Athealth: How pervasive is DV in the United States?
Dr. Warshaw: DV is sufficiently pervasive to be a major public health and public mental health concern. The actual prevalence rates depend on what source you look at and what definitions they use. According to the 2010 National Intimate Partner and Sexual Violence Survey (NISVS) conducted by the CDC, 35.6% of women and 28.5% of men, who were surveyed, reported having been physically assaulted by a current or former spouse, cohabiting partner, boyfriend or girlfriend or date in their lifetime. And, more than 12 million women and men are victims of rape, physical violence or stalking by an intimate partner each year. However, women were more likely to experience violence. According to the Bureau of Justice Statistics, between 1994 and 2010, 4 out of 5 victims of domestic violence were female. One of the key issues to keep in mind is that studies that ask about specific forms of violence (physical assault, sexual violence, stalking, psychological aggression) don’t necessarily capture the ongoing coercion, domination and control that is part of the definition of domestic violence, nor do they necessarily capture the ongoing experience of isolation, entrapment and fear that many DV survivors experience. Part of what the NISVS studies have found is that women are far more likely to be living in fear, experience severe violence, including sexual violence, and are far more likely to experience injuries and other health and mental health consequences. (See Black et. al. 2010, http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf).The NISVS study also provides the first set of national prevalence data on intimate partner violence,sexual violence, and stalking victimization among lesbians and gay men who reported intimate partner and sexual violence over their lifetimes at levels equal to or higher than those of heterosexuals.
Athealth: In your writing, you talk about both “individual” and ‘collective trauma.’ What do you mean by that?
Dr. Warshaw: As clinicians, we often focus on individual trauma - childhood abuse and neglect, adult or adolescent sexual assault, and abuse by an intimate or dating partner as well as the individual effects of combat trauma and military sexual assault. Yet, many people experience collective forms of trauma, as well - trauma that affects people as part of a particular community, culture, or group and - experiences that continue to affect individuals and communities across generations, for example the ongoing legacies of trauma resulting from slavery and colonization,[ii] the trauma of war, poverty, displacement and persecution, the trauma of trans/homophobic and gender-based violence as well as the insidious trauma or micro-violations of objectification, dehumanization and marginalization that many people experience on a daily basis. And, when the majority of people in a given community experience ACE (Adverse Childhood Experiences) scores of 8 or 10, then the trauma is no longer just individual, it is collective, as well and the solutions may also need to be collective.
When we talk about interpersonal violence, we are also talking about betrayal whether by an individual, or of the social contract. Both may also have cumulative effects and both may involve ongoing exposure and risk. One of the challenges of framing things in terms of “trauma” as opposed to abuse, violence or oppression is that one focuses on the impact on the individual (or on entire cultures or communities) and the other incorporates an understanding that there are individuals and systems that are responsible for creating these traumatic experiences. Hence the need for a more integrated trauma/social justice approach. Understanding this, in turn, highlights the need for both individual and collective responses to mitigate these risks, heal from the effects, and transform the conditions that hold them in place.
Athealth: How can trauma associated with DV affect a person’s physical and mental health?
Dr. Warshaw: We know that trauma can have significant health, mental health and substance use-related consequences. There is now an extensive body of research demonstrating that that gender-based violence, in general, can increase the risk for developing a range of health and mental health conditions. There is also a relationship between the extent of violence experienced and the impact on health and mental health; for example, among individuals who experience 3-4 types of trauma, 89% will develop a mental health condition (Rees et. al. 2011) Intimate partner violence (IPV) is (also) associated with a range of trauma-related health and mental health effects.
Research conducted over the past 30 years has consistently demonstrated that being victimized by an intimate partner increases one’s risk for developing depression, PTSD, substance abuse, eating disorders, insomnia, and suicidality, as well as a range of chronic health conditions. Studies have consistently found higher rates of PTSD and depression among survivors of IPV, as compared to those who have not experienced IPV, and rates are higher among survivors, who experience other types of trauma in addition to IPV. For some survivors, abuse by an adult partner is their first experience of victimization. However, many survivors experience multiple forms of trauma over the course of their lives, (such as child abuse; sexual assault; historical, cultural, or refugee trauma), further increasing their risk for developing trauma-related health and mental health conditions. In addition, individuals who perpetrate IPV often actively undermine their partners’ wellness, mental health, and sobriety and control their access to treatment and other supports which also contributes to the adverse health and mental health effects...
Research has also demonstrated that survivors of domestic violence higher of asthma, diabetes mellitus (DM), irritable bowel syndrome (IBS), sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), autoimmune disorders, stress-related symptoms, gastrointestinal disorders, cardiovascular conditions, cervical cancer and poorer cancer outcomes, chronic pain, pregnancy complications & injuries, including traumatic brain injury (TBI). Coercion related to reproduction (birth control sabotage), sexual activity (inability to use barrier protection) health care (access to medication and medical care; ability to follow treatment regimens), deprivation of basic needs (e.g. healthy diet, sleep deprivation) as well as stress-related physiological changes, contribute to these effects/conditions. For more information on reproductive coercion see Miller et. al. 2010http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872678/. For more information on the overall health impact of domestic violence, see the CDC NISVS study referred to above.
Athealth: Would you briefly discuss the Adverse Childhood Experiences (ACE) Study and address how early life stress can increase our risk for developing mental health and substance abuse problems as adults.
Dr. Warshaw: We often talk about the ACE Study as a way to underscore the pervasiveness of trauma in all of our lives and to highlight the effects of early life stress on our physiology and developing brains. This groundbreaking study played a critical role in reshaping our thinking about trauma and its long-term effects. The study involved a collaboration between the Center for Disease Control and Kaiser Permanente, a large managed healthcare organization - in other words a middle class, working population with insurance. The original study examined 7 different adverse childhood experiences (ACEs), which subsequently was increased to 10. These included questions about physical, sexual, and psychological abuse; neglect; witnessing violence toward one’s mother; having a household member who was experiencing substance abuse, mental illness, suicide attempts, or incarceration; and the loss of a parent through separation or divorce.
Of the study participants, over 50% had experienced at least one adverse childhood experience, 25% had experienced two or more, and there was a correlation between the number of adverse experiences and the leading causes of disability and death in the United States, including cigarette smoking, alcohol and drug use, suicide, heart disease, lung disease, liver disease, obesity, bone fractures, and cancer. Initially, it was thought that the long-term health effects, i.e. heart disease, lung disease, liver disease, were mediated by smoking and substance use. Over the past 15 years, however, we have come to understand more about long-term psychophysiological effects of early life stress. Emerging research on epigenetics (how experience influences gene expression, including brain architecture), on our stress response systems and inflammatory responses, and chromosomal ageing (telomere erosion) are just beginning to elucidate some of the potential mechanisms for these downstream effects (Moffitt et. al. 2013 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869039/)
These findings underscore the importance of talking with the people we see in our practices about a range experiences that may be affecting them and their children and developing strategies that support both children and parents in preventing and/or mitigating the impact of these experiences. Some researchers and practitioners have suggested universal screening for adverse childhood experiences in primary care settings. Others have cautioned that what is more important is to provide information about trauma and its effects and create opportunities for people to discuss these issues with a practitioner they feel comfortable with, if and when they determine that would be helpful to them.
The ACE study also has a number of limitations, including that the initial study population was largely middle class and limited in racial diversity and the types of experiences asked about did not include many of the types of trauma that impact people and communities.
However, the study has been important in bringing to light the impact of trauma over the life span and in helping to transform our understanding of abuse, violence and neglect as major factors in the development of health and mental health conditions.
At the same time, our growing understanding of the ways experience can shape our overall physiology and brain architecture also makes it clear that there are many opportunities to counteract these effects throughout the course of our lives.
Athealth: What should we know about resilience, in general?
Dr. Warshaw: While we know that experiencing trauma can have a significant impact on people’s health and mental health, we also know that there are many factors that mitigate these effects. Trauma experienced in early childhood impacts each child differently, and extensive research has been conducted on resiliency factors that reduce the likelihood that children will experience these adverse effects. But one of the most critical resilience factors is a child’s ongoing attachment to a primary caregiver or caregivers. In the context of domestic violence, that is often the mother, who may be experiencing violence by an intimate partner but who may also be working to protect her children from the violence and from the effects of witnessing their mother being abused. Social support, and social fabric also make a difference - having a supportive community whether related to your family, you friends, your neighborhood, your school; to spiritual or cultural activities or traditions; or to sports, music, hobbies or the arts. A feeling of belonging and being valued is important, as well.
In addition, when we talk about the impact of trauma, it is important to do so from perspective of strength and resilience not just one of distress and harm. We know that resilience is the capacity for successful adaptation despite challenging or threatening circumstances. Yet, part of what we also know is that coping strategies that turn out to be harmful or just get in our way may also have been what helped us to survive when other options were not available. While trauma theory shifted the focus from, “What’s wrong with you?” to, “What happened to you?” we also want to know, “Who are you? What have you experienced in your life? What are the things that are important to you? What are the strengths and sources of support you draw on? And, how has all of that brought you to where you are now?” When we are able to hold all of this in mind, it reduces the likelihood that talking about the effects of trauma will be experienced as pathologizing. Part of what makes it safe for people to share their pain and challenges is knowing that they will not be judged or defined by those challenges and being able to trust that they will be seen for all of who they are.
Athealth: Would you please explain to our professional audience how people who are experiencing a mental health condition might be more vulnerable to DV?
Dr. Warshaw: I wouldn’t say that a person is more vulnerable (that implies the problem is in them), but rather I would focus on what places them at greater risk. In other words, if a person has a mental health condition, they may be at greater risk for having their partner use their mental health condition against them. And, the stigma associated with mental illness and with substance abuse increases the likelihood that the abusive partner will be seen as more credible than the person they have been abusing for years.
Athealth: How might DV affect a person’s ability to seek treatment for common mental health disorders like depression and anxiety?
Dr. Warshaw: DV has important implications for MH treatment and providers… survivors may be reluctant to seek treatment because of the ways that their partners may use their condition or the fact that they are receiving treatment against them in custody battles. They may be prevented from accessing mental health services, their partner may try to control their medication - for example, they may prevent their partner from taking medication, coerce their partner into taking an overdose, accuse their partner of being an addict, steal their partner’s meds and sell them) or they may try to insert themselves into the treatment process as a seemingly concerned partner/family member which can have a chilling effect on the person who is being abused, undermining their ability to speak freely without risking retaliation and to make choices that are helpful to them. For example when there is ongoing violence and/or coercion and control, couples therapy is generally not a safe form of treatment.
Athealth: Give us a brief overview of ‘Trauma-Informed Services.’
Dr. Warshaw: Understanding the range of ways we can be affected by trauma and what we can do to help counteract those experiences, mitigate their effects, and transform the conditions that produce them are key aspects of trauma-informed social justice work. Becoming trauma-informed means adding an additional layer of understanding to the work we do, not necessarily defining all of our experiences through a trauma lens.
The key components of a trauma-informed approach stem directly from our understanding of the impact of trauma. They reflect what people find helpful in reducing further traumatization and lead to services and environments that support survivors and their children in recovering from those effects.
Creating trauma-informed services means taking time to think about how trauma might affect a person’s experience of services and what we can do to reduce further traumatization. This includes creating a physical and sensory environment that is accessible, welcoming, inclusive, healing, and attentive to potential trauma reminders (i.e. loud noises, a chaotic waiting room and for some survivors, mixed gender settings); a clinical or programmatic environment that is flexible and responsive to individual needs (and in group settings, collective needs, as well); a cultural and linguistic environment that is responsive to the people and communities being served; and a relational environment that is caring, respectful, empowering, transparent, and emotionally and physically safe. It also means taking into account the traumatic effects of abuse as well as ongoing threats from an abusive partner and previous experience with systems in the ways people process information, remember details, and respond to us as clinicians.
When we understand trauma responses as adaptations to being under siege, then part of our work is to do everything we can to reduce the likelihood that survivors will feel discounted and disempowered in our practices, programs and systems. In other words, how we relate to other people, including within the broader context of their lives, culture, and experiences is a critical part of trauma-informed work.
At the same time we are doing everything we can to reduce further harm, we are also doing everything possible to support strengths and facilitate healing, resilience, and well-being. For some, this might involve offering access to specific trauma treatment; for others, it is more a matter of how the environment and relationships we offer create an atmosphere of safety, connection, and well-being. We can also support survivors to feel more connected and empowered as they prepare for situations in which responses to trauma may be evoked, e.g., going to a court hearing, job interview, or custody evaluation.
Lastly, a trauma framework fosters an awareness of what we bring to our interactions with others, including our own experiences of trauma as well as the ways we are affected when we are truly open to the experiences of other people. This means having agencies or organizations that make supporting staff a priority, including through human resources practices that support staff well-being and supervisory practices that create safe places for reflection and growth.
Becoming a trauma-informed organization is a long-term transformative process that takes administrative commitment, a thoughtful approach, purposeful planning, and sufficient time and resources.
Athealth: Discuss how the ‘Trauma Theory’ has evolved over the past thirty (30) years.
Dr. Warshaw: The evolution of trauma theory over the past three decades has helped provide a crucial bridge between clinical and advocacy perspectives. As knowledge about trauma has grown, there has been a profound shift in understanding of the impact of trauma on individuals, families, and society and a significant reassessment of the ways mental health symptoms are conceptualized. Arising out of the experiences of survivors of civilian and combat trauma, trauma theory views “symptoms” as survival strategies—adaptations to potentially life-threatening situations that are made when real protection is unavailable and usual coping mechanisms are overwhelmed.
PTSD was the first diagnosis to incorporate an understanding that external events could play a significant role in the development of mental health symptoms. This understanding has helped to destigmatize the mental health and substance abuse-related consequences of domestic violence by recognizing the psychophysiological effects of abuse and normalizing human responses to traumas, such as interpersonal violence. The creation of the PTSD diagnosis was also a political act—one designed to give voice to the painful effects of combat trauma and sexual assault.
The concept of complex trauma, which emerged during the 1990s, has offered a more nuanced way of understanding the impact of interpersonal trauma across the lifespan, including the critical role that early caregiving relationships play in how we manage stress; regulate emotions; and feel about ourselves, other people, and the world. This has led to several key insights that are critical to trauma-informed work. First, understanding the neurobiological underpinnings of emotional dysregulation, a hallmark of complex trauma, helps make sense of some of the coping strategies people use to manage their feelings through external means, e.g., self-injury, substance use, when internal regulatory capacities have been disrupted by trauma and/or by keeping them at bay through avoidance, dissociation, and “denial.” Second, understanding how betrayal of trust in childhood can affect our ability to trust as adults helps make sense of the adaptive but sometimes interpersonally challenging sequelae of childhood abuse (i.e., when trusting others turned out to be dangerous, then trusting again may seem risky and limiting one’s engagement in relationships may be protective). These understandings led to a number of important shifts in thinking. First they helped reframe previously pejoratively labeled behaviors as understandable responses to overwhelming trauma. This, in turn, led to a greater appreciation of survivors’ resilience, strength, and survival skills, and to more empathic, less judgmental, and ultimately more helpful (i.e., trauma-informed) responses on the part of providers—responses that increased safety and support rather than further traumatizing. They also led to the recognition that supporting children’s attachment to and the parenting capacity of the non-abusive caregiver is protective of children’s development and is what is most beneficial for children exposed to DV. Out of these understandings also came a more holistic approach to thinking about the biological, emotional, cognitive, and interpersonal effects of abuse, and to more complex and nuanced approaches to healing.
Over the last 15 years, burgeoning genetic and neuroscience research has begun to elucidate the mechanisms through which early experience shapes brain architecture and the important and hopeful concepts of neural plasticity—the ability of our brains to continually learn and grow.[iii] At the same time, research on trauma and resilience, combined with what we have learned from the experiences of survivors, advocates, and clinicians, has begun to clarify helpful ways to respond, both within and across cultures and communities.
Athealth: What kinds of questions are helpful in inquiring about coercion related to mental health and substance use?
Dr. Warshaw: Because coercion related to mental health and substance use are such common forms of abuse, it’s important to ask about these issues specifically and to create opportunities for patients/clients/people to discuss the kinds of things their partner may be doing to undermine and control them. Starting out with a framing question that helps normalize these experiences creates an opening, i.e., “Many people say that that their partners abuse them emotionally or call them ‘crazy’ or other demeaning names related to their mental health or to their use of alcohol or other drugs. For example, some people tell me that their partner does things to make them feel like they are ‘going crazy,’ or that their partner tries to interfere with their treatment or medication, or does things to undermine them with their friends and family or with other people or places they might turn to for help. Have you had to deal with anything like that?” Then, depending on the person’s response you can bring up some of the other kinds of tactics an abusive partner might be using.
We would not recommend asking the following questions as a checklist. Rather, what’s important is being familiar with them so you can raise them as part of a conversation about these issues. In addition to reading NCDVTMH’s Mental Health and Substance Use Coercion Surveys Report (see link below) I would also suggest looking at the tipsheet we developed for survivors on mental health and substance use coercion (http://nationalcenterdvtraumamh.org/wp-content/uploads/2012/01/Mental-Health-and-Substance-Abuse-Coercion.pdf), and an upcoming tIpsheet for health, mental health and substance abuse treatment providers, all of which are or will be on our website.
Has your partner ever used issues related to your mental health or use of substances against you?
Has your partner ever tried to control your medication, or access to treatment? Has he/she actively undermined your sobriety/recovery? Has he/she done things to make you feel worse?
Has your partner threatened to take your children away because you are receiving substance abuse or MH treatment?
Has your partner blamed you for his/her abusive behavior by saying you’re the one who is “crazy” or an “addict?”
Has your partner deliberately done things to make you feel like you are “going crazy” or “losing your mind?”
Has he used your substance use or mental health condition as a way to undermine you with other people?
Has your partner ever forced you to use substances, take an overdose, or kept you from routines that are healthy for you?
Are there other things your partner has done that you’d like to discuss?
Depending on what a person says, how they are feeling about this and what they want to do, you can talk together about potential strategies for addressing these concerns (including safe places to keep medication, strategies for maintaining contact with a therapist, and identifying someone they trust who can validate their perceptions in addition to documenting the abusive tactics and their impact in the clinical record). Providing referrals to a local domestic violence program and/or the National Domestic Violence Hotline can also help survivors evaluate their situations and develop individually tailored safety planning strategies.
Athealth: Before ending the interview, briefly, touch on DV/IPV treatments.
Dr. Warshaw: While there are numerous interventions designed to reduce trauma-related mental health symptoms, most have been developed to address experiences that occurred in the past. Currently, there are only a handful of evidence-based trauma treatments specifically designed for survivors of DV and of these, several are intended primarily for people who have left the abusive relationship. For many survivors of DV, trauma is not only in the past but is also ongoing. Therefore, offering trauma treatment in the context of domestic violence means attending not only to the physical and psychological impact of trauma, but also the direct effects of an abusive partner’s coercive and controlling behavior. For example, incorporating an understanding of the dynamics of domestic violence is essential for responding to the types of issues DV survivors face related to safety, confidentiality, coercive control, parenting, custody, legal issues, immigration, social support, and economic independence, all of which influence how individual survivors are affected by the abuse, their ability to participate in treatment, and their response to treatment, as well.
In addition, there are even fewer treatment approaches that take culture into account. Yet, we know that culture often influences the types of trauma we experience, our beliefs and approaches to healing, and our sources of meaning and support - all of which we would want to incorporate into the treatment we provide. Finally, many of the existing evidence-based trauma treatments focus primarily on reducing symptoms (e.g. depression and PTSD), rather than on addressing the range of ways we can be affected by interpersonal betrayal and abuse. Complex trauma treatment approaches, which have not yet been studied for survivors of domestic violence, address a more complex array of trauma effects and offer more nuanced approaches to healing and a more meaningful array of outcomes. Although they were originally designed for survivors of childhood abuse and neglect, they may turn out to be helpful to DV survivors as well, particularly those whose experiences of abuse have been more prolonged and severe.
In sum, when we are working clinically with someone who is being abused by an intimate partner, it is important that we attend not only to healing the traumatic effects of the abuse but also to increasing access to safety, resources, and support, including linkages to local domestic violence programs and local or national DV hotlines, e.g. theNational Domestic Violence Hotline, 1-800-799-7233 or 1-800-787-3224 (TTY) - and doing so in ways that are culturally meaningful and both DV- and trauma-informed.
Given that domestic violence survivors have a wide variety of life experiences with a range of mental health effects, there is no single treatment model that will fit the needs of all survivors.National Center on Domestic Violence, Trauma and Mental Health(NCDVTMH) offers a range of training, technical assistance and resources for addressing these complex issues.
Athealth: What resources would you recommend to mental health professionals to help them better understand trauma and DV?
1. The newMental Health and Substance Use Coercion Survey Report- Carole Warshaw, MD; Eleanor Lyon, PhD; Patricia J. Bland MA, CDP; Heather Phillips, MA; Mikisha Hooper, BA, 2014
2. Mental Health Treatment for Survivors of Domestic Violence. Carole Warshaw MD and Phyllis Brashler PhD, in C. Mitchell and D. Anglin (Eds.), Intimate partner violence: A health based perspective. New York: Oxford University Press 2009
3. A Systematic Review of Trauma-Focused Interventions for Domestic Violence Survivors, Carole Warshaw, MD, Cris M. Sullivan, PhD, Echo A. Rivera, MA – 2013
4. Empowering and Healing the Battered Woman: A Model for Assessment and Intervention - Mary Ann Dutton, PhD, 1992
Athealth: Dr. Warshaw, thank you very much for taking so much of your time to share your expertise and your knowledge about these very important topics. We wish you much success in your work at the NCDVTMH.
Carole L. Warshaw, MD
29 E. Madison St., Suite 1750
Chicago, IL 60602
NCDVTMH Website: www.nationalcenterdvtraumamh.org
Carole Warshaw, MD, - BIO
Dr. Warshaw is a nationally recognized expert on the intersection of DV, trauma, and mental health and has been at the forefront of developing collaborative models and building system capacity to address the mental health and advocacy concerns of survivors of DV and other trauma. She has written and spoken extensively on these topics and has served as an advisor to numerous health, mental health and advocacy organizations and federal agencies. Originally trained in internal medicine, Dr. Warshaw worked as an ER physician from 1980-1989, during which time she completed a residency in psychiatry and a clinical research fellowship in adolescence at the University of Chicago. She served as the Director of Behavioral Science for the Primary Care Internal Medicine Residency at Cook County Hospital for 10 years and has maintained a part-time private practice in psychiatry since 1989.
Dr. Warshaw also has a long history of advocacy work. In 1993, she co-founded of the Hospital Crisis Intervention Project, a collaborative program of Connections for Abused Women and Their Children (formerly the Chicago Abused Women Coalition) and the Cook County Bureau of Health Services that provides training for health care providers on domestic violence and on-site intervention and advocacy for battered women.In 1999, she founded the Domestic Violence & Mental Health Policy Initiative, a Chicago-based initiative designed to build collaboration between the DV advocacy and public mental health provider communities to better serve the unmet mental health and advocacy needs of DV survivors and their children.
In 2005 she launched the National Center on Domestic Violence, Trauma & Mental Health (NCDVTMH) which is now the US DHHS ACYF, Family Violence Prevention and Services Program Special Issue Resource Center on these issues. NCDVTMH works closely with the other members of the FVPSA-funded Domestic Violence Resource Network (DVRN) to improve research, practice, policy and public awareness around building culturally relevant, evidence-informed and evidence-based approaches to lifetime trauma and domestic violence.
Dr. Warshaw also chaired the committee that wrote the AMA Guidelines on Domestic Violence, co-authored the Futures Without Violence manual, “Improving the Healthcare Response to Domestic Violence” and the AMA’s “Guidelines on the Mental Health Effects of Family Violence” along with numerous other chapters and articles. She served on the National Research Council Committee on the Assessment of Family Violence Interventions, the Family Violence and Abuse and Childhood Trauma committees of the American Psychiatric Association and the AMA National Advisory Council on Family Violence. She is currently a member of the SAMSHA Advisory Committee on Women’s Services and an adjunct faculty member in the Department of Psychiatry at the University of Illinois, Chicago.
[i] Mental Health and Substance Use Coercion Surveys, Carole Warshaw, MD; Eleanor Lyon, PhD; Patricia J. Bland MA, CDP; Heather Phillips, MA; Mikisha Hooper, BA - 2014
[ii] Historical trauma is the cumulative emotional, psychological, and spiritual wounding of individuals and communities across generations, emanating from massive group trauma experiences such as slavery and colonization—the experience of which are still ongoing (Packard 2013). The collective traumas of colonization affect nearly 100% of Indigenous Peoples**.
[iii] Felitti, Anda, Nordenberg, et al, 1998; De Bellis, Van Dillen, 2005; Classen, Pain, Field, Woods, 2006; Lanius, Bluhm, Lanius, Pain, 2006; Lyons-Ruth, Dutra, Schuder, Bianchi, 2006; McEwen, 2006; Nemeroff, 2004; van der Kolk, Roth, Pelcovitz, Sunday, Spinazzola, 2005; Yehuda, 2006.