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VIOLENCE ISSUES: AN INTERDISCIPLINARY CURRICULUM
GUIDE FOR HEALTH PROFESSIONALS Lee Ann Hoff, Ph.D. Faculty of Health Sciences University of Ottawa For Mental Health Division Health Services Directorate Health Canada August 1994 Additional copies are available from: National Clearinghouse on Family Violence Tel. (613) 957-2938 (Ottawa-Hull) TTY (telephone device for the deaf) Permission is granted for non-commercial reproduction
related to educational or clinical purposes. The views expressed in this publication are those of the
author, Published by Public Health Agency of Canada Également disponible en français sous le
titre © Minister of Public Works and Government Services Canada Cat. No.: 1-172-21/129-1997E TABLE OF CONTENTS Foreword Chapter I Overview, Conceptual Framework, Methodology Purpose and Scope Chapter II Core Content: Essential Knowledge, Attitudes, Skills The Concept of Core Content General and Specific Functions of Health Professionals
Chapter III Ethnographic Examples of Abuse Situations: Implications for Education of Health Professionals Example 1: Example 2: Example 3: Example 4: Example 5: Example 6: Example 7: Chapter IV Implementation Issues: Personal/Professional Victimization Personal Abuse History, Provider Stress and Relationship
to Caretaking Chapter V Implementation Strategies: Curriculum Design, Formal and Practicum Instruction A Health Service Paradigm: (Health) Provider, Person, Health, Environment Violence Content in the Health Service Paradigm Curriculum Designs and Recommended Hours of Instruction
Example 8: Comprehensive Clinical Service for a Battered Woman Comprehensive Health Service Components Illustrated
by Case Suggestions for Class/Seminar Planning at Three Levels Beginning Intermediate Advanced A Cautionary Note Regarding Psychiatric Care of Survivors
References (in body of Guide) Violence Theory Appendix A: Clinical Protocol Resources LIST OF TABLES AND FIGURES Tables Table 1: Categories and Functions of Particular
Disciplines Figures Figure 1: Health Service Paradigm FOREWORD Preparing future health professionals to address issues related to family violence in their everyday practice is an essential role for health educators. Family violence refers to violence in relationships of kinship, intimacy, dependency or trust. Within the 1991-1995 Federal Family Violence Initiative, the Mental Health Division, Health Services Directorate, Health Canada was given the mandate to increase the sensitivity and awareness of health professionals to family violence issues, and to encourage the development of resource and training materials to assist health service providers to respond effectively. In this work, special attention has been given to screening and early intervention, as well as to the needs of survivors. Activities have been undertaken collaboratively with other parts of Health Canada, professional health associations, academic networks, national organizations and provincial/territorial governments. The work has been approached from a systems perspective. For the Mental Health Division, preparing current and future health practitioners to deal with family violence issues as a part of everyday practice has been a key issue. This has been pursued through review of curriculum content and approach, as well as identification and development of selected resource materials. It has been a pleasure over the past year to work with Lee Ann Hoff on the development of Violence Issues: An Interdisciplinary Curriculum Guide For Health Professionals. This publication builds from the exemplary resource, Curriculum Guide for Nursing: Violence Against Women and Children written by Lee Ann Hoff and Margaret M. Ross, Faculty of Health Sciences, University of Ottawa, through resources provided by the Ontario Ministry of Colleges and Universities. My colleague Marjorie Carroll, from the Health Service Systems Division, has worked closely with us through the focus group testing at a number of health sciences faculties and the Canada-wide critical evaluation of the final drafts. The Mental Health Division's series of consultations with health sciences faculties across Canada, from March 1993 to June 1994, included dental hygiene, dentistry, medicine, nursing, occupational therapy, pharmacy, and physiotherapy. These consultations underlined the value of reference materials for educators to help them integrate family violence issues into curricula. In addition, the important role of social work and clinical psychology in team approaches to violence issues and the care of survivors was acknowledged. There has also been a growing recognition that every health practitioner needs to have a core understanding of violence issues, to develop basic skills to deal with violence in everyday practice settings and to understand interdisciplinary approaches and the importance of collaboration. The Interdisciplinary Curriculum, Guide represents the hard work and commitment of many health educators and practitioners, and the author's creative energy and capacity to reflect the broad variety of perspectives and disciplines. The Health Services Directorate is proud to have been associated with the development of this resource, which we anticipate will play an important role in the training of future health professionals and, subsequently, in how violence issues, at an individual, family and community level, will be addressed in the health community. Joan E. Simpson Ottawa, August 1994 ACKNOWLEDGEMENTS Those who have suffered the trauma of abuse know that they are the major players in the long healing process. But they also acknowledge the importance of support and other assistance from family, friends, peers and various professionals. The stories that survivors shared for this document attest to the pivotal role health providers can play in rebuilding lives free of violence. I thank these courageous people for opening a window to their lives and suffering so health professionals can better serve survivors' needs as they heal. During the research, analysis, peer review and writing phases of this project, I observed repeatedly the collaborative process so central to the treatment and care of survivors. Special thanks go to all whose insights and suggestions helped bring this work to fruition. Over and over again you modeled the process of health professionals working together on this urgent issue. (Project participants are listed in Appendix D.) This interdisciplinary process itself attests to Canada's extraordinary leadership in commissioning and supporting this first-of-its-kind interdisciplinary curriculum guide on violence. From a "world citizen" perspective, I thank the, Canadian government for the opportunity to participate, through this project, in its roles as international peacekeeper and advocate on behalf of survivors and all those affected by violence. It has been one of the most rewarding experiences of my years in the crisis and mental health field. Lee Ann Hoff INTRODUCTION This brief introduction aims to make the Interdisciplinary Curriculum Guide as user friendly as possible. It recognizes the complexity of the subject matter and the differential roles of various professionals in this health service arena. Additionally, it assumes that some readers are very familiar with most facets of the topic, while others are quite new to it and may be wondering about their particular role in violence education. Chapters I and II are relevant to most readers. For those who are new to the topic, and to teaching, these chapters provide a concise introduction to the vast literature in this field and its specific relevance to health professionals. Those already immersed in the subject may wish only to browse and to evaluate their teaching and practice against the framework presented here. Chapter III offers a first-hand glimpse into the lives of abused people and their families. It translates the more abstract material of the previous chapters into concrete illustrations for educators and clinicians. For readers who are less familiar with the topic, or whose role focuses on identification, support and referral, the examples illustrate the "big picture" and interconnectedness of various abuse situations, while delineating distinctive disciplinary functions. Those grounded in the field may wish to focus on case situations less familiar to them. or use the examples to embellish existing curriculum or teaching plans. Chapter IV is relevant to most readers. It illustrates the connection between personal and professional facets of violence and abuse, and its implications for clinical practice and interdisciplinary collaboration. Chapter V provides detailed, hands-on illustrations of how to translate material from the previous chapters into curriculum development and individual class, seminar or workshop planning at beginning, intermediate and advanced levels. The bibliographic resources are categorized to accommodate readers' varying ranges of familiarity with particular topics, and help prevent newcomers from being potentially overwhelmed by the extensive literature on violence and abuse. Some references appear in more than one section. The "basic library" idea underscores the fact that this Guide does not substitute for standard texts in the field: it provides new teachers with a short list of suggestions about where to begin. Like the bibliographic resources, the appendixes merely introduce readers to the kinds of clinical and curriculum resources available in this rapidly developing field. The items selected can serve as suggestions for identifying the relevant resources available in most communities. Finally, readers are requested to complete the Evaluation Form at the
back of the Guide and return it to the Mental Health Division,
Health Canada. CHAPTER I
Overview, Conceptual After centuries of definition as a private matter in many societies, violence against women and children has taken centre stage as a public issue of concern to all. Responding to local, national and international demands, Canada has pioneered in its campaign and funding priorities to address this urgent human rights issue. Violence Issues: An Interdisciplinary Curriculum Guide for Health Professionals resulted from previous initiatives intended to assist health professionals in their key roles of preventing violence and providing comprehensive health and social services to survivors of abuse. Federal and provincial funding of these initiatives supports the vital link between effective practice and the educational programs for various health professionals. Such programs include pre-service, graduate and continuing education curricula to prepare practitioners for collaborative work on violence issues. Thoughtful reflection by many concerned players underscores a central tenet of violence and abuse as it concerns health professionals: violence prevention - in society and among intimates and family members - and the care of survivors is an interdisciplinary, community concern. Nevertheless, while recognizing role blurring in certain instances and the need for collaboration among health care workers, members of particular disciplines must first master the distinct role their own profession plays in the overall mosaic of a community's health care system. Although most violence among intimates and against family members occurs "behind closed doors," the survivors of abuse, whether attacked in public or private, almost invariably come in contact with a health professional - either for treatment of acute injury, because they are at risk of injury from violence, or as a result of the long-term emotional/mental or physical damage ensuing from abuse. Clearly, then, all health care providers are in strategic positions to prevent violence, detect risk and victimization of vulnerable groups (especially women and children) and provide services to survivors of abuse as well as to their assailants. Yet, despite, widespread recognition of the serious impact of violence and abuse, attention to the topic is largely incidental rather than systematic in the education of health professionals. The unique role of health professionals derives from their numbers, the variety of their practice locations and their contact with potential victims from birth to death. Their central place in this poignant facet of life is also grounded in the fact that health and health care provision constitutes one of the major domains of social life, along with economic, religious, political, legal and educational institutions. While every citizen has a role to play in eliminating the worldwide plague of violence against women and children, the power of health professionals to make a difference on this issue cannot be overstated. Not only can health professionals ease the profound suffering of victims, but their efforts can favourably affect assailants, entire families and society as a whole. Purpose and Scope The topic of violence presents a greater-than-average challenge to most educators and clinicians charged with teaching and role modelling on this practice issue. In addition to the usual complexities of psychosocial health care, violence is linked to values and structures which touch life ways and the social interactions considered sacrosanct by many, though also dangerous to some, especially women and children. The intent is to aid faculty and clinical preceptors in the health professions1 to address violence prevention and the care of abused clients in a manner that is: However, it is recognized that survivors of abuse and their assailants are encountered more frequently, if not routinely, by certain health professions, for example, medicine, nursing and dentistry in emergency and trauma centres, family medicine, obstetrics and gynecology, pediatrics, psychiatry, nurse practitioners2 in maternal/child, women's health and family practice, midwives, medical social work and child welfare practitioners, and graduate students in community health, maternal/child health and psychosocial nursing.3 As with any subject newly introduced for comprehensive curriculum coverage in undergraduate or graduate educational programs, this topic must be adapted to the background of students considering such factors as age, ethnicity and exposure through experience or an undergraduate elective. The recommendations presented can also be applied to in-service education programs for those whose formal education and clinical placements did not systematically address the topic of violence and abuse.
1 The health professions included are dental practice (dentists, dental hygienists, dental assistants, dental therapists), medicine, nursing, occupational therapy, pharmacy, physiotherapy, psychology (clinical), social work (clinical/medical). 2 The term "Advanced Practice Nurse,"
in this Guide includes the following nurses with graduate degrees: nurse
practitioners, nurse-midwives and clinical nurse 3 In non-Canadian settings, the role of physician assistant, usually prepared at the master's level, is also relevant. Because caregivers' contacts with victims, survivors and perpetrators encompass many situations throughout the life span, the major categories addressed are: Disciplinary and Interdisciplinary Issues While the Interdisciplinary Curriculum Guide is comprehensive in scope and in the number of health professions it addresses, implementation of the Guide's recommendations will vary widely according to discipline. The landscape of this poignant topic is fraught with claims, counterclaims, accusations and disavowals of responsibility for violence prevention and the care of victims. This contemporary response contrasts sharply with that of traditional peoples whose customs included community-based supportive rituals and responsibility for individuals and families in crisis or passing through major transitions (van Gennep, 1960 [1909]). Although violent attack - by family member, intimate or stranger - almost invariably carries criminal sanctions, its health sequelae are widely assumed. Now that national and international bodies have proclaimed violence as a grave public health issue, and the health implications of social behaviours, such as interpersonal violence, are undisputed scientifically, it is no longer a question of whether health professional students should be prepared to address this problem. Rather, the question is: How can this task be addressed systematically, and what are the differential responsibilities for victim/survivor care and arenas for collaboration among various health professionals? Violence prevention and the care of traumatized persons are everybody's business, though the parameters of particular professionals' responsibilities vary. Put another way, today's health professionals can be seen as "ritual experts" (substitutes for the wise elder or healer in traditional societies) whose tasks are to assist victims, assailants and children in "contemporary rites of passage" to a violence-free life (Hoff, 1990). The delineation of individual and collaborative tasks to achieve this end is a major goal of this Guide. For example, physicians, nurses, dental practitioners and physiotherapists are frequently the first to encounter a person suffering traumatic injury from abuse. Pharmacists may see survivors attempting to "self-treat" with drugs; occupational therapists and physiotherapists detect abuse in community-based programs for the physically disabled and elderly; clinical social workers and psychologists frequently provide follow-up counselling or psychotherapy. However, all must know the basics, including identification and referral, and some must know the details of crisis intervention and follow-up treatment. The Guide assumes two basic tenets about interdisciplinary collaboration on this and other sensitive health practice areas. There has been considerable debate about language, the terms used to define the problem and the theoretical underpinnings of abuse and violence (Dobash and Dobash, 1979; EFPO, 1993; FVC 1991; Hoff, 1990; Segal, 1987). The analytic framework informing this Guide is eclectic and interdisciplinary, drawing on concepts from crisis theory, victimology, socio-cultural analysis and life-event research, especially the contributions of community activists and feminist scholars who brought the issue of violence to public attention in the first place (Burgess and Holmstrom, 1974; Herman, 1981; Hoff, 1990: Martin, 1976; Pizzey, 1974, Schechter, 1982). Last but not least, the ideas and stories of numerous collaborators were central to developing this Guide. Basic to critical theory, oral history and complementary gender analysis is the importance of making one's values explicitly known. Accordingly, several assumptions are presented. Definition of Violence Violence is a social act. It constitutes behaviour for which the perpetrator is accountable to the moral community. Historically, violence has sometimes been excused as a "cultural norm"; the term "cultural relativism" describes such a misplaced attribution. Another traditional interpretation defines violence as an inevitable outcome of aggressive instincts. Today, however, most violence scholars reject analytic frameworks, such as socio-biology, which serve to maintain violence as a private matter (Davidson, 1977). Instead, violence is now widely interpreted in psychosocio-cultural and feminist terms, that is, as a predominantly social phenomenon with far-reaching effects on personal and public health worldwide (Burstow, 1992; ICWHI, 1992; MacLeod, 1989; FVC, 1991; Report, 1986; Wendell, 1990; Yllo and Bograd, 1987). That is the position taken in this Guide. In such a framework, violence, in most instances, constitutes behaviour learned in a milieu permeated with social inequalities based on age, gender, ethnicity, etc.; and on images of violence and physical force as the dominant modes of conflict resolution. Violence consists of exerting physical force and power over another - usually with the intent of controlling, disempowering and/or injuring the other. Though violent abuse has serious implications for physical and mental health, it is not a medical phenomenon, except in the few instances when a person is found to be "insane" - a legal term designating a person's mental incapacity (and therefore excusability) while behaving violently (Monahan, 1981; VandeCreek and Knapp, 1993). Nor is violence merely a criminal justice phenomenon. Rather, it crosses legal, ethical and health care domains thus rendering it a complex issue with moral, socio-cultural, political and personal ramifications. Physical violence is almost invariably accompanied by verbal abuse. For example, regular verbal threats of abuse or killing cause no immediate physical trauma, but clearly strike terror and fear for one's life in the heart of the victim. The Interdisciplinary Curriculum Guide recognizes the damaging effects of verbal abuse, the particular traumas of racial or ethnic slurs, and the taunts directed at lesbian and gay people or those with disabilities. Such verbal abuse is usually rooted in bias, fear and hatred, and is often followed by threats or acts of physical violence. Persistent psychological abuse, even without physical attack, can devastate a person emotionally and lead to serious health problems. Also, verbal abuse usually precedes physical abuse. However, in order not to underestimate the life-threatening nature of some violence, it is important to distinguish verbal insults, for example in a dating relationship, from sexual or other assault at knife/gunpoint. The terms "abuse" and "violence" are used interchangeably in the Guide, though abuse especially sexual - does not always entail physical injury. For example, an incest victim, after several years of abuse, may have no visible injuries, but most surely she or he is "violated" and almost invariably suffers severe emotional trauma (Herman, 1981). As battered women often say: "It is easier to heal from the physical wounds than the emotional ones," though the two are linked. Violence In and Beyond the Family In most communities worldwide, the greatest risk of attack is from family members (Gelles and Cornell, 1983; Hoff, 1992b; Motsei, 1993). However, the term "family violence" obscures the reality that most perpetrators within the family are men, and most victims are women of all ages and children (Finkelhor, Gelles, Hotaling and Straus, 1983). "Family violence" also deflects attention from the socio-cultural roots of abuse which extend beyond the family to deeply embedded cultural values and traditional social structures which disempower women and children. Further, "family violence" excludes a major violence category: acquaintance and stranger violence and rape, as well as sexual exploitation by therapists and other professionals. Victims and Survivors The term "survivor" is preferred, and refers here to a variety of persons regardless of the relationship to the assailant - family member, intimate, therapist, co-worker, acquaintance, stranger, patient/client. "Victim/survivor" is intended to acknowledge explicitly one's victimization while simultaneously conveying an abused person's potential for growth, development and empowerment, i.e., a status beyond the dependency implied by "victim" (Mawby and Walklate, 1994). An emphasis on growth beyond "victimhood" to "survivor" status is underscored in a contemporary climate in which some individuals, under criminal trial for violent acts, use their history of victimization as grounds for "temporary insanity" pleas and unaccountability for personal behaviour. Certainly, those who have been deeply wounded by abuse deserve an appropriate social and health care response. While so responding, however, it is crucial to acknowledge the inherent freedom, resilience and indeterminate nature of human beings and their capacity to rise beyond tragic circumstances - particularly if they receive social support (Antonovsky, 1987). Foundations of Victimology Current international attention to the abuse and victimization of women and children is due, primarily, to the groundwork of community activists and women's studies scholars, with health professionals joining later. The field is now often referred to as victimology (Campbell and Humphreys, 1993; Hoff, 1991; Russell, 1990). The insights and practice protocols of these pioneers are fundamental in developing complementary programs in health and welfare agencies which traditionally have underserved victims/survivors of abuse. Rather than duplicating such protocols, this Guide incorporates them as major resources for various health care professionals. Violence, Values and Culture Professionals, like other members of a cultural community, are informed by deeply embedded beliefs, myths and traditions concerning women, marriage, the family and violence (Changing the Landscape, 1993; Hoff, 1990; Kurz and Stark, 1988). As a result, despite claims of neutrality and objectivity, research, theoretical formulations and practice protocols on behalf of victims/survivors are value-laden. For example, female genital mutilation (FGM), a rite of passage in some cultures, until recently has been excused under the, guise of a cultural norm. Instead of the cultural relativism illustrated by such a stance, this Guide accepts the World Health Organization definition of FGM as a human rights violation which is now professionally and legally proscribed in Canada and some other countries (Hosken, 1981; Saadawi, 1982; Gullen, 1992).4 The cultural norm excuse for indifference to violence is also revealed in language. After noting repeated episodes of violence against a native woman, the frustrated observer says: "That's the way they are ... What can you do?" The remark fails to connect personal trauma to the tragic political oppression and forced social isolation endured by aboriginal people (LaRocque, 1994; Wakegijig and Jenkins, 1992). Such thinking obscures the reality of pre-reservation life among the Lakota, for example, when wife beating was rare, "taboo," a violation of harmony, moderation and the deeply embedded value of equality between adult men and women (Mousseau, 1989, p.8). In a similar vein, most adults in Western societies believe it is impossible to rear a child without, at some point, using physical discipline, despite research documenting the negative results of this approach to child rearing (Gil, 1970; Greven, 1990). Children in traditional cultures are not just the responsibility of their parents, whose parenting abilities may vary; they are considered the responsibility of the clan or the entire community (Brendtro, Brokenleg and Van Bockern, 1990; Mandamin, 1993). Additionally, some people still believe that women who are raped have somehow "asked for it." As one informant said: "Some don't believe the survivor's reality ... that is one of the worst things they can do." Unfortunately, the legacy of disbelieving victims is still alive. In some treatment settings, survivors may face double jeopardy in that traditional psychiatric theories distort the realities of sexual abuse. For example, in the past, a primary problem of sexual abuse may have been obscured under a diagnosis of "borderline personality disorder." Such a diagnosis may discredit the woman brave enough to disclose her victimization history during treatment, and affirm the value placed on psychiatric nomenclature (Becker, 1963; Burstow, 1992; Daniels, 1978; Goffman, 1963; Mitchinson, 1993; Morgan, 1988; Warshaw, 1989). Victim-Blaming One major result of health professionals' acceptance (until recently) of mainstream values about violence is the blaming of victims for their plight, a legacy embedded in the psyches and attitudes of abused clients as well as their caretakers (Hilberman, 1980; Rieker and Carmen, 1986; Ryan, 1971). One incest survivor asked: "Am I guilty for loving my father? It was up to my dad to draw the line... He was the adult in control." The commonality of self-blame and depression among victims is linked to society's traditional allocation of accountability for violence to victims rather than to their assailants (Caplan, 1993; Cloward and Piven, 1979; Jones, 1980; Martin, 1976; Mawby and Walklate, 1994; Stanko, 1990). The battered woman's query: "How can I please my husband?... I did everything he demanded" varies only slightly from the counsellor's classic question: "What did you do to provoke him?" In other words, victims tend to blame themselves because they have first been blamed by others.
4 The College of Physicians and Surgeons
of Ontario directs its members not to perform female genital mutilation.
If they do so, they can be charged by this This question implies the ironic expectation that battered wives - to stop the abuse and escape death itself - take up the role of fugitive, along with continued responsibility for children, while assailants often go on with life as usual (Hoff, 1990). Recent mandatory arrest laws give a new twist on the tradition among First Nations: if a man battered his wife, he had to leave, he couldn't marry again, couldn't lead or take part in a war party or hunt, or own a pipe (Mousseau, 1989, p. 13). Canadian men's National White Ribbon Campaign similarly illustrates that wife abuse is not merely a women's issue, but a community responsibility. The deeply embedded process of victim-blaming is compounded by the influence of " medicalization, " that is, the tendency to interpret a life problem, whether medical or not, in a medical framework (Hoff, 1989). In the case of violence, this means diagnosing the victim (e.g., depression or "borderline") and excusing the assailant (e.g., temporary insanity), thus alleging psychopathology and obscuring the socio-political roots of the problem (OMA, 1985; Stark, Flitcraft and Frazier, 1979). Client's Experience and Empowerment as Base To be relevant, health service and education protocols, on behalf of victims/survivors, must be grounded in the realities and complexities of the victimization experience. As a battered woman stated in response to the question of what health providers might do to help: "Come to a shelter...listen to our stories ... learn how to be with us ... we don't expect you to do it for us, but just be there to help when we finally decide to leave." Health educators on this topic must therefore immerse themselves - at least vicariously - in the unique and tragic world of victimization as a way to lend credibility to their teaching. Key to survivors' empowerment is a partnership with them which recognizes that they are in charge of their healing and do not expect to be rescued. Incidence of Abuse: Facts/Myths Statistically, most violence worldwide is perpetrated against women of all ages, children (girls and boys) and other men by heterosexual males (homophobia notwithstanding). Nevertheless, some women abuse their male partners, and mothers physically abuse children in numbers approximately equal to that of abusive fathers, stepfathers and boyfriends. This figure is misleading, however, considering that mothers typically spend much more time with children than fathers do, and their abuse is not as injurious physically (Martin, 1983). Similarly, lesbian and gay partners are not immune to violence (Lobel, 1986; Renzetti, 1992). Yet, among couples, the most serious injuries are inflicted by male abusers and, in the majority of instances of female violence, the occasion is self-defence, usually with no medically serious injuries resulting (Wardell, Gillespie and Leffler, 1983). Furthermore, when women do resort to violence, more serious abuse or murder by their male partners often follows (Browne, 1987), thus countering the common myth of violence as an acceptable or necessary response to violence. This Guide also underscores the double jeopardy of those experiencing social and physical isolation rooted in prejudice, inaccessibility of service and geopolitical factors, e.g., native people, immigrant or racial minorities, people with disabilities, lesbian women, rural women and children. Violence and "Learned Behaviour" The incidence of female violence in both heterosexual and lesbian relationships is increasing. While this issue has not been extensively researched, it does suggest evidence of:
Last, but as this Guide's title implies, not least, as in other high-risk, stressful work, health care providers cannot expect to provide appropriate service if they are working alone and have care prove a highly individualistic focus. Since violence is essentially a social phenomenon, a collaborative approach, including the biopsychosocial parameters of the situation, is paramount. Consider, for example, the prevention of further abuse in the case of an infant who is severely injured and in critical medical condition. The mother was sexually molested as a child and now lives with a highly controlling boyfriend. She failed to bond with her infant. A comprehensive team approach would help the abused and abusive mother to heal and prevent further damage to the child. The social worker would work with the overburdened mother and deal with mandated reporting; the physician would treat the injured child and assure follow-up; the nurse would assist with treatment of the child and case coordination, including possible referral for follow-up physiotherapy for the child and counselling for the mother. Through such teamwork health providers can promote:
Approach to Violence Education The Interdisciplinary Curriculum Guide emphasizes an experiential or emic approach to learning. That is, the prevention of violence and the identification and care of abused women and children demands that would-be helpers aim to capture empathically the realities of the victimization experience from the perspective of the victims/survivors themselves. The Guide, therefore, contains ethnographic data to aid one's understanding and action on behalf of these clients. Survivors' stories, as told here, are central to building bridges between lay persons' and professionals' visions of violence and what it does to people. Identifying information about survivors has been altered to protect privacy. Some, on a first reading of these stories, may feel overwhelmed, a response akin to culture shock. While acknowledging limitations of the written word, such a reaction can enhance the reader's empathy with survivors who live with the realities expressed here for the benefit of health providers. It also signals the importance of self-care and a collaborative approach to this topic. Besides presenting the "inside" reality of survivors, the Guide also tries to capture the "inside" world of health practitioners. It recognizes that the work of violence prevention and victim care can exact a toll on providers, and that peer support and teamwork are crucial if health professionals are to avoid withdrawal out of self-protection. The Guide generally avoids a "how to" approach in favour of presenting general principles arising from these diverse ethnographic sources, including the experiences of community experts working with survivors of all ages. In addition to selected illustrations, it cites bibliographic sources for those wanting more specific examples of curricular and teaching strategies. Another focus is on the complexities of this service domain, for example:
Finally, the Guide complements, rather than replicates, major resources already published for particular disciplines. For example, the Family Violence Clinical Guidelines for Nurses (Canadian Nurses Association, 1992) is a useful document, but not intended as a substitute for systematic classroom and clinical instruction on the topic. Violence Education: Toward a Solution, published by the Society of Teachers of Family Medicine (Hendricks-Matthews, 1992), contains substantive theoretical content and some course development suggestions for family medicine (a major player in the interdisciplinary landscape), and thus supports the major purpose of this Guide: to provide a succinct aid to interdisciplinary curriculum development across the spectrum of violence and survivors of abuse. CHAPTER II
Core Content: Essential Knowledge, This and the following chapter build on the premise that the issues of violence prevention and victim/survivor care, while essentially interdisciplinary, also have discipline-specific features. Therefore, this chapter contains certain generic components which apply to any and all providers in the health and social service system. For example, no matter the discipline, when a service provider hears a victim of rape or battering blame herself, it is basic that the listener provide an alternative message to interrupt the cycle of self-blame for the deviant behaviour of another: "No, it's not your fault... No matter what you said, violence is not an acceptable solution to a problem." It says, in effect: "Society cares about the wrongful injury of its members." Such a message has the potential of reversing the legacy of blaming the victim which has permeated health and welfare agencies. This example of client-provider interaction illustrates that psychotherapeutic communication transcends the professional identity of the provider: an empathetic message is more important than the messenger. The following section outlines generic content essential to the knowledge, attitudes and skills of health team members and includes suggestions on the relevance of this content to practice. The Interdisciplinary Curriculum Guide recognizes a variety of teaching methodologies. Yet, recommendations regarding core content assume the principles of adult learning which emphasize an interactional and experiential vs. hierarchical relationship between learner and teacher (Knowles, 1980). Such an approach allowing ample time for discussion and clarification is particularly important when addressing value-laden content. (Methodology is discussed in greater detail in Chapter V Implementation Strategies.) The Concept of Core Content Core content can be used in several different contexts. In formal pre-service professional programs, it would be part of a total curriculum. (For those professionals already in practice whose formal preparation did not include the content discussed here, these curriculum principles apply to continuing education or in-service programs.) The term "curriculum" refers to the complex array of learning activities or a body of courses organized to achieve specific educational goals. Core curriculum encompasses those courses or learning units required of all students graduating from an educational institution, without which the educational goals would not be met. Moving to the course or unit level, "core violence content" refers to the knowledge, attitudes and skills essential to any person working with survivors and assailants, regardless of the discipline, setting or framework in which she or he learned this content (Hoff and Miller, 1987). The concept of core content is central to the purpose of this Guide for several reasons.
Though already implied, the emphasis on core content here refers primarily to the knowledge, attitudes and skills of the generalist. Specialists' roles in victim/survivor care are also addressed, not only because of their importance in a comprehensive service system, but to help generalists clarify their own responsibilities and know when to refer to others. While recognizing the need for various specialists - given the complexity of this health care issue - the centrality of preventing violence and the serious health and mental heath impairments that can follow underscore the fact that most abused persons are first seen by health providers at various entry points to the health and welfare system. These entry points include primary, secondary and tertiary levels of prevention and service. The potential for violence prevention and the treatment and rehabilitation of victims/survivors exists in each of these three facets. The concepts of primary, secondary and tertiary prevention (Caplan, 1964; Hoff, 1989) are briefly reviewed here for their particular relevance to violence and its sequelae. Primary Prevention Consisting of education, consultation and crisis assessment and intervention,
primary prevention is designed to reduce the incidence of violence and
abuse, promote growth and development through the crisis resolution process
and enhance a potential victim's future resistance to abuse. Traditional
primary prevention strategies include the following.
Secondary Prevention As the name suggests, secondary prevention (associated with treatment) implies that some form of physical and emotional trauma has already occurred as a result of abuse or violent attack, either because primary activities were absent or because of the person's inability to profit from available services. A major aim of secondary prevention is to alleviate the pain of trauma and shorten the length of time a person may be disabled by abuse. This means detection and treatment at entry points, such as trauma and dental centres, and referral for counselling. Crisis intervention and counselling are major next steps in achieving this aim and in preventing institutionalization and serious emotional/mental dysfunction as sequelae of abuse. For example, health professionals frequently observe that, once a battered woman enters the downward spiral to depression (usually because she lacks the social, psychological and financial resources for escape from her abuser), she is more prone than before to desperate crisis-resolution tactics such as substance abuse, suicide or killing her abuser. Tertiary Prevention Tertiary prevention (associated with rehabilitation) alms to reduce the long-term disabling effects of abuse. The unfortunate truth is that this level of prevention is currently relevant in considerable measure because violence by intimates and family members is only recently acknowledged to be a public health issue as opposed to its traditional interpretation as a "private" matter. Also, some health and mental health professionals may have refrained from talking with clients about concerns stemming from their abuse histories out of the perception that this is a "specialist's" job, not theirs. As a result, many clients with chronic mental or physical health problems continue to suffer because the primary problem - abuse or violent attack - was either untreated altogether or obscured in an earlier era by a medical or psychiatric diagnosis. For example, women who suffered an invasive body trauma through sexual abuse as children may suffer extreme anxiety or panic during dental visits. Only recently is abuse and violent attack beginning to appear in the nomenclature of official health statistics - a symbol of its emergence from "behind closed doors" to public concern. For example, trauma to women from battering exceeds that from accidents, mugging and stranger-rape combined. The history of treating female clients who have histories of abuse primarily for "depression" or behaviours ascribed to such diagnostic entities as "borderline personality disorder" is now widely discredited (Burstow, 1992). Increasingly, groups are available in hospital and community settings which offer services tailored explicitly to the needs of abuse survivors. Given current constraints on mental health resources, it is important for health professionals to maintain workable linkages with such groups. Doing so can prevent recidivism among clients whose problems can ultimately be traced to untreated traumatic injury at earlier points of entry to the health and social service system. These realities underscore the urgency of including crisis assessment and intervention as an integral facet of primary prevention in psychosocial health care delivery. On the other hand, since routine attention to victimization in primary care is only now emerging, it is equally important that practitioners in secondary and tertiary care settings move beyond crisis components of care to evaluate and treat victimization as the root or significant part of many long-standing mental health problems. (One issue receiving public and professional examination is "repressed memories" of child abuse attributed to therapist intervention. However, this controversial issue does not negate the importance of believing people's stories of abuse.) The current emphasis worldwide on health promotion and primary care underscores the importance of front-line clinicians in identifying victims of abuse and preventing the long-term damaging effects of neglect at the time of victimization crisis (Bishop and Patterson, 1992; Herman, 1992; Hoff, 1992a; Mandt, 1993). A repeated point made by survivors interviewed for this Guide was that no providers - nurses, physicians or others had asked them about their abuse histories. General and Specific Functions of Health Professionals The core content presented here refers to the essentials within the health care system, or among diverse providers as a whole. It dots not imply that each provider, no matter what the discipline, must master each item. The intent, rather, is to delineate the broad parameters of comprehensive service to survivors. While all providers need a general understanding of the "big picture," no single provider is expected to be "all things to all survivors." It is the task of educators from particular disciplines to specify, for students, which pieces of the whole correspond to their profession's mission (e.g., detection and referral, treatment or follow-up). However, it is legendary that some clients "fall through the cracks" of an uncoordinated system because interdisciplinary collaboration has failed or because of naive assumptions about "somebody else's" responsibilities for particular tasks. Accordingly, this chapter is not intended to overwhelm, but to provide background for the next chapter's ethnographic illustrations and delineation of interdisciplinary and discipline-specific roles. Table I portrays the "big picture" plus areas of role blurring among various health professionals. It also delineates, in general, the roles of particular disciplines to assure comprehensive service and avoid harmful fragmentation of tasks. For example, the primary role of dental practitioners and physiotherapists is to detect signs of abuse, treat and make an effective referral for follow-up counselling while a pharmacist may detect abuse, assess safety, teach about appropriate use of drugs and refer. Though this table distinguishes between generalist and specialist roles, it should not be assumed that graduate training in itself is sufficient preparation for serving the special needs of survivors if it does not include formal instruction, clinical experience and supervision along lines suggested in this Guide and in other resources. Knowledge Essential concepts in the violence field include two broad categories:
Key Concepts As used in this Guide, the term key concepts refers to the theoretical underpinnings to health status and service delivery. The problem, incidence and socio-cultural context: Categories and Functions of Particular Disciplines Discipline
Function
Attitudes Attitudes are based on one's knowledge of a topic, as well as on deeply embedded values, whether these values are rooted in myth or fact. Among lay persons and professionals, the common question "Why do battered women stay?" reflects the traditional belief that it is the victim's responsibility to do something about abuse. Given the legacy of victim-blaming, legal loopholes for women who take action and the real danger a woman faces even with (or sometimes, because of) a peace bond (restraining order), most abused women must still leave their homes to avoid further injury or even death. However, it is a commentary on the powerful influence of attitudes and values on public policy and program planning when we consider that we have not asked instead: "Why are violent men allowed to stay?" or "Why should the victim rather than the assailant be expected to leave?" (Hoff, 1990). A change in cultural norms regarding violence and its widespread tolerance requires an examination of personal attitudes and citizen inaction which support a climate of violence. For example, war and corporal punishment are socially approved forms of aggression, while TV violence could not thrive as it does without consumer support. Deeply embedded values regarding aggression create a scenario in which individuals facing conflict and stress can readily turn to violence as solutions to problems. One male counsellor of abusive men finds that the biggest problem is the tradition of "not holding the guys accountable" for their violence. Success with men who batter, he says, assumes a feminist value system which acknowledges the power dynamic in abusive relationships. It also implies the adoption of the traditional values, such as equality, harmony, cooperation and moderation, that characterized pre-colonial life among First Nations. While epidemic rates of violence cross ethnic, class, gender and national boundaries, all must confront the dramatic fact that rates of violence for many First Nations people now greatly exceed those of other groups. Data reflect the reality that a subjugated people learned violent ways in domestic life from those who confined them to reserves, introduced alcohol and essentially destroyed their way of life (Brendtro, Brokenleg and Van Bockern, 1990; Mousseau, 1989). This pattern is by no means unique to Canada, but is found among many nations, e.g., African countries, Australia, Micronesia, USA, in which one people (the colonizing society) imposed control and their values over another (Hoff, 1992b). A parallel pattern is evident in the domain of gender relations. Women, traditionally nurturant and life-preserving (Ruddick, 1989), increasingly are choosing the violent competitive approaches to conflict resolution that characterize traditional male behaviours. A revised learning curve is therefore required. The dominant, the colonizers, the violent, need to adopt the more peaceful behaviours of those whom they oppressed, while the victimized need to eschew the violence they have learned and reclaim their more harmonious heritage. Since health professionals, like other societal members, are influenced by the dominant values which have spawned and exacerbated the plight of victims/survivors, health professions must take time to clarify the values of candidates before they are selected into the professions and prepared to care for society's abused members. An appropriate attitudinal stance, flowing in part from research-based knowledge, lays the foundation for crisis intervention, counselling and treatment of victims and their assailants. A worker's deeply held values can form barriers to otherwise skilful application of knowledge, if not examined in relation to their potentially negative impact on abused women and children. For example, a judgmental attitude can effectively neutralize the value of "technically correct" communication with a victimized person. When compared with knowledge and skills, attitude presents the greatest challenge for both teachers and learners. In female-dominated professions, such as nursing, physiotherapy, occupational therapy and social work, educators note that a significant attitudinal barrier in dealing with this topic is the students' views regarding feminism. As one nurse educator stated: "They seem to equate it with burning their bra' and lesbianism [1960s stereotypes]. They don't want to appear radical in their thinking... So I had to go around it in a different way and they were more receptive." In male-dominated professions, such as medicine, dentistry and pharmacy, similar dynamics are apparent. Women physicians of feminist persuasion, for example, are challenged with the balancing act of how to include male colleagues in discussions of sensitive gender issues while avoiding both alienation and appeasement. Clarification of values, then, aims to expose all students to a broader conception of gender analysis including progressive concerns with child care, equal pay and parenting, degrading media portrayals of women and nurses, gender and other disparities in the health care system, stopping violence - issues affecting all of society, not merely a minority of radical feminists. Without a climate that promotes discussion of values, myths and stereotypes, some may feel silenced in order to fit into the profession and institutions in which they work. For example:
Skills Caring for abused persons requires a number of skills.
Consider the example of a woman hospitalized for complications of Pregnancy. Among risk factors to be considered are gestational diabetes and abuse by her spouse. Epidemiologically, the risk of gestational diabetes is 2% to 6%. The risk of current or past history of abuse is around 95% (McFarlane, 1992; Rodgers, 1994; Stewart, 1993). Each risk factor comprises essential core content in medical and nursing curricula. Most nursing and medical educators would concede that gestational diabetes is less complex for student mastery than the issue of wife beating. Thus, when considering these two content areas in curriculum development, decisions can more easily be made against the standard of essential knowledge, attitudes and skills. Unlike wife battering, gestational diabetes is not embedded in values an myths which may affect both the practitioner's ability to broach the subject in routine assessment and the woman's willingness to disclose. Rarely would such factors complicate a physician's or nurse's assessment and teaching of diabetes. Accordingly, this example suggests that curriculum planners allocate relatively less time for diabetes than for wife battering. In fact, gestational diabetes might be covered in reading and self-directed learning, while wife battering almost certainly requires teacher-facilitated classroom discussion. Essential knowledge in this example includes: CHAPTER III Ethnographic
Examples Of Abuse This section elaborates further on the essential knowledge, attitudes and skills needed by health professionals in specific abuse situations: These survivor stories do not exhaust the victimization/abuse spectrum. Rather, the intent is to illustrate the complexity of victimization and the interrelatedness of abuse across several categories as a basis for curriculum planning. Faculty use of the stories - or portions thereof - will vary according to the professional mission within the overall health system and the level of student. Or, instructors might use them as a starting point for developing their own teaching tools. The examples provide a mini-field experience of sorts for entering the world of victimized people and connecting that experience to planning health and social services with them. By listening carefully to survivors' stories - here, in the literature and in real life situations we take the first important step in helping. The next step follows from an understanding of "here's my role ... here's what we do together." The stories are presented as aids for faculty to illustrate the range and interdisciplinary implications of violence prevention and victim/survivor care. Their direct use with students is an individual faculty decision depending on class, unit or course objectives. For example, students might be assigned the task of identifying, in small groups, their own and others' roles, as noted in each example. As already suggested, students from specific disciplines would not be expected to respond alone to the multi-faceted service ramifications of these examples. Rather, it is understood that many undergraduate students (e.g., medicine, nursing, occupational therapy, physiotherapy) may be limited to identifying victim status and providing support, listening, crisis intervention and referral. Clearly, such care is not only important, but may constitute the first step toward the comprehensive service most abuse situations demand. Others (e.g., dental practice, pharmacy) might only identify, maintain a supportive attitude and refer. Still others (especially graduate students in family medicine, midwifery, nursing, psychology and social work) may be active participants in meeting survivors' counselling and follow-up treatment needs. Besides the survivor story, each example contains a discussion of.
Though only seven situations are presented, the discussions include suggestions for addressing the needs of persons in similar abuse categories. For example, the concepts of social isolation, multiculturalism and bias are relevant to several abuse situations: battering of a visible immigrant minority or lesbian woman, female genital mutilation or the rape of a native or disabled woman. The illustrations may assist faculty of particular disciplines in providing a curriculum and teaching-learning situations that will meet three goals: Child Abuse/Battering Bobbie, age 7, is brought by his mother, Ms. Sarah Jones (hereafter Sarah),5 to a local emergency facility for an acute rash. During the physical examination and treatment, emergency personnel note that Bobbie has several welts on his buttocks. Following treatment for the rash, while Bobbie is resting, the nurse speaks with Bobbie's mother about the welts which she and the physician suspect might have originated from use of a strap to discipline Bobbie. Sarah readily acknowledges that she strapped Bobbie several times and goes on to say that she has been discussing her problems with a child protective caseworker, but has not told the worker about strapping Bobbie. She describes her discipline of Bobbie as "mild compared with the beatings he took from his father." in fact, one of the reasons she finally left her husband is that she was afraid for the children as well as herself (Sarah's other child is a daughter, age 9). Sarah states that, on one occasion, she was nearly strangled to death, and on another occasion she took after her husband with a meat cleaver but became very frightened when she realized how close she came to possibly killing him. Most of these violent incidents occurred when her husband drank excessively. Sometimes Sarah also drank a lot, thinking if she joined him, maybe she could appease some of his outbursts. Sarah has watched some TV shows on child abuse. "But, you know," she says, "when we grew up you knew... you misbehaved? you knew you had it coming." Sarah claims she is trying to get hold of herself and stop disciplining Bobbie so harshly. She says the worst times are after she has a "disappointing dating relationship with a man and I take out my frustration on my kids." "Sometimes," she says, "instead of hitting the kids, I just let 'em fight, and I sit there and eat or drink too much." Since leaving her husband Sarah is parenting her two children alone on public assistance, while also attending a vocational training program "in order to better myself" Sarah is interested in a parents' support group her caseworker mentioned, but she has not yet found time to attend. Nor has she ever attended any groups for substance abusers. "Maybe if I went to one of those AA [Alcoholics Anonymous] meetings I could find a husband who wouldn't beat me. " Key Issues/Concepts The concepts illustrated in this case include: 5 This document avoids the use of titles for clients as well as providers. Though first names are used in these stories, it is understood that unequal use of titles in clinical practice may mirror power imbalances within the health care system as a whole. Does the situation warrant a report to child protective services? General understanding of the law says "yes." Though Sarah seems to sense that strapping her child may not be appropriate, she apparently believes, as many parents do, in the necessity of physical discipline. Also, while intimacy constitutes a basic human need, Sarah's behaviour appears "desperate" enough to compromise her goal of finding a non-violent husband, in addition to wreaking havoc in her single parenting role. Health professionals attempting to help Sarah and Bobbie with the interrelated problems of psychosomatic ailments, physical injury from discipline, substance abuse and the tradition of women's responsibility for children will need to examine their own attitudes, experiences and beliefs about the issues involved here. Clinical Practice Skills Key practice skills illustrated on behalf of Sarah and her children include: At the interdisciplinary/generalist level: Specialists who might serve in this case for follow-up care are: Suggested Learning/Practice Situations It is unlikely that clinical assignments could provide all students with a direct practice opportunity comparable to this case or one in which physical trauma requires extensive follow-up treatment. But several approaches could afford a vicarious learning experience, particularly in a maternal/child/family health and related course in nursing, medicine, physiotherapy, occupational therapy, social work and clinical psychology: Greven (1990) Spare the Child. Nicarthy (1989) You Can be Free. Wachtel (1989) Child abuse: Discussion paper. Rape and Childhood Sexual Abuse Susan is a 35-year-old woman with two children, currently working as an advocate in a rape crisis centre. As a child, from age 6 until she was 11 Susan was sexually abused by an uncle who assisted her mother with child care, especially while her father was away for week-long stints on his job as a travelling salesperson. Not only was Susan unable to tell her mother about the abuse, but she also was emotionally abused by her mother and Physically abused by her father. On one of those occasions her teeth were knocked loose, but Susan's mother told the dentist a story to cover up what really happened. To escape her miserable home life she left at age 16, worked as a waitress while finishing high school and married her boyfriend at age 18. Susan is now aware that she married for financial security and to escape her abusive background. Her marriage was never very solid. As Susan tells it, in response to her disinterest in sex, "my husband forced it on me" several times, but "I didn't think of it then as rape." After coming out as a lesbian, Susan finished college, divorced her husband, now shares joint custody of the children with him and says their relationship is "friendly." She describes him as a "good man, a good father" and understanding of her lesbian identity. Susan lives alone, has a supportive group of friends and is now drug-free and successfully employed. Before reaching this point, however, for several years Susan was frequently depressed, dependent on tranquillizers and anti-depressant drugs and in emotional turmoil, primarily, she says, as a survivor of childhood sexual abuse, the effects of which she dealt with through repression and dissociation. I don't think I really wanted to die, I wanted the pain to end... I just wanted out. I didn't see any other avenue... I really do think that therapy is necessary but I also think that it's a re-abuse experience because you have to re-live it all. I think it's the only way but it's horrible. After her divorce, and the successful therapy dealing with the abuse history, Susan went on to finish a degree in human services administration, developed a very solid relationship with her lesbian partner, a professional in government service, and was doing very well in her class work. In college, one of Susan's classmates became interested in her romantically. Finally, I started talking to my friends and was really pressured to take this man to court. But, you know, the, fact that I'm a lesbian and my partner was a public official all had big repercussions on my choice. I felt limited in my choices, but then I felt guilty because this man is still at large. And I felt angry at myself for not handling it well. You know I think actually my lesbianism probably was a factor in this man because you know there is this real myth and lie out there that lesbians just need a good lay and they'll never be lesbian again. That's all they need," Key Issues/Concepts The concepts illustrated by this case through several life-cycle phases include: Susan's situation dramatically illustrates the process of multiple victimizations that can be traced to several deeply embedded values in mainstream culture: Victimization assessment and crisis intervention skills around Susan's childhood sexual abuse and rape as an adult might have prevented some of the most damaging traumatic aftermath she experienced if they had been carried out immediately following the abuse. The failure of such primary and secondary preventive efforts demands victimization assessment skill and tertiary prevention efforts - albeit delayed - which correctly identify the primary problem as victimization. Had such an assessment been conducted, some of the psychological trauma Susan suffered (depression, self-destructive behaviours, eating disorders, etc.) might have been less severe. Other practice skills could include:
At the interdisciplinary/generalist level, several points of early identification were possible: Specialists in this case include a psychotherapist or group sensitive to gender, sexual abuse and diversity issues, including peer support groups for survivors of sexual abuse. Students of any discipline in a psychosocial or psychiatric course would participate in identifying the primary problem of victimization regardless of where someone is seen in the total health system. The student who observes that such identification has not been made by the interdisciplinary psychiatric team should confer with the clinical instructor or preceptor regarding strategies to make this primary issue visible in the treatment planning process in psychiatric settings. Routine victimization assessment could have assisted health and mental health staff in focusing on Susan's primary problem much earlier. Seminar discussions on homophobia and rape might help students avoid similar crises around sexual assault and homophobia. Suggested Learning/Practice Situations Susan's student status and vulnerability to acquaintance rape suggests introduction of the entire topic during orientation to college life, preferably with a presentation from a sexual assault survivor or staff member of a campus or community-based sexual assault service. Other potential learning situations include:
Russell (1990) Rape in Marriage. Warshaw (1988) I Never Called It Rape. Violent Adolescents and Abusive Dating Relationships Jennifer, age 16, and Daryl, age 17, have been dating for six months. Before that, Jennifer dated Tim, now age 17, for two years. Jennifer broke up with Tim because he was verbally abusive to her, very controlling and very demanding sexually. In fact, Jennifer had stopped seeing Tim off and on over the two years they dated, but always went back after his begging and pleading because, as Jennifer explained, "I had no one else to talk to who really seemed to love me." Jennifer was clearly not alone in her desperation for love. Tim was abused as a child (usually beaten and locked in a closet for misbehavior). On two of these occasions he was treated for a broken tooth and a ruptured eardrum which the emergency physician and dentist each traced to abuse. On referral from both the physician and the dentist, Tim's parents saw a family counsellor, but refused to return after two sessions. Although Jennifer was very dependent emotionally on Tim, what really scared her into breaking up was getting a diagnosis of Chlamydia after several bladder infections. Jennifer had never been that interested in sex and worried about getting pregnant because Tim refused to use a condom after they had been intimate for a couple of months, and Tim said Jennifer was his "first and only girl." Despite her realistic concerns, Jennifer always gave in to Tim's demands because she was afraid of losing him" and she needed someone she could feel close to. Jennifer's family life was a source of stress and little comfort to her. Her parents -- both successful professionals - were cold and uncommunicative with each other, and very controlling with their three children - Jennifer, Corrine (age 12) and Janice (age 9). Sometimes Jennifer felt that if she had only been a boy her parents would have been less hard to please. No matter what kind of grades she brought home (usually close to the top), there was always a remark that she could do better. Though Jennifer was by no means overweight, she was always dieting, as her mother let her know in more ways than one that almost anything was better than "getting fat." Jennifer and her two sisters were close and colluded in their complaints against their parents, while Jennifer fought off bouts of depression mostly because she wanted to "be there" for her two sisters. Since both parents seemed so wrapped up in their work, the three girls used to wonder among themselves why they were born in the first place. During Jennifer's visits with a primary care practitioner at the women's health clinic of the community health centre, she learned a great deal about her risk of AIDS and other communicable diseases. She also accepted a recommendation to join an adolescent support group that focused on relationship and self-esteem issues for girls at risk of developing eating disorders. As a result of these group sessions, Jennifer decided, among other things, that she would refrain from sex until she felt more secure with herself and had better prospects of respect and commitment from her boyfriend. Meanwhile, at a school dance Jennifer attended with her new boyfriend, Daryl, Tim came by and asked her to dance. Jennifer refused, and they got into a loud argument. Daryl came to Jennifer's defense and threatened he would "have it out with you [TIM] outside if you don't stay away from Jennifer." Jennifer became very frightened by Daryl's threat of violence, particularly because she had felt much safer with him than with Tim. She asked Daryl to take her home, and at the next week's group session at the health clinic she discussed this incident and what it meant for her. Meanwhile, a teacher chaperon at the dance talked with Tim and persuaded him to see the school counsellor. During homeroom periods, this teacher had observed Tim's behaviour for some time and sensed a troubled history. Key Issues/Concepts Jennifer's story is replete with suggestions of the psychosociocultural roots of violence and abuse in familial and gender relations. Concepts illustrated by this example include: Jennifer's situation evokes some of the very powerful value issues most societies confront:
This case can also serve to help health professionals and their students examine traditional gender relations within their own ranks as an essential prerequisite to dealing with these issues as manifested in clinical scenarios. Violence based on bias regarding sexual identity similarly evokes powerful feelings and values that need to be discussed in a non-threatening environment. Clinical Practice Skills This case and the related situations among adolescents require: At the interdisciplinary/generalist level, initial contacts include the primary care physician or nurse and dentist hygienist, primarily by incorporation of victimization assessment into health assessment protocols and teaching about violence prevention (e.g., when presenting for Chlamydia symptoms or routine dental care). A support group facilitator (any discipline so trained) would explore sexuality, sexual identity and self-esteem issues, gender relations, violence in dating relationships and prevention of abuse. The role of specialists, in this case, depends on the outcomes of the above actions, but might include: Suggested Learning/Practice Situations In developmental psychology, social psychology, sociology and similar courses pre- or co-requisite with the health major, concepts, such as self-esteem, psychosexual development, family dynamics, stress and social support, can be addressed as foundations for later application in clinical situations. Other learning situations could include:
Eggert (1994) Anger Management for Youth. Holden and Powers (1993) "Therapeutic crisis intervention," The Journal of Emotionaland Behavioural Problems. Sadker (1994) Failing at Fairness. Sonkin (1990) Wounded Men: Healing Child Abuse.
Clara, age 40, is the daughter of Joseph and Magdalene who spent most of their childhood and adolescence in one of the residential church schools to which most Native children were sent until the 1970s. Clara's parents died in their 50s from injuries resulting from a car crash which occurred while driving under the influence of alcohol. The oldest of five children, Clara divides her time working as a social services administrator, as a peer counsellor for adolescents On a reserve in Ontario and as caretaker of her three children. She and her husband have assumed responsibility temporarily for the care of one niece, age 10, and two nephews, ages 12 and 15, children of her sister who is studying dental hygiene at a local community college after escaping from an abusive marriage. Clara poignantly describes the intergenerational odyssey of First Nations people struggling to deal with their rage and the human misery wrought by subjugation of a whole people through colonization and the destruction of their culture. Her parents' memories of life in the residential school included the dramatic image of "a Bible in one hand and a zipper in the other" to describe the widespread sexual abuse of children in these schools. With only abusive authoritarian "caretakers" as role models, no formal preparation for the preservative tasks of parenting and with the easy availability of alcohol as an escape from despair, Clara readily understands why her parents did not know how to parent her and her siblings. Though now closed, the cycle of abuse set in motion by these schools as agents of the mainstream culture's colonizers will be visited on generations to come. Clara says that it has left "blood memories" which some elders want desperately to unlock so they can heal from their rage. And how do they heal? "Maybe someone is just kind to them," Clara declares. But most important is getting in a circle with their own people and listening to elders who know, who remember and cherish their own culture. As a result of the residential school system's damage to her parents, Clara lived for a time with her grandparents, but at age 9 was taken away from them and placed in a foster home sponsored by Children's Aid. There she was sexually abused by both the foster father and one of his sons. When the social worker made supervisory visits, she made it clear that she did not want to talk with Clara about the abuse; instead, the focus was on the cleanliness of the house. After leaving the abusive foster home at age 15 and attempting reconciliation with her family, Clara finally began to understand her rage, and has been able to grieve for herself, her extended family and her people by attending the healing circles conducted in her community. The support and process of self-healing she experiences there have also given her the insight and strength to facilitate the healing of her nephew, Jason, now in her care, and attending an adolescents' healing group sponsored by the school and health centre on the reserve. Jason, age 15, was arrested when he was caught trying to steal a car and while in jail, was raped by an inmate - all this while his mother seemed locked in a violent marriage. Clara emphasizes the importance of providing a safe place among their own people for First Nations members where they are allowed to feel and to grieve their losses. These healing circles are pivotal, no matter how many years may have passed since victimized persons buried their wounds and the rage they have directed toward themselves instead of at the people and the unjust institutions that victimized them. Clara says that some women in these circles are already in their 60s and 70s when the disclose for the first time the assaults they have suffered. Key Issues/Concepts The situation of Clara and her extended family dramatically illustrates the toll taken on the human spirit and on physical and mental health by colonial policies calculated to eliminate an entire culture. Central to colonial subjugation are the multiple losses and unresolved grief felt by entire communities who lost not only their "children" to a foreign education system, but also their culture and their homeland. Facilitating the grief and continued healing of survivors, like Clara, her family and other First Nations people, demands the recognition and acceptance of several key factors:
This case scenario dramatizes the most critical piece of an attitudinal framework that can enhance the prospect of healthy outcomes by professionals working with First Nations survivors of abuse: the individual pain, grief and disproportionate frequency of self-destructive or violent behaviours among native people must be situated in the sociocultural context of their oppression as an entire society. Without this historical perspective, the victim-blaming tendency is likely to surface in work with individual victims who need help not judgment - as they strive, among their own people, to rebuild their lives beyond victimhood. Clinical Practice Skills Key practice skills needed on behalf of Clara, her extended family and other survivors among First Nations people include: The communal values characterizing traditional cultures suggest that many of the services provided to First Nations people will emphasize teamwork and collaborative roles, regardless of professional identity. Physicians, nurses, physiotherapists and dental practitioners, especially, will assume routine assessment and treatment roles for the immediate injuries and chronic pain sustained by violence and accidents often related to substance abuse. All should seek opportunities to respond with particular attention to the native community's intention to take charge of its own healing. Elders, spiritual healers and others prepared by the native community to assume primary responsibility in the healing process are the most important specialists for native survivors. Students of all professions from the native community can observe and assist as directed by the particular discipline, elder or spiritual healer; non-native students from all disciplines can observe and assist as invited or needed on behalf of various survivors. Suggested Learning/Practice Situations Clara's case suggests several learning opportunities: Mousseau (1989) The Medicine Wheel Approach. Dumont-Smith and Sioul-Labelle (1993) National Family Violence Survey, Aboriginal Nurses Association of Canada. Working Together to Meet Children's Needs (1993) One Voice ... Communities Caring for Children. York (1990) The Dispossessed: Life and Death in Native Canada. Abuse of Caregiver and Risk of Older Adults in Home Care Catherine is 64, a former teacher, and now the home caregiver for John, her 69-year old husband. John has been cognitively impaired since his early 60s, and has been a wheelchair user for the last 10 years due to knee and other injuries from a car accident. In addition, John has various cardiovascular ailments and sometimes becomes very irritable and physically resistant to care, though he recognizes Catherine and seems to take comfort in her continued presence. His resistance at times extends to the visiting nurse and physiotherapist treating his knee. Catherine is very active as an advocate on behalf of the needs of caregivers who increasingly are left to pick up the pieces when public services are terminated. She describes: Catherine describes a situation from her advocacy group, in which 24-hour care was provided by three different aides with "very poor training and very poor supervision." One of these aides became upset with the family's rearrangement of the apartment for the client's convenience, so "she [the aide] just turned around and hit her [the client]. Now, the police should have been called at that point. But the -profit-making agency .. they just simply keep them on, they don't fire them. " Catherine observes: that some: of her fellow caregivers financially abuse their clients. Most older persons: feel powerless to prevent it, and supervisory standards have loopholes allowing its continuance. In her own situation, Catherine says of the termination of professional nursing services: don't think that I can go it alone. I really don't." Asked if she's ever been abusive to her husband, Catherine says: No, no ... you have to be careful of yourself even if you know better, you might get mad yourself...one of the real feelings that you live with is guilt. When I lose my temper it's over the, silliest thing. Well, it really isn't silly. It's an awful lot Of work. But it's a real problem at the end of the day, and I guess sometimes I need to stop and get right away from it, and if 1 say anything it's going to be awful. I would never hit him. You can be sure of that. My brother had phoned me at Christmas and it had just been a terrible time and he said what are you going to do. And I said, "I'm looking for two plastic bags, two pieces of rope and somebody to pull them both." And then he said, "Well, I better come in." And I said "No, don't come near me. It's just awful. Things like that are very stressful times, Christmas and those things are really bad .. usually, though, I just take an extra tranquillizer.Catherine is bitter and feels deeply abused and neglected by "the system" which she says takes unfair advantage of women like herself who must fill in for needy older persons, such as her husband, when money is tight. Commenting on her near-despair and what protects her from drastic action, Catherine says: Only once, when one of the nurses went after me, I really got upset. Despair, I get mad, frustrated, more than despair... This one nurse really asAs for the physiotherapist, Catherine said: "Well, she's just in and out so I couldn't really talk to her, and anyway, she's just supposed to attend to my husband's knee." Asked what kept her from hitting her husband, given the lack of assistance and support, she said: "I guess it goes against everything I believe in." Key Issues/Concepts The case of Catherine and her husband illustrates the fact that abuse prevention involves more than the clinical skills of risk assessment and intervention in an actual or potential crisis. It is entwined with several social and public policy issues:
Catherine's case illustrates the deeply embedded values of ageism and sexism. The example points to the need for a society-wide shift in attitudes and values. Ageism would be replaced by respect for, and appropriate care of, older persons. This implies reclaiming traditions in which older people were valued and respected for their wisdom and life-long service to the community, not discarded as no longer useful to a profit-oriented economy. Exploitation of women's unpaid work (often obscured in the language of "family" and caregiver" as euphemisms for "woman"), as socially prescribed and largely accepted by most women, would be replaced by an acknowledgement of the contribution such work makes to the economy and rewarding it accordingly. When such financial reward is neither expected nor possible, at the very least caregivers should be provided with the necessary supports for the unpaid work to continue without resorting to abuse as a result of unalleviated stress. Clinical Practice Skills Key practice skills illustrated on behalf of Catherine and her husband John include: Interdisciplinary/generalist collaboration in a complex situation like this is pivotal not only to clinical outcomes, but also to the potential influence on policy decisions. To the extent that home care services are available only through "doctor's orders," physicians need to assess and authorize nursing and occupational therapy services for psychosocial as well as physical health care needs of both the identified client and the caregiver, as well as provide ongoing support themselves. All home and community-based providers in this scenario (nursing, occupational therapy, physiotherapy, pharmacy) are in strategic positions to assess for homicide and suicide risk. They would also establish the need for continued psychosocial support, even when physical care needs may have been met. In this case, specialists include advocates, social workers and attorneys specializing in the protection of older adults. Students (especially nursing, social work, medicine, physiotherapy, occupational therapy) would conduct comprehensive health and crisis assessment (including risk of assault and suicide). Continued support by a student for Catherine and John would facilitate all of the above. Suggested Learning/Practice Situations Since ageism and the gender-based division of labour permeate this case situation, curriculum planning might include: Suggested Readings Ponders (1990) National Survey of Abuse of the Elderly in Canada. Preston and Reset (1989) "Husbands and wives as caregivers," The Journal of Gerontology. Ross (1991) " Spousal caregiving in later life: An objective and subjective career, Health Care for Women International. Film: A House Divided, National Clearinghouse on Family Violence, Canada. Visible Immigrant Minority Woman: Battering/Abuse by Family and Mental Health System Leela is a 3 1-year-old woman who emigrated from an Asian country with her extended family 12 years ago, two years before her marriage. She was married for eight years and has a son, Ash, age 5. Leela was hospitalized for psychiatric care three years ago following beating episodes by her husband over several years. Ashok witnessed his father's violence and is now in the care of his maternal grandparents. Divorce is very much frowned on in Leela's culture and in her very tight-knit family, even when there is violence. Leela hoped that, if she got an education and some financial independence, she might at least succeed in getting away from her violent husband even if she couldn't divorce him. Leela started taking classes toward a social work degree at a local university. On one occasion, following a beating, Leela confided in a professor teaching a class in social welfare who was also an immigrant from the same country: He told me, "By all means don't go to a white social worker." I was really stunned and said: "I'm really surprised to hear a comment like that from you." And he said to me: "You don't understand how people look at us." And he was trying to encourage me to keep it within the family. He also said that he was giving a good example [of keeping thin s within the immigrant community]: "Just look at my situation. My wife started working and I go home and I'm all alone."As the beatings escalated, Leela's isolation deepened. Once after a beating she went to a hospital emergency department, but did not get the help she needed. So she left her husband and went back to her family home. I thought, I'm going to go the road of psychologists because they don't really have as much power [as psychiatrists]... like they'll help you if you have problems emotionally but they can't give you a prescription and can't have you admitted on their word."But after the psychologist fell asleep on her, Leela said: "To heck with it, I'll just buy some books, I'll read what's good for me; I'll take what's bad for me-, I'll leave and that's it, because what else do you do?" Describing her admission to a psychiatric ward, Leela said: My family brought the police on me. I was cooking for them, cleaning for them and I was acting normal listening to all those religious things. At least they were educated so they are afraid to say so, but the more religious the family the more they think you're crazy, the, more they think you are possessed by the devil and I don't know what else.Leela's family called her sister from Chicago to help them get Leela in to the psychiatric hospital. During an apparently normal family evening, Leela's mother became ill, and Leela tried to call the doctor. I was lucky enough that I had gone to the Women's Career Centre. The lady said one thing is once you are on medications your brain doesn't work, you can't talk, your body has no energy. Whatever the drug was, I told the psychiatrist, and I even told my family and the police: "You kill the soul and you are making the body live." This is what they do to all the psychiatric patients, they kill the soul. And I said, you will kill me inside if you give me drugs, because I tell you I don't want it.. See they know, and still they give you drugs. And this was the reason why they took me off that medication. If they hadn't taken me off that medication I wouldn't have talked to that lady... She was willing to listen to my story. And caring and listening from a stranger is enough for you. The visible immigrant minority status of Leela and her family renders them doubly vulnerable to the crisis and psychological aftermath of violent abuse. Major issues and concepts illustrated by this situation include:
The belief in cultural relativism is central to understanding Leela, her family and the related situations presented by the case. Many are still willing to use "culture" as an excuse to look the other way when women are abused, rather than recognizing abuse as a universal human rights violation, regardless of the cultural group in which it occurs. This case also reveals the 'influence of racism and its contribution to the social isolation felt by many immigrant and native groups: "You don't understand how people look at us." Leela regarded her professor's advice not to talk to a white social worker as misguided, but caregivers must recognize the origin of the professor's fear and advice in his probable experience of racist attitudes in mainstream culture. Clinical Practice Skills Besides the clinical skills needed for any victimized person, this situation reveals the need for: In this situation, the interdisciplinary/generalist role underscores the need for awareness, by all health and mental health providers, of the special needs of disadvantaged groups. Also, vigilance is needed to avoid cultural relativism as well as the interpretation of cross-cultural differences in a narrow psychopathological framework. Specialists, in this case, include mental health professionals prepared to assess and treat persons with psychopathological disturbances (i.e., clinical psychologists, clinical social workers, occupational therapists, psychiatric nursing specialists, psychiatrists) with knowledge of how the victimization experience can result in psychopathological disturbances and sensitivity to gender and cultural issues in psychotherapy. Other specialists are community groups with expertise in the problems and issues of visible minority and immigrant groups, and psychiatric survivors. Students would assist with, and participate in, the above generalist roles. Graduate students would also participate in specialist roles. Suggested Learning/Practice Situations The groundwork for successful clinical work with immigrant and native groups could be laid in prerequisite social science courses, e.g., applied anthropology or socio-cultural issues in health care. Students might be assigned a mini-fieldwork experience to get to know the concerns and issues of a person from a different cultural group, and then write about the experience and share it in seminar discussions. Other learning situations could include:
Suggested Readings Hoff (1992b) "Review Essay: Wife Beating in Micronesia," ISLA: A Journal of Micronesian Studies. Hosken (1981) "Female genital mutilation and human rights," Feminist Issues. Jang and Morello-Frosch (1991) "Domestic violence in the immigrant and refugee community," Response to the Victimization of Women and Children. MacLeod and Shin (1993) Like a Wingless Bird... . Walker (1992) Possessing the Secret of Joy. A Man Who is Both Victim and Abuser Robert', age 34, works as a data-processing technician in the postal service. He has been married to Jane, age 31, for seven years and is the father of two children, ages 5 and 3, both girls. Robert grew up in a small town, where his family struggled economically because of his father's frequent layoffs from his mining job and trouble with alcohol. Robert describes his childhood as "rough, especially when my Dad was drunk." Though he was often physically disciplined by both his mother and father, Robert denies being abused as a child: "I was a rebellious kid and gave my folks a hard time, so I guess I had it coming. In my family everybody knew their place, and if you stepped out of line, well, things could get kinda scary." Asked if his mother was abused, Robert said "No, but she was pretty careful not to cross Dad, especially when he was drinking." After the birth of their first child, Robert and Jane started arguing more and more. When the baby was a year old, Jane wanted to put her in day-care and go back to work as an executive secretary, because she was "getting bored" being home by herself all the time. Robert felt that he should be earning the money, and Jane should stay home and take care of the baby and house, at least until the baby was older. Deep down, Robert was threatened by the prospect of Jane's job advancement beyond his, since she had a college degree and he didn't. When Jane went ahead and got a job anyway, Robert became furious and gave her a black eye when he came home one day and she announced her new job. Robert says he was shocked at himself, because he remembers vividly how scared his mother was of his father, hoping he would never hit her. But still, after he'd hit Jane once, Robert found it harder and harder to control himself as their arguments escalated. After striking out at Jane every few weeks or so for a couple of years, often after putting her down for "the dirty house and rotten meals," one day while Jane was cooking and Robert was having a couple of beers, during a heated argument Jane threw a frying pan with hot grease at Robert, hitting him in the face and leaving bums and an open wound. After Robert's attempt at self-treatment from the home medicine closet, Jane brought Robert to the emergency room herself, remorseful at what she'd done. In the course of assessment, Robert said: "I suppose I had it coming... Seems like I'm getting just as bad as my Dad." Jane was reluctant to talk about the incidents of abuse she had endured from Robert over the years. During two of those incidents she had required medical treatment and physiotherapy (Robert brought her to the hospital), but each time Jane told the attending physician/nurse team an unlikely story about how she had incurred the injuries. Robert and Jane claim that they love each other, but neither has ever had counselling for their problems. Key Issues/Concepts The conflict and violent interchange between Robert and Jane reveal several key issues and concepts concerning violence and gender relations: Related Situations Attitudinal/Values Content The negative messages Robert received from his family life about the danger of his father's controlling behaviour and threats of violence resulted in Robert's determination not to behave in a similar fashion himself. Yet, his later behaviour toward Jane points to powerful influences beyond the family: Clinical Practice Skills Recognition of, and routine inquiry about, the signs and symptoms (incongruity between injury and explanation, psychosomatic complaints), usually associated with domestic violence in emergency medical settings, might have uncovered the stress and abuse earlier, despite Jane's pattern of denying the abuse. Later violent episodes might have been prevented had the victimization and assault potential been assessed each time Jane was treated for injuries inflicted by her husband. In addition, this case highlights the following skills: The interdisciplinary/generalist roles here include routine victimization and assault assessment by health and mental health professionals at all entry points to the health care system, and very careful communication among team members about findings and next steps. A primary care nurse, physician, advanced practice nurse or follow-up counsellor teaches assault potential criteria to anyone at risk and coordinates the overall crisis intervention and referral process. Specialists include groups for abusive men, family/couple therapists (following personal ownership of abusive behaviour), groups for women at risk of abuse and forensic psychiatry specialists. Students observe and assist with all of the above. Suggested Learning/Practice Situations This example underscores the importance of incorporating victimization and assault assessment into routine protocols in emergency settings, prenatal clinics, maternity services and other entry points to the health care system for women and men, that is, any clinical setting to which students are assigned. It is reasonable to predict that, had such risk assessments been done, and had Robert been referred to a group for men and Jane to a women's group, certain stressors might have been alleviated and violence prevented. Suggested Readings Edelson and Tolman (1992) Intervention for Men Who Batter. Hoff (1992a, 1993) "Battered Women" Pts. 1 and 2, Journal of American Academy of Nurse Practitioners. Hoff and Rosenbaum (1994) "A victimization assessment tool," Journal of Advanced Nursing. Mousseau (1989) The Medicine Wheel Approach. Sugg and Inui (1992) "Primary care physicians' response to domestic violence," Journal of American Medical Association. professional Victimization It is one thing to embrace the required knowledge, attitudes and skills considered essential by the Interdisciplinary Curriculum Guide and the experts cited in the Basic Library. But there are related issues to be considered as well if this Guide's recommendations are to succeed: Since the incidence of physical and sexual abuse among the general female population is very high (FVC, 1991; Russell, 1990; The Daily, 1993), and since women constitute either majorities or large numbers within the health professions, it is highly probable that abuse histories also exist among students and faculty of these professions. Since the male-female power disparity and the cloak of silence that have, until recently, preserved women's abuse it secrets" are also reflected in the health professions, it is also probable that many such traumas may not have been dealt with by faculty, clinical preceptors or students. In addition, a person in an abusive situation may find that barriers surface in her or his work with other victims. One nursing student discusses the situation of a classmate: Since this is a curriculum guide and not a therapy manual, the intent is to make explicit a factor which for some, if heretofore hidden, can interfere in the teaching/learning process. For example, when a student - at least midway in clinical courses - bursts into tears and leaves class during a film on child abuse. it may signal an issue about the curriculum-personal trauma interface. Students make it very clear that they expect an early introduction to potentially disturbing topics, such as abuse, and their possible connections to students' personal histories. They do not expect counselling or therapy from faculty for troubling abuse histories; they do expect easily accessible services with a contemporary approach to the problem, and non-intrusive understanding from instructors as they deal with the issue. As one student commented: "Information is disseminated all over the place. It would be nice if there was some sort of printed pamphlet where it could be at your fingertips, to have handy if you need it." Such a resource should include policies on sexual harassment. Of course, faculty can neither predict nor prevent student upsets during discussion of emotionally laden topics. But their probability can be reduced by explicitly informing new students that later clinical learning experiences may trigger unanticipated personal responses. This early introduction in the curriculum may motivate a student to seek counselling for belatedly uncovered problems which have not been resolved as had been assumed. When such guidance fails, crisis intervention by faculty for distressed students is appropriate while ongoing counselling is not. An issue that presents a greater challenge is dealing with the prospect that fellow faculty and professional colleagues may be living in high-risk situations, but may feel even more reluctant to disclose their plight than students might. This scenario is compounded by several factors.
As health providers confront their own feelings, they may identify with either the victim or assailant, depending on past experience and other factors. Physicians and nurses in trauma and emergency centres, and social workers in child and adult protective services are most frequently exposed to the shocking reality of violence, though no health workers are immune. If a particular student or clinician avoids some victims, it may be less from indifference or neglect than from the need for self-protection and support. Another prospect is that some students, clinicians or faculty members may themselves be abusing their partners, children or frail elderly parents. These grim realities must be built into educational and personnel services for students and professionals, and should include the fostering of a climate for appropriate disclosure and accountability, and planned avenues for peer support, time out and self-care activities as essential prerequisites for effective service on behalf of victims. Abuse of Individual Practitioners and Providers' Abuse of Patients As in the case of women generally, women in the health professions can easily be deluded about female equality because of external freedoms such as driving a car, obtaining a credit card and entering traditionally male professions, e.g., medicine, law and engineering (Faludi, 1991 ). Many gender stereotypes and workplace inequalities from the larger society are reproduced in the health care system. For example, in the high-status profession of medicine, women physicians suffer sexual harassment (Phillips and Schneider, 1993) and pay inequities, while areas of specialization (e.g., family medicine, psychiatry, pediatrics) tend to support traditions about "women's work." In the lower-status profession of nursing, the minority of male nurses advance to higher paying administrative jobs more rapidly. One white male nurse noted that he has to consciously struggle not to take advantage of privileges that come his way daily only because of gender and race. Gender inequalities in nursing could not be sustained without collusion - and sometimes reverse sexism - by the female majority (Roberts, 1983). For example, some schools of nursing, apparently without benefit of a gender, race and class analysis, are treating male students as a "minority" needing affirmative action protection (Barbee, 1993; Hoff, 1994). In a similar vein, the abuse of individual practitioners usually follows gender, race and class lines. In general health and residential care settings, physiotherapists, occupational therapists and female nursing staff have long been the object of unwanted sexual advances by male patients and staff (Kettl et al, 1993; McComas, 1993). Physicians continue to be the major source of verbal abuse of nurses (Cox, 1991a, 1991b). But in psychiatric settings, where the incidence of physical attacks by patients against staff is generally higher, the most vulnerable are female nursing assistants, often women of colour and definitely the lowest paid group among the hierarchy of direct care staff (Lipscomb and Love, 1992). Professional nurses are the next most frequently injured while higher-status staff are least often injured. There is comparable disparity in the administrative attention paid to abuse prevention, protection and compensation of nurses at various levels of practice (Lanza, 1992). Some have noted, with chagrin, that formal nursing organizations were late in their support of the contemporary women's movement (Allen, 1985; Vance et al, 1985). Less often, writers note that nursing has been all but ignored by those feminists eager to open the doors of high-status professions, such as medicine and law, to women (Gordon, 1991). Nor is it often noted that women in medicine frequently suffer the same harassment and abuse as female nurses. While frequently discounted in the larger system, nurses have continued society's necessary work of caring for the sick - sometimes with risks to their own health and safety - though their work is often poorly compensated and "hidden" from policy makers and feminists alike (Rachlis and Kushner, 1994). Meanwhile, most female health workers, regardless of discipline, face the additional stressors of doing the lion's share of society's unpaid work - child care, cleaning, cooking and planning the family's leisure activities - even as they assume major leadership roles in health system services for victims of abuse. Progress demands recognition around and social change of, the fact that violence is a societal problem, not just a women's issue. A broader-based analysis recognizes the inherent connection between the devaluation of women generally, and women's work in particular - whether performed by physicians, physiotherapists, nurses, secretaries, nursing assistants or others (Keddy, 1993; Murphy, 1988). The analysis would also make explicit the fact that all women health professionals as well as lesser-paid women in the health care hierarchy - have more in common with one another than is apparent. Finally, a feminist and multicultural critique of the entire health care system would underscore the important principle that women, children, men, survivors of abuse and other clients, and society as a whole are not well served by inequalities based on gender, ethnicity or other characteristics that make one "different." Consider, for example, the following comment by a battered woman who was employed as a nursing assistant, on how nurses could be more helpful to abuse victims. An individual may be personally expert, but structural barriers may effectively neutralize her or his ability to practise. How can health professionals advocate for others if they have not first advocated for themselves (Murphy, 1988)? How can they empathically enter an abused person's world and intervene in the disempowerment of victimization, while feeling trapped themselves in rigid structures? A nursing student described her continuing concern over the directives she received regarding a teenage rape victim who gave birth: These examples point to three commonalities between women in the health
professions and battered women of all ages.
Traditionally, when the formal and informal boundaries of this work were less sharply drawn, women dominated in both realms; attendance at childbirth was the nearly exclusive task of women. But the systematic extinction of women healers and midwives followed by the social construction of formal medicine as the domain of men, and lower-status work as the domain of women, left, in its wake, the current hierarchical health care system, including a continuous struggle of midwives for the right to practise (Ehrenreich and English, 1973; Freidson, 1970). Such disparities in a system "ordered to care" (Reverby, 1987) virtually defy coming to terms with the empowerment/disempowerment dynamics central to the collaborative treatment and care of victims. Last but not least, power dynamics are dramatically revealed in the sexual exploitation of patients by health professionals and other providers such as clergy (Burgess and Hartman, 1986). The provider's abuse of her or his greater power in these relationships constitutes a profound violation of trust which survivors may spend a lifetime trying to regain. In some instances, the client's presenting problem is prior sexual abuse which compounds the trauma resulting from a provider's exploitation. One of the most unfortunate features of the victim-blaming legacy is a view of sexual abuse victims as "damaged goods" - a perspective which facilitates an abusive provider's sense of "entitlement" (Herman, 1981). Besides the damage to patients, as more survivors disclose their exploitation and professional regulatory bodies tighten their disciplinary standards, professional careers are plundered - emphasizing the need for increased vigilance among all professionals to prevent and report such abuse. These stark realities must be faced and dealt with if health professionals
are to actualize their enormous potential for interdisciplinary work on
behalf of victimized clients. If all providers are sensitive to power
dynamics and feel empowered, they are in highly strategic positions to
help break the cycle of abuse - among individuals and families, within
professional relationships and in society as a whole. It has been said
that those who do not know history are doomed to repeat it (Ashley, 1976;
Hoff, 1991; Roberts, 1983). The historical moment, as exemplified by the
very production of this Guide, portends a turning point, an unprecedented
opportunity for health professionals of both genders, and other professionals,
to work together and make an enormous difference on behalf of abused women,
children and others in Canada and worldwide. CHAPTER V Implementation Strategies: The nationwide consultations by Health Canada and other data bases for this Guide revealed wide interest and considerable curriculum activity among health professionals on the topic of violence. The abuse of children, women and older adults was addressed in some way ranging from "reading only" to several hours of classroom instruction. This was particularly true in nursing, family medicine and the mental health professions. Overall, however, clinical instruction on abuse is incidental more than planned. Nearly all the faculties surveyed or interviewed for this project cited "time pressures" and inadequate preparation as barriers to adequate coverage of this "new" topic. With these findings in mind, and building on core, content and issues, this chapter addresses guidelines for moving from incidental to systematic coverage of victimization and abuse in concert with other health education curricular demands. The approach taken also assumes: Medical, nursing and other health profession faculties are in an historically strategic position to undo this perception by forging links with community caretakers of abused citizens - as many have already done. Meanwhile, grassroots pioneers in the violence prevention movement are facilitating the preparation of a new generation of health professionals willing and able to work collaboratively to stem the tide of violence against women and children. As health professionals join this movement, it is important that they refrain from co-opting or superimposing narrow standards on the work already demonstrated to be effective (Ahrens, 1980). In other words, this Guide is a continuation of a fruitful process already begun. By no means is it the last word. A Health Service Paradigm: (Health) Provider, Person,6 Health, Environment Recognizing that there are many paths to the same goal (Cohen and Wardell, 1992; Kerr, 1992; Mandt, 1993), that diversity is a treasure, not a problem, and that faculty participants in this project requested concrete suggestions, this chapter presents examples of how this content might be approached and some pitfalls to be avoided, given the nature and complexity of the issue. As already noted, this Guide does not substitute for basic texts on the topic. Accordingly, the citation of particular theorists is left to faculty of the various disciplines. Here the focus is on a health service paradigm which highlights four key concepts and their relevance to victim care and violence prevention across disciplines: provider, person, health and environment. Figure 1 depicts the health service paradigm's key (or anchor) concepts (provider, person, health, environment) and how these concepts relate to violence at progressive levels of a professional health curriculum. Not all health educators are enamoured of conceptual or theoretical models.
Indeed, models are neither necessary nor sufficient in designing curricula.
They are merely inexact visual depictions of reality - in this case, the
domain of health care for abused people - designed to help clarify and
respond appropriately to that reality. Models thus can serve as a frame
of reference for addressing violence content in a way that fits the educational
philosophy, assumptions and mission of particular disciplines. 6Person,as used here, encompasses family as well. Figure 1: Health Service Paradigm This model illustrates the centrality of the four key/anchor concepts
in the health service paradigm: provider person6, health environment.
A few supporting concepts (especially those pertaining to victimization
are illustrated as welt e.g. threat to safety, vulnerability, stress/hazards;
coping (healthy and unhealthy). The model also shows the emphasis on these
concepts at three levels of the curriculum;. introduction, elaboration
synthesis.
This model is an original creation for this Guide adapted from Curriculum Guide for Nursing (Hoff and Ross), and general nursing literature. The Health Service Paradigmin Figure 1 illustrates how violence and abuse can be addressed at three levels of complexity: Another key concept that characterizes education in all health professions is the problem-solving process,7 borrowing heavily from the scientific method and including the following steps.
7 Nurses call this the "nursing process" though the process, generically, is by no means unique to nursing. Violence Content in the Health Service Paradigm The following paragraphs contain suggestions of how faculty might address victimology content using the health service paradigm as an organizing framework. This approach assumes that faculty have defined social science and humanities pre- and co-requisites to the health major with its emphasis on clinical courses and professional issues. For example, if social science/humanities prerequisites require a sociology course, faculty can specify that the course include several concepts basic to understanding violence and victim care. This could include the family, deviance, gender, race, class and diversity issues, and social institutions and their impact on individuals. On the other hand, if there are no prerequisites to the health major and students are left to elect such a course, faculty must deal with the coverage of such concepts elsewhere. Similar assessments can be made vis-à-vis concepts from psychology (e.g., self-esteem, "learned helplessness," aggression) and anthropology (e.g., values, ethnocentrism, cross-cultural differences). Since many of the concepts are germane across disciplines, students from various disciplines would attend at least some of these pre- and co-requisite courses together, encouraging further interdisciplinary collaboration. Introduction Students' (future providers) introduction to the professional health major will include violence as an interdisciplinary, international public health issue intersecting with the social-psychological, ethical and legal ramifications of service. Beginners are alerted to the socio-cultural milieu and various power disparities as the context or environment in which violent behaviour is born and nurtured. Just as a toxic waste dump or nuclear power plant leak has deleterious effects on health, so does a cultural climate of violence, especially for the most vulnerable persons in society: children, women, older persons, those in double jeopardy for being "different." The concept of person invites the student to consider her or his own personal experience with abuse (physical or sexual abuse as a child, observation of parental violence, rape) and to attend to any memories or traumas stirred up by the prospect of treating or caring for abuse victims in various clinical practice situations. Learning activities at this level might include assigned reading and analysis of newspaper and campus media sources regarding the extent of the problem and its relevance for clinicians. For example, attendance at and discussion of events associated with the "Montréal massacre" of university women might alert students to make the connection between their personal vulnerability and the larger social issues demonstrated by this violent backlash against recent advances by women. Elaboration During this phase of the curriculum, students are taught the details of environmental hazards, including: In the spirit of Patricia Benner's (1984) "novice to expert" concept, students at this phase ideally can integrate what they have learned by implementing treatment plans and crisis intervention strategies on behalf of various victims. For example, the generalist function of victimization assessment, diagnosis, treatment of physical injuries, crisis intervention and appropriate referral should be routine on behalf of any person at risk and in any home or health care setting. Because of the complexity of victim/survivor care, students may not necessarily feel expert at this point; nor is expertise expected in any other area of professional health practice on graduation. Indeed, internships, preceptor arrangements and residencies are the norm rather than the exception following formal education. Nevertheless, if victim/survivor treatment and care are systematically addressed throughout the curriculum, graduates are less likely to experience the surprise and shock that interviewees described during this project development, or be left to learn about such care "on the job." The appendixes of this Guide contain clinical protocol resources already available in community and hospital-based settings. The next section discusses four curriculum designs and comprehensive health service components (including crisis intervention) applied on behalf of a battered woman, her children and her assailant. This is followed by suggestions for class/seminar planning at beginning, intermediate and advanced levels. Curriculum Designs and Recommended Hours of Instruction Consideration of these curriculum concepts addresses frequently asked questions by collaborators in this project: Should there be a special course on violence/abuse? Should the content be "integrated" through curriculum levels, and/or will problem-based learning eventually become the universal norm? The majority of faculty and students interviewed do not believe a special course is the best approach for generic (undergraduate) students in any of the health disciplines. If such a course is introduced early and focuses on theory, the students may not be ready for some of its shocking content, especially those who have been very sheltered or have suffered abuse themselves. Nor will they have the necessary clinical background to make connections between theory and practice. On the other hand, if students have no theoretical introduction to the topic, they almost invariably will be surprised and feel unprepared for general clinical assignments at beginning levels that involve tasks on behalf of victimized persons. The example of the student assessing "physical responses only" of a 14-year old girl who gave birth following rape, presented in Chapter IV, dramatically illustrates this point. It is up to particular faculty groups to specify a curriculum design appropriate for their discipline and designate the number of instructional hours (classroom and practicum) faculty should allocate to violence and victimization content. Increasingly, faculty and students experience time constraints related to knowledge explosion, advances in health care technology and new topics - including, now, violence - flowing from the contemporary value of health care as a basic right. Interviewees and focus group participants acknowledge the problems of an "add-on" approach to these issues. Faculty deciding on total hours of theory and practice in this content area for undergraduates of any discipline may find the following reference point helpful. Internationally recognized standards (Hoff and Miller, 1987) for general crisis content, including victim/survivor care, suggest the rough equivalent of a three-or-four-semester credit course which ideally emphasizes analysis of case examples. This recommendation should be considered in the context of a discipline's overall mission and its functions in violence prevention and victim care among disciplines, as discussed in Chapter 1. Faculty and students alike stress the need to carefully examine curricula for:
There is no single best curriculum design for addressing this core content in a manner that prepares students for practice with the population of abused persons and assailants. The issue is more complex for professions with both baccalaureate and graduate level entry points to clinical practice (e.g., nursing and social work). This Guide includes four curriculum approaches for faculty consideration vis-à-vis generic (undergraduate) and graduate programs in the health professions: a single separate course; a curriculum thread; a series of short courses; and problem-based learning. Single Separate Course This approach is the most straightforward. However, as already noted, it has disadvantages except for graduate students (family medicine, nurse practitioners, the mental health disciplines) and post-RN nursing students. Most of these students have the educational and clinical background for mastering complex violence content in a single course. If an entire course will not fit into total curriculum requirements, violence content can be addressed in substantive units through courses such as women's health, crisis theory and intervention, family dynamics and treatment, and socio-cultural issues in health care. Curriculum Thread This approach corrects some of the disadvantages of a separate course for undergraduate students. As one faculty interviewee emphasized: "Violence and abuse can constitute a curriculum thread in health promotion and the three levels of prevention: primary, secondary, tertiary." However, this approach presents the serious challenge of continuous all-faculty vigilance to avoid "losing the thread" somewhere along the line - the "needle in a haystack dilemma." If the thread approach is selected, the following undergraduate course
areas most readily lend themselves to addressing victimization and related
crisis content (keeping in mind variation in course titles from school
to school, and pre- or co-requisites which students may take with other
disciplines).
Series of Short Courses This approach represents the middle ground between the single separate course and the curriculum thread, thereby addressing some of their disadvantages and challenges. Three courses of two credits each could cover broadly: This curriculum design also addresses the need for students' grounding in their own discipline (through parallel clinical courses in respective disciplines), while progressively exploring interdisciplinary issues as they emerge in the classroom and real world of clinical experience. A clearly defined short-course series provides students with a systematic framework for examining and applying the theoretical, attitudinal and skills content relevant to the abuse situations encountered in various clinical placements at progressive levels of complexity. Instruction would include the "big picture," interdisciplinary facets and each discipline's distinct role with survivors. This design also reduces the faculty challenge of keeping track of curriculum threads and allows for easier designation of faculty responsibility for crisis and victimology concepts according to preparation and interest. For example, when mid-level students work with seriously disturbed psychiatric clients with a history of abuse (in tertiary care settings) they are already grounded 'in the primary and secondary prevention concepts illustrated by the case examples presented in Chapter III of this Guide. Problem-Based Learning In this approach, pioneered at McMaster University's Faculty of Health Sciences (Mustard, 1982), victim/survivor care and the prevention of violence would constitute some of the case situations and health care issues students examine in small-group format with a tutor and through clinical experience in diverse settings. The case situations and expectations of student research and analysis are tailored to beginning, intermediate and advanced student levels. In some health professions - especially medicine - the entire curriculum is organized around problem-based learning. But even in other curriculum designs, many educators use facets of this teaching model, particularly in clinical seminars. This approach is very learner-centred and interactive, thereby lending itself as particularly appropriate for addressing the violence content illustrated by the case examples in Chapter III. On the other hand, survivor cart and violence prevention may receive only incidental coverage, a common problem revealed in surveys and consultations for this project. This limitation might be mitigated, however, by specifying victimization and abuse situations as "required" cases in tutorial seminars and clinical experience at progressive levels of complexity. These curriculum design suggestions assume that students will have varying amounts of direct contact with victims/survivors, but that all will have some direct contact, even if gained through a classroom visit by survivors willing to share their experience. They also assume that regardless of overall design, all educational approaches will emphasize interaction between learner and teacher, as well as case situations for critical inquiry and problem solving. Finally, recommendations assume an introduction to theoretical underpinnings - sociology, psychology, human development and anthropology pre- and co-requisites. The following case illustrates various facets of comprehensive clinical service for a battered woman:
Example 8: Comprehensive Clinical Service for a Battered Woman Mrs. Sophia Penotti, three months pregnant, was brought by her husband to the local hospital emergency service for vaginal spotting. She was tearful on admission, appeared highly anxious, but on inquiry by both the triage nurse, and examining physician, Mrs. Penottli stated she was and fearful about losing her baby. Examination revealed a contusion on Mrs. Penotti's arm which she said occurred when she "stumbled and fell against a chair" during a recent spell of "nausea and dizziness." Mr. Penotti appeared overly solicitous and had to be strongly persuaded to remain in the waiting area while Mrs. Penotti was examined. Following examination, the nurse spent about 10 minutes with Mrs. Penotti discussing health issues such as smoking during pregnancy, diet, etc. The nurse also inquired further about her sadness, particularly since no serious physical complications of pregnancy were evident despite the spotting. Mrs. Penotti denied anything that would have indicated abuse in the relationship with her husband. She was urged to see her regular pregnancy care provider for a follow-up appointment within a week, or sooner if more serious bleeding ensued. As it turns out, Mrs. Penotti and her husband had been having fierce arguments ever since she learned she was pregnant. During several of these arguments, Mr. Penotti had struck his wife, but medical treatment was not pursued following any of the attacks. Since this was to be her fourth child, Mrs. Penotti's husband wanted his wife to have an abortion; she adamantly refused to do so, not only on religious grounds, but because she finds most of her meaning in life in her role as a mother of her other three children, ages 5, 3 and 2 years. Five months after this incident, Mm Penotti, now eight months pregnant and semi-conscious, was brought by ambulance to the emergency department of the same hospital following ingestion of approximately 50 aspirin and several OTC sleeping pills one hour earlier. Besides the systemic sequelae of the drug overdose, examination also revealed that Mrs. Penotti had two loose teeth, various contusions and strangle marks on her neck. Some fetal distress was also noted. Distraught relatives who accompanied the ambulance informed staff that Mrs. Penotti had come to their house earlier in the evening after another beating by her husband. She said that she was thinking of getting a divorce and going on welfare because "no matter what I do, he treats me like a dog." Her family had taken pains to talk to Mr. Penotti urging him to stop his violence, and suggesting that they try one more time to "work things out." Mrs. Penotti followed her family's advice, went home, tried to make up, but this time her husband nearly killed her by strangulation. Having concluded that she had done everything she could to stop the violence, Mrs. Penotti saw suicide as her only option. She was found by her family after they placed a follow-up call to the house: and learned from the 5 year old child (who had witnessed the violence) that "Mommy won't wake up." Following medical treatment and recovery, Mrs. Penotti spent 10 weeks in a battered women's refuge, followed by ongoing casework through the ,welfare department, the start Of divorce proceedings and rebuilding her life as a single parent. Comprehensive Health Service Components Illustrated by Case The case of Mrs. Penotti and her family illustrates a range of services on behalf of someone who has survived abuse. These services fall into four major categories:
Prevention In addition to the initial emergency visit with "spotting" as the presenting complaint, the risk factors in this family might have been detected, and life-threatening injuries prevented, at several points within the health and social service systems: This involves medicine, dentistry, nursing and physiotherapy (depending on nature of injury). Crisis Assessment, Intervention and Management This includes several steps, although not all disciplines necessarily implement each step: Identification or triage and life-threatening risk assessment (all disciplines): The legacy of considering violence among intimates and family members as a "private" issue may still serve as a barrier to prevention (as suggested above) and to identification of persons at risk from violence and abuse. Intake workers need to be alert to the fact that many abused persons, particularly battered women, are reluctant to disclose their plight because of fear and the legacy of "blaming the victim." Often they may present with psychosomatic complaints or anxiety, and may reveal abuse as the source of these symptoms only following explicit inquiry by an empathetic health provider. It therefore cannot be overstated that screening questions be incorporated into whatever protocols are in use as part of routine health assessments throughout the health and social service system. Victim identification and preventive activity is unlikely to occur until all health professionals are committed to asking routinely about actual or potential abuse at various entry points to the human service system. The screening protocol should include questions about suicide and assault potential and resource depletion, since these problems are often secondary to the primary problem of abuse and may signal the severity of trauma from victimization (Stephens, 1985). The probability of reducing life-threatening risk for all concerned is greatly increased through such questioning. For example, instead of suicidality, Mrs. Penotti might have had fantasies of killing her husband. Or, if she retaliated with violence, her husband may have appeared for treatment. Therefore, both women and men, whether at risk as victims or assailants, should be screened. Suggested questions for such screening include the following. It is possible, of course, that Mrs. Penotti might still have denied the cause of her injuries during the earlier emergency visit, but that likelihood is decreased when health personnel throughout the system are prepared not only to detect incongruities between injuries and the woman's "story," but also to question suspicious injuries, in a sensitive manner, and to implement a follow-up plan that would not jeopardize her safety or leave a full five months between visits. Comprehensive crisis and mental health assessment (crisis specialists, social work, clinical psychology, psychiatric nursing, family medicine, psychiatry): In Mrs. Penotti's case, and in similar instances, this facet of care would occur in the social work or psychiatric liaison service affiliated with emergency departments. (See Basic Library and Appendix A: Clinical Protocol Resources.) Crisis counselling (family medicine, psychiatric nursing, psychology, social work): (See Basic Library and Appendix A: Clinical Protocol Resources.) Referral: Two instances indicate the need for referral:
Service for Mr. Penotti includes collaboration between the criminal justice system and treatment programs for men who batter. (See Basic Library and Appendix A: Clinical Protocol Resources.) The comprehensive service plan includes special attention to the children who witnessed violence and/or may have abused themselves. Mrs. Penotti's situation underscores the fact that the "natural crisis management" measures which she and her family took are not sufficient for a public health phenomenon, such as violence, but must be supplemented by services from formal institutions. The Crisis Paradigm in Figure 2 illustrates key elements of Mrs. Penotti's service needs. Figure 2: Crisis Paradigm
Crisis origins, manifestations and outcomes, and the respective functions of crisis management have an interactional relationship. The intertwined circles represent the distinct yet interrelated "origins" of crisis and "aids to positive resolution," even though personal manifestations are often similar. The solid line from "Origins" to positive resolution illustrates the opportunity for growth and development through crisis; tile broken line depicts the potential danger of crisis in the absence of appropriate aids. Steps of Formal Crisis Management 1. Assessment (including risk of injury to self and others) From: Hoff, L.A. (1990) Battered Women as Survivors (London and New York.- Routledge). The medicine wheel approach in Figure 3 complements most facets of the crisis model and emphasizes the role of the entire community. For example, the concept of the circle and the medicine wheel is that the end means a new beginning, to "mend the sacred hoop." The concept of crisis entails "danger [of the present] and opportunity" to move toward a future free of violence. The medicine wheel approach may connect people to First Nations ceremonies and the sweat lodge; the crisis model cites "contemporary rites of passage" for people at risk. Both models also address the needs of the victim as well as the assailant. The wheel's work with victims, assailants and children occurs in a four-part community-embedded process focusing on past, today, tomorrow and future, complementing the crisis management process (assessment, planning, implementation, follow-up). The delivery of these comprehensive service components to survivors of abuse and their assailants within a multi-faceted service system demands the assumption of multiple roles by individual providers. In Educating Future Physicians for Ontario, Working Paper 9 (1993), consultation with clients revealed their perception of physicians within nine roles: For instance, a battered woman at any entry point may need precise information about realistic dangers from her spouse and from self-medication, and how to detect life-threatening risk of assault, particularly if she has become jaded from repeated abuse or has begun to take her partner's violence for granted. The role of counsellor and "ritual expert" applies to all mental health professionals, crisis specialists or graduates such as in family medicine. Figure 3: Medicine Wheel Approach to Domestic Violence
Table 2 summarizes the four components of comprehensive service by discipline. For the most part, these service components should be incorporated in primary, secondary and tertiary care settings. Table 3 summarizes the four components by level of student: beginning, intermediate, advanced (undergraduate) and graduate or crisis/victimization specialist. The delineation, by discipline and level of student, can serve as a framework for planning formal and clinical instruction within various curriculum approaches to violence content: a single course, curriculum thread, series of short courses or problem-based learning. Table 2: Comprehensive Service Components by Discipline Service Component
Discipline
Table 3: Comprehensive Service Components by Student Level
Code: X Do perform - Do not perform Suggestions for Class/Seminar Planning at Three Levels Every committed teacher, whether experienced or new to the topic, works hard to keep the teaching/learning process from becoming rigid, boring or negatively perceived by students, regardless of the reason. Because of the topic's sensitivity and the possibility of personal abuse histories in students, teachers or both, the ordinary challenges of teaching are magnified. A further challenge lies in the importance of interactive methods, an approach which may be difficult for teachers with no formal preparation in such methods. This means, in part, scouting out new ideas for presentation of material and effective engagement of students in the learning process. To that end, the curriculum materials cited in Appendix B are particularly recommended. The following examples of class/seminar planning are aimed at translating the global curriculum content of this Guide into concrete classroom situations. These are not lesson plans as such, but ideas and a time frame for addressing some of the key concepts and practice skills at beginning, intermediate and advanced levels in undergraduate curricula across disciplines regardless of the overarching curriculum design. For each of the three levels the following items are included: The total number of hours suggested is 12 for formal classroom and/or workshop discussion: Clinical placement may include an agency focusing on service for victims only (e.g., battered women's shelter), or any setting (health institution or community agency with primary, secondary or tertiary care focus) in which students are expected to incorporate assessment and intervention strategies on behalf of any client at risk of abuse. Beginning Rationale/Focus The emphasis is on description and primary prevention in personal and student-role behaviours. The clear focus in the beginning for any student of any discipline is to introduce the topic and sensitize students to the issue (including possibly their own history) without overwhelming them but at the same time conveying that they have an important role to play in violence prevention. Students can thereby confront the issue in manageable doses and master strategies of identification and referral congruent with their early role as students of a health profession. Topics/Objectives
1. Read at least one textbook chapter and one
article from a discipline-specific or related journal which includes a
summary of the problem and implications (Of the following, instructor may wish to have students select One or two. Most important, students should begin thinking about the topic in preparation for class discussion.) 2. Talk to at least one person (not your best friend or spouse) about one or two of the following questions and be prepared to discuss in class:
For example: T F Some adolescents who have been sexually abused really are seductive. T F Sometimes violence is the only way to resolve conflict. T F Perpetrators of crimes can pick an easy target out of a crowd. T F People who have been victimized should press charges, T F Girls who are incest victims have mothers who in many instances have been abused themselves. T F Most boys who have been abused as children become batterers later. T F People who work with victims are trying to work out their own issues with mortality. T F Men as well as women can adopt a feminist perspective on social issues. it make you feels If no: Why not? 5. Read a current newspaper article about violence
or abuse and identify roots of the issues, plus assumptions, attitudes
or myths implied by the 6. Discuss, with one other person, at least two
realistic actions that anyone ('including beginning students) can take
to prevent violence in personal and Classroom/Seminar/Workshop Discussion (Preferably in divided sessions to allow sufficient processing time once topic is introduced.)
Roots of violence (Why so much violence?):
(Students may be assigned to research these. If the teacher prepares a summary, more time is left for discussion of issues that are more complex.)
Rationale/Focus Emphasis is on analysis, clinical application and a critique of clinical performance based on principles described in the literature. This level of instruction assumes introduction of the topic along lines suggested above, plus the student's mastery of beginning skills of clinical practice according to discipline. It focuses on the student's understanding and application of assessment and intervention strategies on behalf of a range of abuse survivors in a variety of clinical settings. Further, it assumes that not all students will encounter each type of victim/survivor. Rather, students will learn the basic strategies through their own research, didactic or video presentations, through direct experience with survivors and assailants in discreet clinical practicum situations and vicariously through seminar or workshop discussions, and through presentations by survivors themselves or community-based experts. Topics/Objectives Hours: six to eight classroom, 28 clinical practicum, depending on functions of particular disciplines, as noted above. 1. Read textbook chapters, journal articles and
other primary sources across the categories of abuse and the basics of
crisis assessment diagnosis, 2. Examine the clinical protocols for victim and assailant identification and treatment in various agencies. Be prepared to critique in class or clinical seminar. 3. Incorporate the crisis management process
(including protocols for victim identification. etc.) as a routine in
various assignments according to clinical area Classroom/Seminar/Workshop Discussions Rationale/Focus The emphasis at this level is on synthesis of concepts and refinement of skills which were the focus of the previous levels. Depending on discipline, students at this level may also work with families and groups in teaching roles. This level presumes that students have completed basic reading and research on abuse, have grasped essential concepts of crisis intervention and treatment on behalf of survivors and assailants, and have had planned opportunities to work with persons in actual or potential situations of abuse, though in terms of clinical skills they may still feel "rough around the edges," as is the case with most undergraduates.8 Topics/Objectives Hours: two classroom, eight clinical. 1. Examine in further depth the violence/abuse literature in areas of clinical preference e.g., children, women, older adults, assailants. 2. Interview community-based experts, e.g., child
protective workers, rape crisis counsellors, battered women's advocates,
regarding volunteer 3. Assist local high school personnel in developing and conducting a presentation on violence prevention in dating relationships. 4. Engage health professionals in a pre-natal
clinic around routine victimization assessment of pregnant women, and/or
conduct a support and 5. Volunteer to work with women and children
in a refuge for battered women. This includes opportunities for male students
to work especially with 6. Explore opportunities to observe courtroom procedures in which women obtain restraining orders, or peer counselling groups for men who batter. 7. Explore opportunities to do a police patrol "ride along" as a means of gaining in-depth experience in crisis situations and safety measures. 8. Explore opportunities to observe or work with practitioners serving special risk groups e.g., refugees, the disabled, First Nations people. Ideally, students should be encouraged to develop these or other projects in small groups, including members of other disciplines whenever possible.
8 While crisis intervention and short-term crisis counselling is within the domain of undergraduate preparation, longer-term counselling and psychotherapy are graduate level functions. Class/Seminar/Workshop Discussions Regardless of which design is used, as students and generalists throughout the health and social service system consider their role with survivors and/or referral to mental health professionals, a cautionary note is indicated. Through the consultation process used to develop this Guide, "psychiatric survivors" provided some of the most poignant examples of client-provider interaction within the health care system. Members of the various chapters of Psychiatric Survivors of Ontario note the origin of their organization's title. After having first survived violence and abuse from intimates, family members or strangers, they then survived the psychiatric system intended to serve them. The concerns of this group, while a minority among clients, are shared by many psychiatrists, other therapists and policy analysts, as documented by the reform efforts under way in Ontario and elsewhere (Breggin, 1992; Marks and Scott, 1990; Putting People First, 1993; Scheper-Hughes and Lovell, 1986). Contemporary psychiatric practitioners and social analysts support a key position of community activists: "victim-blaming" and ascribing causality of abuse to the alleged psychopathologies of victims, while excusing assailants on psychiatric grounds is now a discredited legacy (Burstow, 1992; Hilberman, 1980; Hoff, 1990; Mitchinson, 1993; Stark, Flitcraft and Frazier, 1979). Survey, interview and focus group data revealed the remnants of a psychopathology approach by a curricular emphasis on teaching victim/survivor issues in psychiatric courses. A recommendation therefore bears considering. While health educators (especially in medicine, nursing, occupational therapy, clinical social work and psychology) must address the needs of women in psychiatric settings whose care at victimization crisis points was inadequate, several focuses should be emphasized in the treatment of these women (regardless of which curriculum design is selected): Clearly, if crisis concepts and intervention strategies are first introduced in a psychiatric course, a tertiary preventive level (and the assumption of psychopathology) is implied, rather than the current emphasis on primary care and preventive intervention which are so important in situations of abuse and violence. Since most health profession students will already have experienced life crises of their own, and will confront the crises of others in their first clinical experience (which is rarely, if ever, in a psychiatric setting), the concept of crisis and its relation to victimization should be introduced in concert with concepts of stress and the health service paradigm, regardless of the general curriculum design. This implies that the time allotted to psychiatric courses could be reduced or refocused, as some of the psychosocial concepts traditionally reserved for these courses will have been addressed earlier (e.g., in courses on family health) as essential content for all clinical situations. Faculty Preparation in Victimology As already noted, faculty preparation needs will vary according to individual backgrounds and teaching assignments. Survey results and the consultation process for developing this Guide revealed that most faculty and clinical preceptors perceive the need for explicit preparation such as through curriculum development workshops to increase their knowledge and confidence in addressing violence content. Such a workshop might be offered in a collaborative format including health educators, practitioners serving as mentors and community-based experts delivering care to victims/survivors of abuse. Also, faculty who are expected to teach in this topical area, but who have had minimal or no direct experience working with victims, ideally should prepare themselves further by volunteering, for example, in a battered women's refuge or sexual assault crisis centre, arranging for a police patrol ride-along experience or observation in court, working several shifts in an emergency medical centre treating victims, or a similar experience that would supplement professional education attained at a time when victim/survivor care was not a focus of health curricula. Evaluation and Future Development of this Guide Users of this Interdisciplinary Curriculum Guide and others concerned
with the topic are requested to complete the evaluation form at the
end of the Guide. Suggestions are welcome not only on the Guide
itself and its primary audience of health profession educators, but
also for ideas and bibliographical sources for updates of the teaching
resources. Collaborators are also invited for expanding this Guide
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Jenkins (1992) Aboriginal Family Violence Consultations (Toronto:Ontario Federation of Indian Friendship Centres). Walker, A. (1992) Possessing the Secret of Joy (New York: Harcourt Brace Jovanovich). Warshaw, D. (1988) I Never Called It Rape (New York: Harper &
Row). Bibliography Of Abuse Categories (selected) A. Violence Theory Bolton, F.R. and S.R. Bolton (1987) Working with Violent Families: A Guide for Clinical and Legal Practitioners (Newbury Park, CA: Sage Publications). Brown, J. Carlson and C.R. Bohn (1989) Christianity, Patriarchy and Abuse: A Feminist Critique (New York: Pilgrim Press). Burgess, A. and C. Hartman (eds.), (1989) Sexual Exploitation of Patients by Health Professionals (New York: Praeger). Davies, J. (1990) Protect Yourself: A Woman's Handbook (London: Piatkus). Finklehor, D., R.J. Gelles, G.T. Hotaling and M.A. Straus (eds.), (1983) The Dark Side of Families: Current Family Violence Research (Beverly Hills, CA: Sage Publications). Fortune, M. (1989) Is Nothing Sacred? When Sex Invades the Pastoral Relationship (New York and San Francisco: Harper San Francisco). Gelles, R.J. and P. Cornell (eds.), (1983) International Perspectives on Family Violence (Lexington, MA: Lexington Books). Gelles, R.J. and D.R. Loseke (eds.), (1993) Current Controversies on Family Violence (Newbury Park, London, New Delhi: Sage). Gendron, C. (1991) Developpement d'un instrument d'identification des femmes violentées en milieu conjugal, Research Report (Quebec: Groupe de recherche multidisciplinaire feminists, Université Laval). Gendron, C. and M. Beauregard (eds.), (1989) L'Avenir-Santé au Féminin (Quebec: Gaetan Morin). Gordon, L. (1986) "Family violence, feminism, and social control," Feminist Studies, 12. Hampton, R.L. (ed.), (1987) Violence in the Black Family: Correlates and Consequences (Lexington, MA: Lexington Books). Hanmer, J., J. Radford and E.A. Stanko (1989) Women, Policing and Male Violence: International Perspectives (London, New York: Routledge). Hanmer, J. and M. Maynard (1987) Women, Violence and Social Control (Basingstoke:MacMillan). Hoff, L.A. (1990) Battered Women as Survivors (London and New York: Routledge). Horner, B. (1993) Crime Prevention in Canada: Toward a National Strategy, 12th Report of the Standing Committee on Justice and the Solicitor General (Ottawa: Supply and Services Canada). Horton, A.L. and J.A. Williamson (eds.), (1988) Abuse and Religion: When Praying Isn't Enough (Lexington, MA: Lexington Books). Hotaling, G.T. et al (1986) Coping with Family Violence: Research and Policy Perspectives (Beverly Hills: Sage). Masson, J. (1984) The Assault of Truth: Freud's Suppression o the Seduction Theory (New York: Farrar, Straus and Giroux). Mawby, R.I. and S. Walklate (1994) Critical Victimology (London: Sage). Pressman, B.M. (1987) Family Violence: Origins and Treatment, rev. ed. Distributed through the Office for Educational Practice, University of Guelph, Guelph, Ontario. Ramazanoglu, C. (1987) "Sex and violence in academic life or you can keep a good woman down" in J. Hamner and M. Maynard (eds.) Women, Violence and Social Control (Basingstoke: MacMillan) Chapter 5. Schlesinger, B. and R. Schlesinger (eds.), (1988) Abuse of the Elderly: Issues and Annotated Bibliography (Toronto: University of Toronto Press). Stanko, E.A. (1990) Everyday Violence: How Women and Men Experience Sexual and Physical Danger (London: Pandora). Stanko, E.A. (1985) Intimate Intrusions: Women's Experience of Male Violence (London: Routledge and Kegan Paul). Straus, M.B. (1988) Abuse and Victimization across the Life Span (Baltimore: Johns Hopkins University Press). B. Basic Categories of Abuse and Victimization B.1 Child Abuse Ambrose, J.B. (1989) "Orofacial signs of child abuse and neglect," Pediatrician, 16(3-4), 188-192. Bagley, C. and K. King (1990) Child Sexual Abuse: The Search for Healing (London and New York: Routledge). Baldwin, L. (1990) "Child abuse as an antecedent of multiple personality disorder," American Journal of Occupational Therapy, 44, 978-983. Bass, E. and L. Davis (1988) The Courage to Heal: A Guidefor Women Survivors of Child Sexual Abuse (New York: Harper, Perennial Library). Besharov, D. (1990) Recognizing Child Abuse: A Guide for the Concerned (New York and Don Mills, Ontario: Collier MacMillan). Blain, S.M. (1991) "Abuse and neglect as a component of pediatric treatment planning," Journal of California Dental Association, 19(9), 16-24. Briere, J. (1989) Therapy for Adults Molested as Children: Beyond Survival (New York: Springer). da Fonseca, M.A., R.J. Felgal and R.W. Ten Bensel (1992) "Dental aspects of 1248 cases of child maltreatment on file at a major county hospital," Pediatric Dentistry, 14(3), 152-157. Davis, L. (1990) The Courage to Heal Workbook: For Women and Men Survivors of Child Sexual Abuse (New York: Harper & Row). Driver, E. and A. Droisen (eds.), (1989) Child Sexual Abuse: Feminist Perspectives (New York and Don Mills, Ontario: MacMillan). Greven, P. (1990) Spare the Child: The Religious Roots of Punishment and the Psychological Impact of Physical Abuse (New York: Alfred Knopf). Grubman-Black, S. (1990) Broken Boys/Mending Men: Recovery from Childhood Sexual Abuse (Blue Ridge Summit, PA: Tab Books). Helfer, R. and R.S. Kempe (1987) The Battered Child, 4th ed. rev. and expanded (Chicago: University of Chicago Press). Hillman, D. and J. Solek-Tefft (1988) Spiders and Flies: Helpfor Parents and Teachers of Sexually Abused Children (Lexington MA: Lexington Books). Hunter, M. (1990) Abused Boys: The Neglected Victims of Sexual Abuse (Lexington, MA: Lexington Books). Lafontaine, J. (1990) Child Sexual Abuse (Cambridge, UK and Cambridge, MA, USA: Polity Press). Marron, K. (1988) Ritual Abuse: Canada's Most Infamous Trial on Child Abuse (Toronto: Seal Books). Mrazek, P. and H. Kempe (eds.), (1987) Sexually Abused Children and Their Families (London: Pergamon Press). Plummer, C. (1984) Preventing Sexual Abuse: Activities and Strategiesfor Those Working with Children and Adolescents: Curriculum Guide for K-6, 7-12 and Special Populations (Holmes Beach, FL: Learning Publications). Powers, J. and B. Jaklitsch (1989) Understanding Survivors ofAbuse: Stories of Homeless and Runaway Adolescents (Lexington, MA and Toronto: Lexington Books). Report of the Committee on Sexual Offenses against Children and Youths (1986) Sexual Offenses Against Children Vol.1: (Ottawa, Canada: Ministry of Supply and Services). Report of the Committee on Sexual Offenses against Children and Youths (1986) Sexual Offenses Against Children Vol. 2: (Ottawa, Canada: Ministry of Supply and Services). Sanford, L.T. (1990) Strong at the Broken Places: Overcoming the Trauma of Childhood Abuse (New York: Random House). Sgroi, S. (1988) Vulnerable Populations, Vol 1: Evaluation and Treatment of Sexually Abused Children and Adult Survivors (Lexington, MA: Lexington Books). Sgrol, S. (1988) Vulnerable Populations, Vol 2: Evaluation and Treatment of Sexually Abused Children and Adult Survivors and the Mentally Retarded (Lexington, MA: Lexington Books). Sibbald, P. and C.S. Friedman (1993) "Child Abuse: Implications for the Dental Health Professional," Journal of the Canadian Dental Association, 59, 909-912. Sonkin, D. (1990) Wounded Men: Healing Child Abuse (New York: Harper & Row). Tower, C. (1989) Understanding ChildAbuse and Neglect (Boston: Allyn and Bacon). Wachtel, A. (1989) Child abuse: Discussion paper (Ottawa: National Clearinghouse on Family Violence, Health and Welfare Canada). B.2 Incest and Other Sexual Exploitation Barnes, P. (1989) The Woman Inside: from Incest Victim to Survivor, Resource Guide and Workbook (Racine, WI: Mother Courage). Barry, K. (1979) Female Sexual Slavety (Englewood Cliffs, New Jersey: Prentice-Hall). Blume, S. (1990) Secret Survivors: Uncovering Incest and its Aftereffects in Women (New York: Wiley, Ballantine Books). Brucke, H. (1986) "An overview of incest with suggestions for occupational therapy treatment," Occupational Therapy in Mental Health, 54, 63-76. Burgess, A. and C. Hartman (eds.), (1986) Sexual Exploitation of Patients by Health Professionals (New York: Praeger). Butler, S. (1985) Conspiracy of Silence: The Trauma of Incest, rev. ed. (Volcano, CA: Volcano). Fortune, M. (1983) Sexual Violence: The Unmentionable Sin -An Ethical and Pastoral Perspective (New York: Pilgrim Press). Gubar, S. and J. Hoff (eds.), (1989) For Adult Users Only: The Dilemma of Violent Pornography (Bloomington: Indiana University Press). Hechler, D. (1988) The Battle and the Backlash: The Child Sexual Abuse War (Lexington, Ma: Lexington Books). Herman, J. (1981) Father-Daughter Incest (Cambridge: Harvard University Press). McClure, M.B., (1990) Reclaiming the Heart: A Handbook of Help and Hope for Survivors of Incest (New York: Warner). Meiselman, K. (1990) Resolving the Trauma of Incest: Reintegration Therapy with Survivors (San Francisco: Jossey-Bass). Mendel, M.P. (1994) The Mate Survivor (Newbury Park, CA: Sage). Paludi, M. (1990) Ivory Tower: Sexual Harassment on Campus (Albany: State University of New York Press). Pheterson, G. (ed.), (1989) A Vindication of the Rights of Whores (Seattle: Seal Press). Rosenberg, J. (1989) Fuel on the Fire: An Inquiry into "Pornography" and Sexual Aggression in a Free Society (Orwell, VT: Safer Society Press). Thomas, T. (1989) Men Surviving Incest: A Male Survivor Shares the Process of Recovery (Walnut Creek, CA: Launch Press). Wright, M. (1981) "Incest: A historical and behavioral perspective in family life," Canadian Journal of Occupational Therapy, 48, 121-124. B.3 Rape/Sexual Assault Braswell', L. (1989) Quest forRespect: A Healing Guide for Survivors of Rape (London: Pathfinder Press). Brownmiller, S. (1976) Against Our Wills (Toronto and New York: Bantam Books). Burgess, A. (1985) Rape and Sexual Assault. A Research Handbook (New York: Garland Publications). DeKeseredy, W.S. (1988) Woman Abuse in Dating Relationships: The Role of Male Peer Support (Toronto: Canadian Scholars Press). Estrich, S. (1987) Real Rape: How the Legal System Victimizes Women Who Say No (Cambridge, Mass: Harvard University Press). Fortune, M. (1983) Sexual Violence: The Unmentionable Sin (New York: Pilgrim). Levy, B. (ed.), (1991) Dating Violence: Young Women in Danger (Seattle: Seal Press). Sanday, P. Reeves. (1990) Fraternity Gang Rape: Sex, Brotherhood, and Privilege on Campus (New York: New York University Press). Tornaselli, S. and R. Porter (eds.), (1986) Rape (Oxford [Oxfordshire], New York: Blackwell). Warshaw, D. (1988) I Never Called It Rape (New York: Harper & Row). B.4 Wife Battering/Partner Abuse Browne, A. (1987) When Battered Women Kill (New York: Free Press). Clark, A. (1987) Women's Silence, Men's Violence: Sexual Assault in England, 1770-1845 (London; New York: Pandora). Dobash, R.P. and R.E. Dobash (1979) Violence Against Wives: A Case Against the Patriarchy (New York: Free Press). Firsten, T. (1990) An exploration of the role of physical and sexual abuse for psychiatrically institutionalized women (Toronto: Ontario Women's Directorate, Ministry of Health). Gendron, C. (1989) "La violence contre les femmes: généralios et particularités d'un problerne de sociétéin Gendron and Beauregard (eds.) Les Femmes et la Santé (Boucherville: Gaetan Morin) 285-303. Gondolf, E. (1987) Men Against Women: What Every Woman Needs to Know about Violent Men (Bradenton, FL: Human Services Institute). Gondolf, E. and D. Russell (1988) Man to Man: A Guide to Men in Abusive Relationships (Bradenton, FL: Human Services Institute). Hoff, L.A. (1990) Battered Women as Survivors (London and New York: Routledge). Innes, J.E., P.A. Ratner, P.F. Finlayson, D. Bray and P.B. Giovannetti (1991) Models and strategies of delivering community health services related to women abuse (Edmonton: University of Alberta.) A National Health Research and Development Project, Health Canada. Jaffe, P., D. Wolfe and S. Kaye Wilson (1990) Children of Battered Women (Newbury Park, CA: Sage). MacLeod, L. (1981) Battered but not beaten ... preventing wife battering in Canada (Ottawa: Canadian Advisory Council on the Status of Women). MacLeod, L. (1989) Wife battering and the web of hope: Progress, dilemmas and visions of prevention (Ottawa: Health and Welfare Canada, National Clearinghouse on Family Violence). NiCarthy, G. (1987) The Ones Who Got Away: Women Who Left Abusive Partners (Seattle: Seal Press). NiCarthy, G. (1989) You Can Be Free: An East-to-Read Handbook for Abused Women (Seattle: Seal Press). Okun, L. (1986) Woman Abuse: Facts Replacing Myths (An Extensive Review of the Literature (Albany: State University of New York Press). Walker, L. (1989) Terrifying Love: Why Battered Women Kill and How Society Responds (New York: Harper & Row). B. 5 Abuse of Older Adults Abuse and Neglect of the Elderly (1989) Health and Welfare Canada (Ottawa: Minister of Supply and Services Canada). Advocacy Centre for the Elderly (1991) Elder Abuse: The Hidden Crime (Toronto:Community Legal Education Ontario). Aronson, J. (1985) "Family care of the elderly: Underlying assumptions and their consequences," Canadian Journal of Aging, 4(3), 115-125. Family Violence Prevention Unit, Health and Welfare Canada (1991) Elder Abuse Bibliography (Ottawa: Health and Welfare Canada, National Clearinghouse on Family Violence). Gnaedinger, N. (1989) Elder abuse: A discussion paper (Ottawa: Health and Welfare Canada, National Clearinghouse on Family Violence). Kartes, L. (1990) ADecision-Making Model for Assessing and Intervening in Cases of ElderAbuse and Neglect, Council on Aging of Ottawa-Carleton. Mayer, L. and D. Galan (1993) "Elder abuse and the dentist's awareness and knowledge of the problem - A national survey," Journal of the Canadian Dental Association, 59, 921-926. McDonald, P.L., J.P. Hornick, G.B. Robertson and J.E. Wallace (1991) Elder Abuse And Neglect in Canada (Toronto: Butterworths). Mental Health Division, Health Canada (1993) Community Awareness and Response: Abuse and Neglect of Older Adults (Ottawa: Health Canada). Ontario Association of Professional Social Workers (1992) Elder Abuse: A Practical Handbookfor Service Providers. (Toronto: Ontario Association of Professional Social Workers). Pillemer, K.A. and D.W. Wolf (1986) Elder Abuse: Conflict in the Family (Massachusetts: Auburn House Publishing Company). Podnieks, E. (1993) "Elder abuse and neglect: A concern for the dental profession," Journal of the Canadian Dental Association, 59, 915-920. Podnieks, E. et al (1990) National Survey on Abuse of the Elderly in Canada: 7he Ryerson Study (Ottawa: Health and Welfare Canada, National Clearinghouse on Family Violence). Pruschno, R. and N. Resch (1989) "Husbands and wives as caregivers: Antecedents of depression and burden," The Journal of Gerontology, 29(2), 159-162. Ross, M.M. (1991) "Spousal caregiving in later life: An objective and subjective career," Health Carefor Women International, 12(l), 123-135. Ross, M.M., P.A. Ross and M. Ross-Carson (1985) "Abuse of the elderly," The Canadian Nurse, 37-39. Roesch, R., D.G. Dutton, V.F. Sacco (eds.), (1990) Family Violence: Perspectives on Treatment, Research, and Policy (Burnaby: British Columbia Institute on Family Violence). C. Diversity Categories C.1 Aboriginal/Native Women Canadian Council on Social Development (1991) Voices of Aboriginal Women: Aboriginal Women Speaking Out About Violence (Ottawa: The Canadian Council on Social Development). Dumont-Smith, C. and P. Sioui-Labelle (1991) National Family Violence Survey, Aboriginal Nurses Association of Canada. Dust, D. (1991) "Conjugal violence: Changing attitudes in two northern native communities," Community Mental Health Journal, 27, 359-373. LaDuke, W. (1991) "Domestic violence in a Native community: The Ontario Native Women's Association Report and Response," Indigenous Women, l(l), 39-41. Mousseau. M. (1989) 7he Medicine Wheel Approach to Dealing with Family Violence, West Region Child and Family Services, Inc. (Dauphin, Manitoba, Canada). Ontario Federation of Indian Friendship Centres (1992) Consultation Report: Long Term Care and Support Services (Toronto: Ontario Federation of Indian Friendship Centres). Ontario Federation of Indian Friendship Centres (1992) Summary of Findings Report: Ontario Aboriginal Health Policy (Toronto: Ontario Federation of Indian Friendship Centres). Wakegijig, A. and R. Jenkins (1992) Aboriginal Family Violence Consultations (Toronto: Ontario Federation of Indian Friendship Centres). York, G. (1990) The Dispossessed: Life and Death in Native Canada (London, UK: Vintage). C.2 Female Genital Mutilation and Ritual Abuse Final Act (1992) The first study conference on genital mutilation of girls in Europe. (London: WHO, UNICEF, UN Centre for Human Rights). Gullen, J. (1992) Report on thefirst international study conference on genital mutilation of girls in Europe (Ottawa: Family Service Centre). Hosken, F. (1981) "Female genital mutilation and human rights," Feminist Issues, 1(3), 3-23. Saadawi, N.E. (1982) The Hidden Face of Eve: Women in the Arab World, S. Hetata Trans., ed. (Boston: Beacon Press) Original work published 1980. The Horn of Africa Resource and Research Group (1992) Somali Women's Community Education Project (Ottawa: Family Service Centre). Walker, A. (1992) Possessing the Secret of Joy (New York: Harcourt Brace Jovanovich). C.3 Lesbian Women Carlson, B.E. (1992) "Questioning the party line on family violence," Affilia, 7(2), 94-100. Chesley, L.C., D. MacAulay, and J.L. Ristock (1992) Abuse in Lesbian Relationships: A Handbook of Information and Resources (Toronto: Toronto Counselling Centre for Lesbians and Gays). Lobel, K. (1986) Naming the Violence: Speaking Out About Lesbian Battering (Seattle: Seal Press). Renzetti, C.M. (1992) Violent Betrayal: Partner Abuse in Lesbian Relationships (Newbury Park, CA: Sage). Ristock, J. "Beyond ideologies: Understanding violence in lesbian relationships," Canadian Woman Studies, 12(l), 74-79. C.4 Visible Minority and Immigrant Women Bell, D "Intraracial rape revisited: On forging a feminist future beyond factions and frightening politics," Women's Studies International Forum, 14(5), 385-412. Hoff, L.A. (1992) "Review essay: Wife beating in Micronesia," ISLA: A Journal of Micronesian Studies, 1(2), 199-221. Hooks, B. (1989) Talking Back: Thinking Feminist, Thinking Black (Boston: South End Press). Jang, D., D. Lee and R. Morello-Frosch (1991) "Domestic violence in the immigrant and refugee community: Responding to the needs of immigrant women," Response to the Victimization of Women and Children, 13(4), 2-7. Kohli, R. (1991) "Violence against women: Race, class and gender issues," Canadian Woman Studies, 11(4), 13-14. Mama, A. (1989) "Violence against black women: Gender, race and state responses," Feminist Review, 32, 30-47. MacLeod, L. and M.Y. Shin (1993) Like a Wingless Bird: A Tribute to the Survival and Courage of Women Who Are Abused and Who Speak neither English nor French (Ottawa: Minister of Supply and Services Canada). Mohanty, C.T., A. Russo and L. Torres (eds.), (1991) Third World Women and the Politics of Feminism (Bloomington, IN: Indiana University Press). Palmer, A.0. "Undeclared war: African-American women writers explicating rape," Women's Studies International Forum, 14(5), 363-374. Pinedo, M. and M. Santinoli (1991) "Immigrant women and wife assault" in Towards Equal Access: Working with Immigrant Women Survivors of Wife Assault (Toronto: Ministry of Citizenship). Riutort, M. and S. Small (1985) Working with Assaulted Immigrant Women: A Handbook for Lay Counsellors (Toronto: Ontario Ministry of Community and Social Services). Smith, V. (1990) "Split affinities: The case of interracial rape" in M. Hirsch and E. F. Keller (eds.) Conflicts in Feminism (New York and London: Routledge). "Working Together to Meet Children's Needs: Recommendations Related to Aboriginal Children" (1993) Journal of Ontario Association of Children's Aid Societies, 37(3), 11. C.5 People with Disabilities Beating the Odds: Violence Against Woman with Disabilities (1989), (Toronto: DisAbled Women's Network). Driedger, D. and A. D'Aubin (1991) "Discarding the shroud of silence: An international perspective on violence, women and disability," Canadian Woman Studies, 12(l), 81-83. Family Violence against Women with Disabilities (1993), (Ottawa: National Clearinghouse on Family Violence). Masuda, S. with J. Ridington (1990) Meeting Our Needs: An Access Manual for Transition Houses (Toronto: DisAbled Women's Network). McPherson, C. (1990) Responding to the Abuse of People with Disabilities (Toronto: Advocacy Resource Centre for the Handicapped). McPherson, C. (1991) "Violence against women with disabilities: Out of sight, out of mind," Canadian Woman Studies, 11 (4), 49-50. Morris, J. (1991) Pride Against Prejudice: Transforming Attitudes to Disability (London: The Women's Press). Sobsey, D. and C. Varnhagen (1990) Sexual Abuse and Exploitation of People with Disabilities: A Study of the Victims. D. Men Against Violence/Treatment for Abusive Men Adams, D. (1988) "A profeminist analysis of treatment models of men who batter" in K. Yllo and M. Bograd (eds.) Feminist Perspectives on Wife Abuse (Beverly Hills: Sage Publications) 176-199. Canadian Treatment Programs for Men Who Batter (1989), (Ottawa: Health and Welfare Canada, National Clearinghouse on Family Violence). Canadian Centre for Justice Statistics (1994) Canada's Treatment Programs for Men Who Abuse Their Partners (Ottawa: Health Canada, National Clearinghouse on Family Violence). Edelson, J. and Brygger (1986) "Gender Differences in Reporting Battering Incidences," Family Relations, 3, 377-382. Edleson, J.L. and R.M. Tolman (1992) Intervention for Men Who Batter (Newbury Park CA: Sage). Gondolf, E. (1985) Men Who Batter: An Integrated Approachfor Stopping Wife Abuse (Holmes Beach, FL: Learning Publications Inc). Gondolf, E. and D. Russell (1986) "The case against anger control treatment programs for batterers," Response, 9(3), 2-5. Gondolf, E. (1987) Research on Men Who Batter (Bradenton, Florida: Human Services Institute). Gondolf, E. (1988) Battered Women as Survivors: An Alternative to Treating Learned Helplessness (Toronto: Lexington Books). Goodwin, R. (1988) "Power and Control: Why men dominate women," Humanist in Canada, Summer, 31-33. Hart, B. (1988) "Beyond the duty to warn: A therapist's duty to protect battered women and children" in K. Yllo and M. Bograd (eds.) Feminist Perspectives on Wife Abuse (Newbury Park, CA: Sage) 234-248. Holmes, M. and C. Lundy (1990) "Group work for abusive men: A proferninist response," Canada's Mental Health, December, 12-17. Kaufman, M. (1987) "The construction of masculinity and the triad of men's violence" in M. Kaufman (ed.) Beyond Patriarchy: Essays by Men on Pleasure, Power and Change (Toronto: Oxford University Press). Mathews, F. (1993) Making the Decision to Care: Guys and Sexual Assault (Ottawa: Health Canada, National Clearinghouse on Family Violence). Pence, E. and M. Paymar (1986) Power and Control: Tactics of Men Who Batter (Duluth: Minnesota Program Development, Inc). Purdy, F. and N. Nickle (1981) "Practice principles for working with groups of men who batter," Social Work with Groups, 4(3/4), 111-122. E. Feminist Perspectives and Health Providers Allen, M. (1985) "Women, nursing and feminism: An interview with Alice J. Baunigart," The Canadian Nurse, 81(l), 20-22. Ashley, J. (1976) Hospitals, Paternalism, and the Role of the Nurse (New York: Teacher's College Press). Belenky, M.F., B.M. Clinchy, N.R. Goldberger and J.M. Tarule (1986) Women's Ways of Knowing (New York: Basic Books). Boston Women's Health Book Collective (1992) The New Our Bodies, Ourselves (New York: Simon and Schuster). Braude, M. (ed.), (1987) Women, Power, and Therapy: Issuesfor Women (New York: Haworth Press). Burstow, B. (1992) Radical Feminist Therapy: Working in the Context of Violence (Newbury Park, CA: Sage). Chenevert, M. (1983) STAT: Special Techniques in Assertiveness Training for Women in the Health Professions (St. Louis: Mosby). Chiarelli, M. and F. Nadon (1985) "Commentary - Women and mental health: A feminist view," The Canadian Nurse, 81(l), 23. Chin, P. and C.E. Wheeler (1985) "Feminism and nursing: Can nursing afford to remain aloof from the women's movement?" Nursing Outlook, 33(2), 74-77. Coburn, D. (1988) "The development of Canadian nursing: Professionalization and proletarianization," International Journal of Health Services, 18(3), 437-454. Edwards, A. (1987) "Male violence in feminist theory: An analysis of the changing conceptions of sex/gender violence and male dominance" in J. Hamner and M. Maynard (eds.) Women, Violence and Social Control (Basingstoke: MacMillan) Chapter 2. Ehrenreich, B. and D. English (1973) Witches, Midwives and Nurses: A History of Women Healers (Old Westbury, NY: The Feminist Press). Foner, N. (1994) The Caregiving Dilemma: Work in an American Nursing Home (Berkeley: University of California Press). Hagell, E.I. (1989) "Nursing knowledge: Women's knowledge. A sociological perspective," Journal of Advanced Nursing, 14, 226-233. Hamlin, R.B. (1992) "Embracing our past, informing our future: A feminist re-vision of health care," American Journal of Occupational Therapy, 46(11), 1028-1035. Hamlin, R., K. Loukal, J. Froehlich and N. MacRae (1992) "Feminism: An inclusive perspective," American Journal of Occupational Therapy, 46, 967-970. Keddy, B. (1993) "Feminism and patriarchy in university schools of nursing: An unsettling dualism" conference address: Women's Issues and Nursing Education, Moncton, Atlantic Region Canadian Association of University Schools of Nursing. (Unpublished.) McComas, J. (1993) "Experiences of student and practising physical therapists with inappropriate patient sexual behaviour," Physical Therapy, 73(11), 762-770. Muller, R.J. (1992) "Interwoven threads: Occupational therapy, feminism and holistic health," American Journal of Occupational Therapy, 46(l), 1013-1019. Murphy, R. (1988) "Hospital Nurses' Experience of Work Examined in the Light of Caring Ideology," Master's thesis (Carleton University, Ottawa). (Unpublished.) O'Neill, G. and M. Ross (1991) "Burden of care: An important concept for nursing," Health Care for Women International, 12(l), 111-121. Reverby, S. (1987) Ordered to Care (Cambridge: Cambridge University Press). Roberts, S. (1983) "Oppressed group behaviour: Implications for nursing," Advances in Nursing Science, 5(4), 21-30. Valentine, P. (1992) "Feminism: A four letter word?" The Canadian Nurse, 88(11), 20-23. Yllo, K. and M. Bograd (eds), (1987) Feminist Perspectives on Wife Abuse (Newbury Park CA: Sage). F. Professional Issues, Social Change and Political Process Chenevert, M. (1988) Special Techniques in Assertiveness Training, 3rd ed. (St. Louis: Mosby). Ehrenreich, J. (ed.), (1978) The Cultural Crisis of Modern Medicine (New York and London: Monthly Review Press). Freidson, E. (1970) Profession of Medicine: A Study in the Sociology ofApplied Knowledge (New York: Harper & Row). Graydon, J.E., W. Kasta and P. Khan (1992) The Personal andProfessional Impact on the Nurse Qf Verbal and Physical Abuse: Final Report (Toronto: University of Toronto). Hedin, B. (1986) "A case study of oppressed group behaviour," Image: Journal of Nursing Scholarship, 53-57. Lanza, M.L. (1992) "Nurses as patient assault victims: An update, synthesis, and recommendations," Archives of Psychiatric Nursing, 6(3), 163-171. Lefort, S.M. (1993) "Shaping health care policy," The Canadian Nurse, 89(3), 23-27. Mason, D.J., B.A. Backer and C.A. Georges (1991) "Toward a feminist model for the political empowerment of nurses," Image: Journal of Nursing Scholarship, 23(2), 72-77. Murphy, R. (1988) "Hospital Nurses' Experience of Work Examined in the Light of Caring Ideology," Master's thesis (Carleton University, Ottawa). (Unpublished.) Navarro, V. (1986) Crisis, Health and Medicine: A Social Critique (London: Tavistock). Phillips, S. and M.S. Schneider (1993) "Sexual harassment of female doctors by patients," New England Journal of Medicine, 329(26), 1936-1939. Rachlis, M. and C. Kushner (1994) Strong Medicine: How to Save Canada's Health Care System (Toronto: Harper Collins Publishers, Ltd). Salvage, J. (1985) The Politics of Nursing (London: Heinemann
Nursing). APPENDIX A: Practice Manuals for Health and Social Service Disciplines Domestic Violence Protocol Manual: For Social Workers in Health Facilities (1985) Canadian Association of Social Work Administrators in Health Facilities. Available from National Clearinghouse on Family Violence, Health Canada, Ottawa, Ontario, K1A 1B4.Family Violence Clinical Guidelines for Nurses (1992) Canadian Nurses Association. Batterer's Treatment Program: Program Philosophy, Goals and Design (1993), (Lawrence, MA: Greater Lawrence Mental Health Centre, Inc.). Child Sexual Abuse: Guidelines for Community Workers. Strengthening Community Response (1991), (Ottawa: Health and Welfare Canada). Denham, D. and J. Gillespie (1992) Wife Abuse: A Workplace Issue - A Guide for Change (Ottawa: Family Violence Program, Canadian Council on Social Development, Available from National Clearinghouse on Family Violence, Health Canada, Ottawa KlA 1B5. Elder Mistreatment Guidelines for Health Care Professionals: Detection, Assessment and Intervention (1988), (New York: Mount Sinai/Victim Services Agency Elder Abuse Project). Family Violence Against Women with Disabilities (1993), (Ottawa: National Clearinghouse on Family Violence). Family Violence Clinical Guidelines for Nurses (1992), (Ottawa: Canadian Nurses Association) Available from National Clearinghouse on Family Violence. Family Violence Resource Materials for the Dental Community: An Annotated Bibliography (1993) Mental Health Division, Health Canada. Health Care Related to Abuse, Assault, Neglect and Family Violence: Guidelines (1989) Report of the Subcommittee on Institutional Program Guidelines (Ottawa: Health Services Directorate, Health Canada). Loree, D.J. and R.W. Walker (eds.), (1991) Community Crime Prevention: Shaping the Future (Ottawa: Ministry of Supply and Services Canada). MacLeod, L. (1990) Counselling for Change: Evolutionary Trends in Counselling Servicesfor Women Who are Abused and for Their Children in Canada (Ottawa: National Clearinghouse on Family Violence). Making Changes: A Book for Women in Abusive Relationships, A Directory and Introduction to Abuse in All Aspects (Halifax: Nova Scotia Advisory Council on Status of Women). The Mountain and Beyond: Resources for a Collaborative Approach to Domestic Violence (1993), (Ottawa: Health Canada) Contains a video, ideas for collaboration at work, and a reference and planning workbook. Available for loan through professional associations; information available from National Clearinghouse on Family Violence, Health Canada. Recent Resources on Dating Violence for Educators, Counsellors, Parents and Teens (1993), (Ottawa: Canadian Council on Social Development, Box 3505, Station C, Ottawa, K1Y 4G1. Resource Kit (1992) Schools and Communities - Partners for a Safe Society (Toronto: The Safe School Task Force, 60 Mobile Drive, Toronto, Ontario M4A 2P3). A Specialized Geriatric Consultation Service (1993), (Toronto: Regional Geriatric Program of Metropolitan Toronto). Your Rights: An Assaulted Woman's Guide to the Law (1991), (Toronto: Ontario Women's Directorate Publications Department). Wife Assault Protocol (1992), (Ottawa: Ottawa General Hospital, Emergency Service. 501 Smyth, Ottawa, Ontario K1H 8L6). APPENDIX B: Manuals, Film and Teaching Kits The Family Violence Audio-Visual Source Guide (1993) National Film Board of Canada, Health and Welfare Canada. Also available from university libraries. Curriculum Management for the Medical Management of Wife Abuse for Undergraduate Medical Students (1990) Ontario Medical Association. Programs for People in Crisis. A Guide for Educators, Administrators, Clinical Trainers (1987) L.A. Hoff and N. Miller (Boston: Northeastern University Custom Book Program). Kit includes:
1. National Clearinghouse on Family Violence. Family Violence Prevention Unit, Health Canada, Ottawa, Ontario K1A 1B5. 2. ProvinciaUterritorial ministries of health. 3. Provincial/territorial ministries of social services. 4. Provincial/territorial ministries of education. 5. Provincial/territorial women's bureaus or commissions on status of women. 6. Provincial justice ministries and local police departments for legal issues. 7. Regional and local family service associations. 8. University women's studies programs and libraries. 9. Local hospitals and community agencies for clinical protocols. APPENDIX C: Methodology The methods employed to develop this Guide focused on participatory and collaborative activities in a three-stage process: The first stage occurred at the University of Ottawa School of Nursing, and was funded by the Ontario Ministry of Colleges and Universities. It culminated in production of the Curriculum Guide for Nursing: Violence Against Women and Children in English and French (Hoff and Ross, 1993). This resource was translated and published in 1994. Though focused by the funding body mandate on nursing as a key health profession, it was clear from the outset that violence is an interdisciplinary topic, with essential content and case illustrations applying across the health professions. Accordingly, the series of focus groups and individual interviews included not only nurse educators, clinicians and nursing students across all levels of professional nursing, but also many constituencies representing rural urban geographical areas throughout Ontario. These included: Stage 2: Adaptation for interdisciplinary Audience-July l993- December 1993
Stage 3: Preparation of Interdisciplinary Curriculum Guide and Peer Review Process - January 1994 - August 1994
See Appendix D for a list of project participants and reviewers. APPENDIX D: Adamowski, Kazimiera, Ottawa General Hospital, Ottawa APPENDIX E:
B: Suggestions for use and revision 1. Please comment on your use (or plans for use)
of this GUIDE: 2. What have you found most useful about this
GUIDE? 3. What have you found least useful about this
GUIDE? 4. Please list any bibliographic sources you
think should be added to future edition of this GUIDE (include section):
5. Please comment on your need for consultation
or other assistance in implementing the recommendations of this GUIDE:
6. Additional comments/suggestions (add pages
as necessary): 7. Your professional discipline: Send completed Evaluation Form to: Violence Prevention and Mental Health Program, Mental Health Unit, Health Canada, Postal Locator 1909D1, Ottawa, ON K1A 1B4 |
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