Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa.

BACKGROUND: While intimate partner violence (IPV) has well documented impact on women and children, few interventions have been tested for mothers and children in the domestic violence shelter system. OBJECTIVE: We used mixed methods to explore effects of a pilot intervention combining trauma focused cognitive behavior therapy (TF-CBT) (verbal therapy method) with art and play therapy (non-verbal therapy methods) in New York City and Johannesburg, to compare efficacy between high and low-middle income contexts. PARTICIPANTS AND SETTING: School-aged children and their mothers from one domestic violence shelter in each city were invited to participate. METHODS: Children were screened for depression and post-traumatic stress disorder (PTSD). Children participated in a weekly group session lasting 1-2 hours over 12 weeks and mothers received 3 group sessions. Quantitative data comprised pre-and post-intervention child self-reports (n = 21) and mother's report (n = 16) of child depressive and PTSD symptoms. Qualitative in-depth interviews were conducted with children (n = 11) and mothers (n = 8) who completed the intervention. RESULTS: At baseline, children showed high rates of symptoms of probable depression and probable PTSD (33 % and 66 % respectively). By endline, depressive symptoms significantly reduced (mean of 13.7-8.3,p = 0.01) and there was a non-significant trend towards PTSD improvement (40.0-34.4, p = 0.21). Children revealed the art helped them express difficult emotions and experiences with their mothers. Multiple children felt it assisted in managing challenging behaviours. CONCLUSION: This pilot trauma-informed art and play therapy group intervention holds promise in mitigating the effects of IPV for children and mothers in domestic violence shelters.

A cross-sectional survey of pregnant women's perceptions of routine domestic and family violence screening and responses by midwives: Testing of three new tools.

BACKGROUND: Implementing Domestic and Family Violence (DFV) screening, support, and prevention within maternity services is becoming common practice but women's experiences of screening are not routinely evaluated. AIMS: (1) Explore pregnant women's experiences of routine DFV screening and perceptions of responses by midwives; and (2) undertake preliminary testing of three new tools. METHODS: Using a cross-sectional design, pregnant women (n = 210) attending an antenatal service were surveyed. Three new measures: beliefs about DFV screening; non-disclosure of DFV; and midwifery support were tested. RESULTS: Most women (92.3% n = 194) recalled being screened. Twelve (5.8%) respondents had/were experiencing DFV. A quarter (24.1% n = 49) had experienced or witnessed violence in the home as a child. The scales were reliable and factor analysis established validity. Women reported positive beliefs (mean 35.38, SD 3.63 range 19-40) and views about midwifery support (mean 24.88, SD 3.08 range 18-30). There was less agreement about why some women do not disclose DFV (mean 21.97, SD 4.27, range 8-30). Women who experienced or witnessed violence as a child, or were experiencing violence now were less comfortable with screening. Comments (n = 75) revealed support for routine enquiry that was confidential, explained, and occurred in a trusting relationship. DISCUSSION: Women were supportive of screening, but actual rates of disclosure were low. Women acknowledged the importance of screening but did not want their information shared. CONCLUSIONS: Women value screening, even if DFV is not disclosed. Exploring women's experiences is central to ensuring quality care.

Australian nursing and midwifery student beliefs and attitudes about domestic violence: A multi-site, cross-sectional study.

Nurses and midwives have a professional responsibility to identify and provide effective care to those experiencing domestic violence. Pre-registration preparation may develop this capability. In order to inform curriculum development, this study explored Australian nursing and midwifery students' attitudes and beliefs about domestic violence. Data were collected between June and October 2017. Descriptive statistics were calculated and comparative analysis performed on independent variables. Thematic analysis was performed on open-ended qualitative responses. Participants included 1076 students from nine Australian universities. The majority were enrolled in nursing programs (88.4%), followed by midwifery (8.6%), and combined nursing/midwifery (2.4%) programs. There was no statistically significant difference in scores by year level across all subscales, suggesting there was no developmental change in beliefs and attitudes toward domestic violence over the course of study. Nursing students held views that were more violence-tolerant than midwifery students. Australian and Chinese-born males were more likely to refute that domestic violence is more common against women. Students had a limited understanding of domestic violence suggesting a critical need to address undergraduate nursing and midwifery curricula.

Responding to violence against women: A qualitative study with midwives in Timor-Leste.

PROBLEM: The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. AIM: This research explores the barriers and enablers that midwives report in responding to domestic and sexual violence in Timor-Leste, a country with a very high rate of violence against women. The aim is to inform a systems approach to health provider training and engagement applicable to Timor-Leste and other low-resource settings. METHODS: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. FINDINGS: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. CONCLUSION: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managers within a health facility, work creatively to overcome barriers to implementation, and link them with wider community-based resources.

Violence against the elderly: the conceptions of nursing professionals regarding detection and prevention. / Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção.

OBJECTIVE: To analyze the conceptions of the nursing professionals working in Basic Health Units regarding the detection and prevention of violence against the elderly. METHODS: Descriptive, exploratory, qualitative study. Performed in two BHUs in Mossoró/RN, using a semi-structured interview script, from March to August of 2013. Sample composed of four nurses and six nursing technicians. The content analysis, pre-analysis, material exploration, and treatment of results were performed. RESULTS: Four categories were identified: Strategies used to identify violence against the elderly; Types of violence against the elderly; Conduct used after finding a suspicion of violence; SUS and the problem of violence against the elderly. Many professionals recognize/distrust possible cases, however, they do not know how to proceed. The dimension of the problem requires that pragmatic interventions be performed in the clinical setting and in the social context. FINAL CONSIDERATIONS: There is a need for continuing education for professionals and greater communication between the bodies responsible for reporting and embracement.

[Psychopathology of intrafamily violence]. / Psychopathologie des violences intrafamiliales.

Intrafamily violence is a major public health problem, due to its frequency and the severity of its consequences. The aim is to establish links between violence and psychopathology, for the perpetrators as well as the victims. Data reveal a higher frequency of certain mental health disorders and history of abuse in the perpetrators, without it being systematic. It is important to adopt a global and multidisciplinary approach, and a holistic perspective faced with the people concerned by these acts. Health professionals, from the social sector and associations must therefore work together in a network to manage and attempt to prevent crisis situations.

[When the trap closes in]. / Quand le piège se referme.

The poignant testimony of Anne L. illustrates perfectly how the spiral of an abuser's hold closes around the victim. She describes how she met Charles and how their relationship, between passionate love and hate, hope and disillusion, progressed from psychological war to beatings, resulting in absolute domination. Supported today by a specialised network, even though she has managed to leave him, many questions remain for this victim and her scars are far from healed.

Longitudinal evaluation of a training program to promote routine antenatal enquiry for domestic violence by midwives.

BACKGROUND: Routine enquiry about domestic violence during pregnancy is accepted best practice. Training is essential to improve knowledge and practice. Few studies have undertaken a comprehensive evaluation of training impact over time. AIM: To evaluate the longitudinal impact of a domestic violence training and support program to promote midwives' routine antenatal enquiry for domestic violence using a mixed methods design. METHOD: Data sources included (1) surveys of midwives at 6 months post-training, (2) interviews with key stakeholders at 12 months, (3) chart audit data of screening, risk, and disclosure rates (for 16 months). Measures included midwives' knowledge, preparation for routine enquiry, knowledge of domestic violence and perceptions of impact of the training and support for practice change. FINDINGS: Forty (out of 83) participant surveys could be matched and responses compared to baseline and post-training scores. Wilcoxon signed-rank test identified that all 6-month follow-up scores were significantly higher than those at baseline. Level of preparedness increased from 42.3 to 51.05 (Z=4.88, p<.001); and knowledge scores increased from a mean of 21.15 to 24.65 (Z=4.9, p<.001). Most participants (>90%) reported improved confidence to undertake routine inquiry. A chart audit of screening rates revealed that of the 6671 women presenting for antenatal care, nearly 90% were screened. Disclosure of domestic violence was low (<2%) with most women at risk or experiencing violence declining referral. CONCLUSIONS: Training, support processes, and referral pathways, contributed to midwives' sustained preparedness and knowledge to conduct routine enquiry and support women disclosing domestic violence.

South Asian women's coping strategies in the face of domestic violence in the United States.

We conducted in-depth telephone interviews with a convenience sample of 20 South Asian women experiencing domestic violence in the United States. Utilizing the emotion-focused and problem-focused coping framework, the researchers analyzed the narratives of abused South Asian women. Emotion-focused coping strategies include (a) spirituality and/or religion and (b) the role of children. Problem-focused coping strategies include (c) informal and formal support and (d) strategies of resisting, pacifying, safety planning. Implications for practice and future research in the United States and internationally are discussed.

Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção / Violencia contra ancianos: conceptos de profesionales de enfermería sobre la detección y prevención / Violence against the elderly: the conceptions of nursing professionals regarding detection and prevention

Resumo OBJETIVO Analisar as concepções dos profissionais de enfermagem atuantes em Unidades Básicas de Saúde quanto à detecção e prevenção de idosos violentados. MÉTODOS Estudo descritivo, exploratório, qualitativo. Realizado em duas UBS, Mossoró/RN, utilizando roteiro de entrevista semiestruturada, em março a agosto de 2013. Amostra composta por quatro enfermeiros e seis técnicos de enfermagem. Realizada análise de conteúdo. RESULTADOS Identificaram-se 4 categorias: Estratégias utilizadas para identificar a violência contra o idoso; Tipos de violências contra o idoso; Conduta utilizada após constatação de uma suspeita de violência; SUS e a problemática da violência contra o idoso. Muitos profissionais reconhecem/desconfiam dos possíveis casos, entretanto, não sabem como proceder. A dimensão do problema exige que sejam realizadas intervenções pragmáticas no meio clínico e no contexto social. CONCLUSÕES Há necessidade de educação permanente para profissionais e maior comunicação entre as instâncias responsáveis pela denúncia e acolhimento.

Resumen OBJETIVO Analizar los conceptos de enfermeros activos en unidades básicas de la salud sobre la detección y prevención del maltrato hacia personas ancianas. MÉTODOS Estudio exploratorio, descriptivo y cualitativo, realizado en dos UBS, en Mossoro/RN, por medio de entrevistas semiestructuradas entre marzo y agosto de 2013. Se realizó el estudio con cuatro enfermeros y seis técnicos de enfermería. Se llevó a cabo el análisis de contenido. RESULTADOS El análisis se divide en 4 categorías: Estrategias utilizadas para identificar la violencia contra ancianos; Tipos de violencia contra personas mayores; Acción utilizada luego de detectarse la violencia; y SUS y el tema de la violencia contra ancianos. Muchos profesionales reconocen/desconfían de los posibles casos, sin embargo, no saben cómo proceder. La magnitud del problema requiere de intervenciones pragmáticas que se lleven a cabo en el ámbito clínico y en el contexto social. CONSIDERACIONES FINALES Existe la necesidad de una educación continua para profesionales y una mayor comunicación entre los organismos responsables de la queja y acogida.

Abstract OBJECTIVE To analyze the conceptions of the nursing professionals working in Basic Health Units regarding the detection and prevention of violence against the elderly. METHODS Descriptive, exploratory, qualitative study. Performed in two BHUs in Mossoró/RN, using a semi-structured interview script, from March to August of 2013. Sample composed of four nurses and six nursing technicians. The content analysis, pre-analysis, material exploration, and treatment of results were performed. RESULTS Four categories were identified: Strategies used to identify violence against the elderly; Types of violence against the elderly; Conduct used after finding a suspicion of violence; SUS and the problem of violence against the elderly. Many professionals recognize/distrust possible cases, however, they do not know how to proceed. The dimension of the problem requires that pragmatic interventions be performed in the clinical setting and in the social context. FINAL CONSIDERATIONS There is a need for continuing education for professionals and greater communication between the bodies responsible for reporting and embracement.

Knowledge gap in domestic abuse care.

More than one quarter of nursing staff say they lack confidence in supporting people who face domestic abuse, an RCNi survey reveals.

Domestic violence in pregnancy: midwives and routine questioning.

The Confidential enquiry into maternal and child health (CEMACH) (2004) set the standard for maternity care to protect women from domestic violence. Twelve women who were murdered by their partner and 43 further deaths from disclosure with no appropriate referrals prompted the routine enquiry for domestic violence to be initiated in 2000. The death rate from domestic violence had marginally decreased slightly in the latest report from The Centre for Maternal and Child Enquiries (CMACE) (2011) with 11 women murdered by their partner and 34 further deaths from disclosure with no referrals. The aim of this article is to review the current literature in order to explore evidence that questions the confidence of midwives when asking about domestic violence in pregnancy. The article aims to highlight the concerns that midwives face when confronted with a positive disclosure of domestic violence, and to provide a flow chart to aid in referral.

Prenatal screening for psychosocial risks in a high risk-population in Peru using the KINDEX interview.

BACKGROUND: Prenatal stress and other prenatal risk factors (e.g. intimate partner violence) have a negative impact on mother's health, fetal development as well as enduring adverse effects on the neuro-cognitive, behavioral and physical health of the child. Mothers of low socio-economic status and especially those living in crime-ridden areas are even more exposed to a host of risk factors. Societies of extreme violence, poverty and inequalities, often present difficulties to provide adequate mental health care to the most needed populations. The KINDEX, a brief standardized instrument that assesses 11 different risk factors was used by midwives to identify pregnant women at-risk, in a suburban area with one of the highest levels of domestic violence in Lima. The instrument was designed to be used by medical staff to identify high-risk child-bearing women and, based on the results, to refer them to the adequate psychological or social support providers. The aim of this study is to assess the feasibility of psychosocial screening using the KINDEX in a Latin American Country for the first time, and to explore the relationship of the KINDEX with thee major risk areas, maternal psychopathology, perceived stress and traumatic experiences. METHODS: The study was conducted in cooperation with the gynecological department of a general hospital in a suburban area of Lima. Nine midwives conducted interviews using the KINDEX of ninety-five pregnant women attending the gynecological unit of the hospital. From these, forty pregnant women were re-interviewed by a clinical psychologist using established instruments in order to assess the feasibility of the prenatal assessment in public health settings and the relationship of the KINDEX with maternal perceived stress, psychopathology symptoms and trauma load during pregnancy. RESULTS: We found high rates of risk factors in the examined pregnant women comparable with those found in the general population. Significant correlations were found between the KINDEX sum score and the three risks areas, stress, psychopathology and trauma load as assessed in the Clinical Expert interviews. The different risks assessed by the KINDEX are related to higher levels of stress, psychopathology and trauma load, depending on the risk. CONCLUSIONS: The relationship between past adverse experience and current stressors with perceived maternal stress, psychopathology symptoms and traumatic experiences confirm the importance of prenatal assessment for psychosocial risks. The use of KINDEX by midwives providing obstetrical care to pregnant women in urban Peru is feasible and can be used to identify high-risk women and refer them to the adequate mental health or social services for necessary attention and support. Early interventions are essential to mitigating the adverse effects of maternal stress, trauma and psychopathology on the fetus and child.

"It Gave Me My Life Back": An Evaluation of a Specialist Legal Domestic Abuse Service.

Community-based advocacy services are important in enabling victims to escape domestic abuse and rebuild their lives. This study evaluated a domestic abuse service. Two phases of research were conducted following case-file analysis (n = 86): surveys (n = 22) and interviews (n = 12) with victims, and interviews with key individuals (n = 12) based in related statutory and community organizations. The findings revealed the holistic model of legal, practical, mental health-related, and advocacy components resulted in a range of benefits to victims and enhanced interagency partnership working. Core elements of a successful needs-led, victim-centered service could be distilled.

Addressing domestic violence through antenatal care in Sri Lanka's plantation estates: Contributions of public health midwives.

Domestic violence in pregnancy is a significant health concern for women around the world. Globally, much has been written about how the health sector can respond effectively and comprehensively to domestic violence during pregnancy via antenatal services. The evidence from low-income settings is, however, limited. Sri Lanka is internationally acknowledged as a model amongst low-income countries for its maternal and child health statistics. Yet, very little research has considered the perspectives and experiences of the key front line health providers for pregnant women in Sri Lanka, public health midwives (PHMs). We address this gap by consulting PHMs about their experiences identifying and responding to pregnant women affected by domestic violence in an underserved area: the tea estate sector of Badulla district. Over two months in late 2014, our interdisciplinary team of social scientists and medical doctors met with 31 estate PHMs for group interviews and a participatory workshop at health clinics across Badulla district. In the paper, we propose a modified livelihoods model to conceptualise the physical, social and symbolic assets, strategies and constraints that simultaneously enable and limit the effectiveness of community-based health care responses to domestic violence. Our findings also highlight conceptual and practical strategies identified by PHMs to ensure improvements in this complex landscape of care. Such strategies include estate-based counselling services; basic training in family counselling and mediation for PHMs; greater surveillance of abusive men's behaviours by male community leaders; and performance evaluation and incentives for work undertaken to respond to domestic violence. The study contributes to international discussions on the meanings, frameworks, and identities constructed at the local levels of health care delivery in the global challenge to end domestic violence. In turn, such knowledge adds to international debates on the roles and responsibilities of health care professionals in responding to and preventing domestic violence.

The voices of Brazilian women breaking free from intimate partner violence.

Intimate partner violence (IPV) is a global problem with a direct effect on the health of the victims and their communities. With the intention to inform nursing care delivered to women experiencing IPV, this qualitative study was conducted, specifically to understand the meaning that IPV has for assaulted women and to identify the factors that contribute to breaking the cycle of violence. Data collection included interviews and discussion of photographs. Participants were recruited from within a shelter for women experiencing violence. Findings from five women were inductively coded into three categories: "experiencing violent acts," which describes the period in which the women lived with the aggressor; "marks of the violent acts," which portrays the consequences of IPV; and "women's support," which indicates the current supports or lack thereof for these women. Nurses and other healthcare providers will benefit from hearing the women's voices through their words and photographs and will recognize the need for holistic care that includes the physical, sexual, and emotional needs of abused women.

Cognitive behavioral therapy for depressed adolescents exposed to interpersonal trauma: an initial effectiveness trial.

Four clinical trials have shown that a history of interpersonal trauma is associated with diminished response to cognitive-behavioral therapy (CBT) for adolescent depression. An efficacious CBT protocol for adolescent depression was modified to address cognitive deficits and distortions associated with interpersonal trauma. Initial feasibility, acceptability, and treatment impact of the modified treatment (m-CBT) were evaluated in a randomized effectiveness trial conducted in community clinics. Clients were 43 referred adolescents with a depressive disorder and a history of interpersonal trauma. Adolescents either received m-CBT or usual care (UC) therapy. Results indicated that m-CBT was delivered with good fidelity by community clinicians, but that number of sessions completed was attenuated in both m-CBT and UC. Adolescents reported high levels of treatment satisfaction and acceptability for the new treatment. There were significant reductions in depressive symptoms over time, but no differences in outcomes between groups. Although the new treatment produced promising results, it did not outperform UC. Implications for treatment development are considered.

A multidimensional model of psychobiological interactions in functional dyspepsia: a structural equation modelling approach.

OBJECTIVE: Gastric sensorimotor function, abuse history, 'trait' and 'state' psychological factors and 'somatisation' all play a role in functional dyspepsia (FD) and its associated impaired quality of life (QoL), but their interplay remains poorly understood. We aimed to test a comprehensive, a priori hypothesised model of interactions between these dimensions in FD. DESIGN: In 259 FD patients, we studied gastric sensitivity with a barostat. We measured abuse history (sexual/physical, childhood/adulthood), 'trait' (alexithymia, trait anxiety) and 'state' (positive/negative affect, depression, panic disorder) psychological factors, somatic symptom reporting (somatic symptom count, dyspepsia, irritable bowel syndrome and fatigue symptoms) and QoL (physical, mental) using validated questionnaires. Confirmatory factor analysis (CFA) was used to assess whether four a priori hypothesised latent variables ('abuse', 'trait affectivity', 'state affect' and 'somatic symptom reporting') were adequately supported by the data. Structural equation modelling (SEM) was used to test the a priori hypothesised relationships between these latent variables and the observed variables gastric sensitivity and QoL. RESULTS: Both the CFA and SEM models fitted the data adequately. Abuse exerted its effect directly on 'somatic symptom reporting', rather than indirectly through psychological factors. A reciprocal relationship between 'somatic symptom reporting' and 'state affect' was found. Gastric sensitivity influences 'somatic symptom reporting' but not vice versa. 'Somatic symptom reporting' and 'trait affectivity' are the main determinants of physical and mental QoL, respectively. CONCLUSIONS: We present the first comprehensive model elucidating the complex interactions between multiple dimensions (gastric sensitivity, abuse history, 'state' and 'trait' psychological factors, somatic symptom reporting and QoL) in FD.

Evaluation of a spiritually focused intervention with older trauma survivors.

This study evaluated the effectiveness of an 11-session, spiritually focused group intervention with older women survivors (age 55 years and older) of interpersonal trauma (child abuse, sexual assault, or domestic violence) in reducing trauma-related depressive symptoms, posttraumatic stress, and anxiety. Forty-three community-dwelling women survivors of interpersonal trauma were randomized into treatment (n = 21) or control (n = 22) groups. Participants in group psychotherapy discussed spiritual struggles related to abuse and developed spiritual coping resources. The treatment group had significantly lower depressive symptoms, anxiety, and physical symptoms at posttest compared with the control group. In a separate analysis, posttraumatic stress symptoms also dropped significantly in the treatment group. Gains were maintained at three-month follow-up. This study provides strong initial support for the effectiveness of spiritually focused group intervention for older survivors of interpersonal trauma from a Christian background.

Voices of strength and struggle: women's coping strategies against spousal violence in Pakistan.

This article documents the coping strategies adopted by women victims of spousal violence in Pakistan. By drawing on 21 in-depth interviews conducted in Lahore and Sialkot (Pakistan), we found that the women tried to cope with violence by using various strategies, both emotion focused (e.g., use of religion, placating the husband, etc.) and problem focused (e.g., seeking support from formal institutions, etc.). The data showed that a majority of the women used emotion-focused strategies, especially spiritual therapies, which somehow reduced the violence and provided them with psychosocial solace. Nonetheless, these strategies incurred some costs, such as the consumption of scarce resources, time, and emotional energy. Our data also showed that few women opted for problem-focused strategies, such as seeking help from formal institutions, as these strategies could lead to overt confrontation with their husbands and may result in divorce, the outcome least desired by most of the Pakistani women. We noted that the coping behavior of Pakistani women was complex, subjective, and nonlinear and that the boundaries between emotion-focused and problem-focused strategies were diffuse and blurred. Although the women never surrendered to violence, they were fully aware of their structural limitations and vulnerabilities. Being mindful of the consequences of their actions, women carefully tailored a combination of strategies which could be helpful in resisting or reducing violence but, at the same time, should not be counterproductive. This article argues that Pakistani women alone cannot effectively resist violence while living under a harshly patriarchal regime, where violence against women is embedded in the social, political, and legal structures of society. There are no quick fixes to change the status quo. The Pakistani government, civil society, and formal institutions must proactively support women in reducing their vulnerabilities and facilitate them in expanding their capabilities to address the real causes of violence against them.