Introduction
Intimate partner violence (IPV), more commonly known as domestic violence, is defined as “the use of threat or use of physical, emotional, and/or sexual abuse with the intent of instilling fear, and intimidating and controlling another person” (Rice, 2006). The violence occurs in an ongoing relationship or in one that is over with. The incidence of this problem is huge in the United States: 5.3 million women above 18 years of age are being abused in IPVs (Kramer, 2007). Violence against women is significant in two perspectives: one as a basic human rights violation and a hindrance to gender equality and the second as a developmental issue with harsh consequences to economic growth
(ICRW, 2009). The global issue has been identified as growing due to inaction.
IPV legal issues have instigated policy and decision makers to implement appropriate therapeutic interventions for saving the women and the world from avoidable issues. This paper elaborates on one therapeutic intervention which would work well with pregnant women being abused in IPV. The abuse begins in pregnancy and continues afterward.
What treatment modality would you recommend as appropriate treatment for the problem?
The patient centered approach is the treatment modality suitable for managing a case of IPV in pregnant women. It is a collaborative procedure (Kramer, 2007). The patient-nurse relationship is an active one where the caring and therapeutic philosophies are significant. If the relationship is a strong and trusting one, the pregnant woman may reveal details of her abuse. The provider must take care in enquiring deeply about abuse as the women tend to be survivors and may show reluctance in divulging secrets about their intimate partner. The need of women to make their own healthcare decisions must be remembered in this instance. This type of patient centered-care is practiced in a natural manner. Finding quick care is not the goal of therapy. The patient’s right is respected. She must exhibit the ability to self-direct and practice autonomy. The patient is facilitated by the health care staff that ask and listens patiently about her experiences of abuse. Her perceptions of the abuse are enquired into and guidance will be provided based on her goals and values. The provider does not enforce his views. The client-centered or patient-centered approach is collaborative and not prescriptive. The intrinsic motivation and guidance of resources for change need to be elicited from the patient.
Describe the theoretical orientation associated with the recommended treatment modality
The patient centered approach using the Transtheoretical Model of Prochaska and DiClemente (1992) would be a suitable method to handle women of abuse. The Landenburger’s (1989) process theory postulates that “all women experience an initial or binding phase and many may not progress to the phases of enduring, disengaging, and recovering” following abuse (Kramer, 2007). Recently a “double binding” theory emerged in a study by Lutz and Curry has been spoken of (2006). This theory tells about how the pregnancy is a double challenge for the woman. She makes serious efforts to remain with her abuser husband and “bind” him to accept the child and continue as a normal family.
The Transtheoretical Model has various stages of change. The patients will be going through various stages or major life changes in the process of modifying a problem behavior or enhancing a positive behavior (Kramer, 2007). The process involves decision-making during which emotion, cognition and behavior show transitions. The stages of change begin with the precontemplation period where no action is taken because there is the unawareness of a problem. Consideration of the patient’s different options in the current situation and her options towards any action constitute the contemplation period (Kramer, 2007). Preparation is the process where actions are undertaken. The real action takes place during the Action phase. Maintaining the changes for a long duration constitutes the last phase. Convincing the pregnant woman about the changes for the better, she may be extricated from the binding phase to progress onto the stages of endurance, disengaging and recovery by using the Transtheoretical model.
Describe the specific treatment plan you would develop and employ to treat a family member, couple, or family presenting with the problem you selected for study
Explain:
- Who would be involved in treatment? (Describe who would be invited to participate in the treatment process and why each participant would be invited to do so.)
- How would treatment be administered?
- What treatment schedule would you recommend?
- With respect to treatment duration, how much time would you expect the recommended treatment to require to be effective (number and length of sessions, and number of weeks/years of proposed treatment)?
Treatment Plan
Motivational interviewing
The abused pregnant woman would be treated in a client-centered approach. The main process that would be applied is motivational interviewing using the OARS technique which constitutes the Open questions, Affirming, Reflecting and Summarizing. The open questions would not be just a yes or no question. Pointed questions which would elicit the history of abuse are asked after creating a trusting relationship with the patient (Kramer, 2007). Affirming would include the praise for having survived the abuse. Reflecting would give one an idea of how the woman is thinking. Summarizing would provide the salient features of the abuse. This type of interviewing may be used in all the stages of the Transtheoretical Model (Kramer, 2007).
Transtheoretical Model
In the pre-contemplation stage, the abused woman is not aware of her problem.
She must be coaxed out of her intimidated or submissive nature (Kramer, 2007). Efforts must be taken to re-instill her self-esteem. Interventions must be subtle and she must not be scared off. Simply asking about abuse may be an intervention. She may be asked whether she needs to share her thoughts and problems. Printed material may be given informing her about the interventions possible for the transition. Her choices must be respected (Kramer, 2007)
In the contemplation stages, the person is undecided about taking action. The full number of questions may be asked. The woman may be referred to the legal authorities or the police or shelter. She realizes that she has been abused. Safety plans are facilitated (Kramer, 2007).
In the Action stage, the patient will be helped to make concrete plans (Kramer, 2007). She is not encouraged do leave at this stage. Assistance may be provided for the legal advice, police shelter and counseling. If she goes back to the male, she must not be blamed. She needs to be advised for setbacks. The client affirms steps to reach liberation and healing (Kramer, 2007). Discussion of the reasons for setback like loneliness, finances, fear and pressurization may help prevent them.
In the stage of Maintenance, the woman fully realizes about her trapped condition in IPV (Kramer, 2007). Supports and networks are utilized. The temptation to return to the old behaviors must be restricted. The patient becomes aware of her potential to correct the situation and seek further help. She thinks about constructing a family without the abuser.
Setbacks are possible. If the patient moves back into an earlier stage, she is given time to come out of it. Fear of her abuser, poor finances, retaliation of husband’s friends or family, poor support from her own family are some conditions which may cause setbacks (Kramer, 2007).
Why do you think that the treatment modality you are recommending would be effective?
The above approach would mostly work as the stages are clearly set out. Moreover it is a client-centered approach which has the advantages of respecting the patient’s perspectives and ability. A conducive atmosphere is allowing the change instead of a coercive one (Kramer, 2007). The motivational interviewing with the OARS techniques facilitates the client into drawing the motivations from within themselves. The patient’s autonomy is affirmed. Her informed choice and her arguments for change provide her the self –esteem and confidence. The stages of the transtheoretical model enable the patient to gradually change over a period of about eighteen months or more.
If there is a setback, the client can still be brought back into a previous stage and started from there on (Kramer, 2007). The treatment modality has every chance of meeting success.
Did you find research reported in the literature that provides evidence for the applicability and merit of using the recommended treatment modality? Describe that research
The Prochaska model of readiness to change was studied by Shirazi in 2008.
“It evaluated the impact on readiness to change of an educational intervention on management of depressive disorders based on a modified version of the Prochaska model in comparison with a standard programme of continuing medical education (CME)” (Shirazi, 2008). A randomized control trial was done with 192 general physicians in primary care in Tehran, Turkey (Shirazi, 2008). It was concluded that the physicians could reach higher stages of learning the topic of depressive disorders through the Prochaska technique. The efficacy of the MPQ measure had been documented in a previous study. “The MPQ was taken as a model, translated into Farsi and further modified in order to be adapted to depressive disorders and to the different cultural context” (Shirazi, 2008).
Why do you think that the treatment modality you are recommending would be superior to other possible treatments?
The patient-centered care is definitely superior to the practitioner-centered care. This patient-centered or client-centered care is a collaborative approach and allows the patient to be decision-maker in her treatment. The patient is understood in her process. The practitioner-centered approach is more directive and prescriptive; it does not allow the patient to have any role in decision-making. An abused woman is a survivor and needs to be respected. She needs to be allowed the autonomy to choose and to self-direct. Healthcare providers can help her more if they listen to her about her experiences and how she perceives the abuse. Evoking the motivation from within her gives the provider ideas about what she wants. Guidance may be given according to her needs and values. Her self-determination would be enabled if she was given the choice of a plan. Arguments for change would come from her. A better result is expected when she is motivated from within. The practitioner-centred care expects the abused woman to follow the provider’s advice. Obviously the patient-centered care is more acceptable.
How would you assess the efficacy of treatment? What specific data or behavioral evidence would you use/monitor to assess treatment progress?
Eleven statements were found in the modified MPQ. The attitude stage was determined by the first 3 questions, the intention stage by the next 4 questions and the action stage by the last 4 questions. The GPs who answered less than 6 questions were put in the attitude stage (Shirazi, 2008). If they answered 6-9 questions, they were in the intention stage. If they answered more than 10 questions, they were in the action stage. If the number of physicians in the action stage is maximum or more than the other two, the efficacy of the CME is confirmed (Shirazi, 2008).
References
ICRW, (2009). Intimate partner violence: High costs to households and communities.International Center for Research on Women (ICRW) and United Nations Population Fund (UNFPA).
Kramer, A. (2007). Stages of change: Surviving intimate partner violence during and after pregnancy, Journal of Perinatal and Neonatal Nursing, Vol. 21, No. 4 p. 285-295, Wolters Kluwer Health/ Lippincott Williams and Wilkins.
Landenburger K. A process of entrapment in and recovery from an abusive relationship. Issue Ment Health.1989;3:209–227.
Lutz.F, Curry M, Robrecht LC, Libbus MK, Bullock, L.(2006). Double binding, abusive intimate partner relationships and pregnancy. CJNR. 2006;38(4):119–134.
Prochaska J, DiClemente CC, Norcross J. In search of how people change: application to addictive behaviors. Am Psychol. 1992;47(9):1102–1114
Shirazi, M., A.A. Zeinaloo, SV Parikh, M Sadeghi, A Taghva, M Arbabi et al, (2008). A Effects on readiness to change of an educational intervention on depressive disorders for general physicians in primary care based on a modified —Prochaska randomized controlled. Family Practice 2008 25(2):98-104; doi:10.1093/fampra/cmn008
Rice M. (2006). Domestic Violence: A National Center for PTSD Fact Sheet. Washington, DC: US Department of Veterans Affairs; 2006.