Hello, and thank you for joining us. My name is Adam Chu, and I will be moderating this webinar, which is titled Intimate Partner Violence and Suicide, Intersections in Context and Practice. And our presenter today is Dr. Heidi Carr. Dr. Carr is EDC's Principal Advisor for Mental Health, Trauma, and Violence. She is a licensed clinical psychologist and global mental health expert. Dr. Carr provides strategic direction, oversees business development, and leads EDC's work on raising external visibility on mental health, trauma, and violence. Next slide, please. This is just a funding disclaimer here. The Suicide Prevention Resource Center is supported by a grant from the Substance Abuse and Mental Health Services Administration. The views, opinions, and content expressed here do not necessarily express, excuse me, necessarily reflect those of CMHS, SAMHSA, or HHS. Next slide, please. The Suicide Prevention Resource Center fulfills its goal of advancing the national strategy for suicide prevention by building capacity and infrastructure for effective suicide prevention across the country through training, consultation, and developing resources for a variety of settings from states, tribal communities, and health systems, and that reach individuals across the lifespan. SPRC also fosters a key national partnerships that engage a wide range of stakeholders and also serves as the secretariat for the National Action Alliance for Suicide Prevention. Next slide, please. This is our land acknowledgement, and I just want to give everyone a few moments here to read through it. Thank you very much. Next slide, please. This webinar offers one AMA PRA Category 1 credit. Information about claiming this credit will be displayed at the conclusion of the webinar. Next slide, please. A few logistics here. If you've joined from the desktop application of GoToWebinar, you can access handouts such as the PDF of these slides by navigating to the handouts area of the control panel, and if you use the instant join viewer, you can do the same by clicking on the page symbol on your display. Next slide, please. We will be compiling and holding questions for a Q&A period towards the end of today's webinar, but please feel free to be submitting questions throughout the presentation as they come to mind. You can use the attendee control panel to get to the questions area, and you can click the question mark if you're using the instant join viewer. Next slide, please. I'm now going to turn the floor over to Dr. Carr to provide the webinar overview and begin. Dr. Carr, take it away. Thank you so much. It's a pleasure to be here with you all today. Appreciate you taking the time. I am going to go over three main pieces today in the hour we have. I'm going to start by giving us the contextual background of the intersections between suicide and intimate partner violence so that we understand how they're connected and why we're talking about them together. Then I'm going to go through information about assessing for intimate partner violence within the mental health context. We'll review a little bit of suicide screening as well in that and talk about how when we assess for both, what we need to be keeping in mind in particular. And then I'm going to end with talking about what we do after a disclosure of intimate partner violence, how we handle that situation. We're focusing on intimate partner violence and talking about suicide as it's connected at all these different levels. Please feel free to submit questions in the Q&A period. We're starting with background and context. In terms of suicide in the United States, we know that over the last decade, the suicide rate has been increasing overall, as well as in males and females separately. We know for males, for example, the age-adjusted suicide death rate has increased from 12.3 to 13.5, or as you can see in this slide, we have from 20 to 22, if we want to focus on these years. Overall in females, 5.2 to 5.5. This is for 100,000 people. And overall, we see the rate has changed from 12.3 to 13.5. So we know the rate of suicide is increasing and that that increase is not gender-specific. In terms of intimate partner violence, we know that experience of IPV is far too common. So in terms of reported IPV, which includes severe physical violence, in this source from CDC, about 20% of women report having experienced severe physical violence at some point in their life, and about 14% of men, one in seven men, and that's just on the severe end. When we look at sexual violence from intimate partner, again, we're at about 20% of women and one in 12 men. We do think this is an underestimate for many reasons, especially the data for men across the board. Men tend to report experience of violence less than is the reality. In terms of stalking, which we sometimes don't bring to mind when we're talking about IPV, but it's a very real piece of the puzzle, is about 10% of women and 2% of men report being stalked by an intimate partner. And when we look at levels of psychological aggression, the rates skyrocket. So experiencing aggression, experiencing violence is unfortunately much more common than many people understand for both genders. We know that partner violence, IPV, has escalated during the COVID pandemic. We have data mostly at this point from police departments where they logged how many calls came in for IPV incidents, for domestic incidents, they call them. We also have data internationally that shows that intimate partner violence rose during the pandemic, which unfortunately makes a lot of sense, right? When social services were shut down, when people were spending much more time together in homes, people who were part of unhealthy homes are going to experience more of what makes those homes unhealthy. We know that exacerbating factors for partner violence just in general include worries about security. So we know that in times of conflict or in times of high community stress, partner violence increases. In fact, all domestic violence increases, even violence toward children. When there are health worries, when there are money worries that are affecting a household, we know that that exacerbates the risk of partner violence. Cramped living conditions, a force being isolated with the person who's using violence against you is going to be an exacerbating factor. Restrictions and movements. So when we can't access different things, when services are shut down again and when we have less places to go to get distance during conflicts or after arguments, that can be an exacerbating factor. And we also know that public spaces not having a lot of people. So again, back to this idea of isolation and not having supports that sometimes just being present can serve and decreasing the likelihood that an argument, for example, will balloon into a violent incident is an exacerbating factor. So we should be assuming that clients we see in our practices, if they were experiencing intimate partner violence prior to COVID, that may have worsened. And we should also be expecting more of our patients, more of our clients to be experiencing IPV than prior to COVID. Now an important starting point in aiding our understanding of how intimate partner violence and suicide are related starts with understanding trauma, right? And there's a great deal of research and evidence that we have that early trauma often predisposes us to experiencing later trauma, such as domestic violence. But also, of course, trauma reactions can occur as a result of experiencing domestic violence on its own. So there are a couple of different ways that trauma, both early, but also as a result of the IPV, correlate with suicide. We know that experiencing trauma and the repercussions of experiencing trauma have been shown to be risk factors for suicidal thinking and behaviors kind of across ages. So again, when we look at youth and adolescents who have experienced trauma early, there are increased risk for suicidal thinking and behaviors. When we look at adults who've experienced domestic violence, there are increased risk for suicidal thinking and behavior. We know that people who've experienced adverse childhood experiences in general, including child abuse, are also at greater risk, right, for suicidal ideation and attempts in adulthood. So we know that, that ACEs connection. And then we also know if we look at just the subset of people who meet the diagnostic criteria for post-traumatic stress disorder, that PTSD is significantly associated with suicidal thinking and attempts. So there are multiple layers at which trauma is related to suicide, and we of course can't think about intimate partner violence without thinking about trauma. Sometimes that predates the IPV, and sometimes it results from the IPV. So again, as we're kind of honing in on these intersections of partner violence and suicide, we know that among those who experienced violence by a partner, that violence is connected to other forms of violence, one of which is suicide. Teens who experienced dating violence are also at higher risk for suicidal ideation. When we are looking at actual numbers here, how does the risk unfold? Women who experience intimate partner violence are nearly five-fold more likely to attempt suicide than women who are not, so it's a very, very strong relationship. And when we look at suicide deaths, those that have kind of information about the circumstances leading up to that death. Intimate partner problem is indicated in a very high percentage, 25%, 26%, and that's what the suicide deaths that we know about. We're going to come back to this in just a minute when we talk about those who use violence against others and their suicide risk, but, you know, really, really important to know that in, you know, based on the data, at least 25% of cases where someone ends their life by suicide, they were struggling with an intimate relationship, an intimate romantic relationship. That's often a crisis point for many people. Something that we don't talk about enough as clinicians, for those of us who are clinicians, as prevention experts, is the risk for those who are using violence against a partner, right? Often we talk about abusers or perpetrators. That language is actually not the current language, the best language, based on a variety of factors. We're going to now talk about people who use violence against others. People who engage in intimate partner violence, who use violence against intimate partners, are also at higher risk for suicide than people who do not. Now, what gets one of the most difficult things in the domestic violence field is often this weighing of risk, because talking about being suicidal can be used as a form of control over the partner that you are engaging in psychological aggression toward, right? So if a partner says, you know, if you do this, I'll kill myself. If you leave me, I'll kill myself. If you spend time with your family, I might as well not be here. I'm just going to kill myself. It can be used as a way to control. However, what we know from the data is that the risk of suicide is also real in that people who use violence against partners are at increased risk of dying by suicide. So this is a really difficult conundrum a lot of times in the DV world. It can be less of a conundrum, I think, for mental health clinicians who may have an idea that one of their clients may be aggressive toward their partner, may be using violence in some form. It's important to think about suicide risk. We know that people who engage in intimate partner violence experience higher rates of suicidal ideation, right? We also know that they die more often by suicide. And we know that most suicides that are related to partner violence, the use of partner violence, so people who use violence against their partner, the majority are male perpetrators, okay? If we look at women who perpetrate some type of IPV against their partner, they are not as in as high a risk category for suicide as are men who use partner violence against female partners. And often, as we will review in a little bit about suicide risk factors, often there are prior attempts before someone actually dies by suicide. So often that intent to die is something that has been present, and it's something that can be tracked. It doesn't come out of nowhere in these cases. So that's the contextual background in terms of why suicide and intimate partner violence are related. We're going to spend the next, the bulk of our time in talking about assessment and how we assess. We're going to start with partner violence and weave in a little bit of suicide assessment. So one place I like to start this conversation is in the tone and the framing when we as clinicians are in the position of assessing. This is an account from a Lancet article from a survivor of intimate partner violence who said, you know, I wish mental health practitioners would stop judging us as survivors. See us for how strong and resilient and courageous we are. So this speaks to the wish to not be pathologized as a victim. And this is important, and I think it's important on a couple of different levels. Of course, you know, most of us are familiar with this idea that being able to convey a lack of judgment about our client's personal situation is very important for them being to feel respected. But there's also this piece that fear and discomfort from the practitioner in discussing issues of IPV is also very negative. So a lot of times when we are uncomfortable about a sensitive issue, we will show incredible amounts of empathy and blame, potentially for some external source. And that's not empowering. It's not felt as empowering to many people. So this idea of, you know, seeing people who have experienced IPV as strong but not victims is very important, not only in just kind of the philosophical conversation, but also in terms of what the tone is in the room. And we'll talk a little bit more about this. A variety of professional associations and, you know, virtually all of our federal health centers and offices have called for routine assessment of intimate partner violence in mental health care. And unfortunately, across mental health settings, we're not doing a good enough job. We know that from talking to clinicians. We're not doing a good enough job about assessing. Why do we ever not do a good job in assessing? Usually two things, right? One, we're uncomfortable. We haven't had to receive the training we need to receive. And two, we don't know what to do with the positive disclosure, right? And so that's the point of this next section. Talk about how to assess and what happens to the point of positive disclosure. A little bit more context about the dearth of assessment. Though we have longstanding recommendations, this is nothing new for IPV screening in primary care and mental health settings. We know that from many studies, about 50% of medical providers don't screen at all. For IPV, a little better, but 23% of behavioral health providers don't screen at all, right? And again, looking at the literature, this last bullet is true for all things that we know we should do but don't in clinical care. We feel unprepared to assess. We don't know how to do it and do it right. And we feel uncomfortable about it. And we don't know what to do to respond to disclosures. So let's talk about red flags a little bit. While screening for intimate partner violence is important to do for everybody, every client, every patient, there are red flags that should really help the light bulbs go off. That I need to spend some concerted time this session on this right now. And some of those red flags include the noticeable physical injuries that just appear like they wouldn't be accidental, right? Or repeated or inconsistent with the story that might've been given for how the person received these injuries, that's kind of obvious. But many times, even though it's obvious, we in the mental health and behavioral health realm just don't go there, right? Rationalization, minimization or excuses around a partner's behavior injuries. Often there is a lot of protectionism from the person who is on the experiencing it by PD. And that's for several reasons. One reason is the reality of partner violence is that this is violence you are experiencing at the hands of someone you are very close to, you have an intimate relationship with. In many cases, we love those people, even though they're hurting us. And so there's a lot that we do to try to rationalize or make excuses because we care about the person. It also can be difficult to come to terms with the fact that you are experiencing violence, that your partner is using violence against you. It can be very difficult just to accept that reality and digest what that means. And I think thirdly, our lives are intertwined with our intimate partners. So for some more than others, allowing that realization of this person is hurting me, this is a very unhealthy relationship I need to separate means a whole lot of other negative consequences are coming. Right, if you are financially dependent on that person or if that person is the father of your children and this means splitting your family apart or if you know separating from this person would actually increase your risk, which it does in some cases. So many reasons for this. The key for us as practitioners is to look for these patterns. Rationalizing partner behavior, which you're like, that doesn't seem very healthy or good for you, I'm making excuses. Confusion about events or exactly how things played out. Any kinds of fear that you see about towards the partner, worry about sharing certain things with them, not wanting to burden them with certain information, a lot of self blame, shame potentially about being abused. Part of psychological abuse is wearing that person's self-esteem down. So these kind of patterns that we can get into, for example, blaming ourselves, that's something that's a direct result of abuse. It's when you hear that, when you see that pattern of self-blame, it's a direct result of self-abuse. Of self-blame, a light bulb should be going off. If I wonder where this kind of thinking came from. Feeling guilty about defending themselves or exaggerating their own abusiveness. And if you think about this one, I bet all of you who are seeing patients will have heard something like this. Thinking back on clients, I've heard so much of this. Oh, well, I'm the one that's always screaming at him or I'm the one that's always losing my temper. I'm the crazy one in the house, the one that's always creating the problems. Often we kind of laugh at that, like, okay, this person's being a jokester, but sometimes that is specifically being done, again, kind of rationalize in their own mind or minimize what the partner does. When you have clients who speak from the partner's point of view, when you ask them a question or ask what they're interested in doing and their response is more, well, he would want this, or he believes this about this kind of medication or this kind of therapy, or he believes we should be doing this instead of this. When you hear a lot of that, that should be a red flag. Why is the partner's point of view so important right now? Why is it taking precedence? Some more red flags, life that has shrunk over the course of involvement with a partner. So this means our world becomes smaller because this person is saying, I don't like those friends. I don't want you to see those friends. They're a bad influence. I really don't like your family. We're moving, we're changing cities or too much family. I want you to spend more time at home with me. I don't like when you wear those kinds of clothes. I only like these kinds of clothes, right? When our whole world and the possibilities and options shrink. That's an example of this. Descriptions of a partner as having a bad temper or having a drinking problem. Again, a lot of times we're minimizing bad temper, maybe just the cusp of what's happening. Drinking problem is highly correlated with intimate partner violence in relationships. Highly correlated for all the reasons we know. Think well when we're drinking and we react before we think about consequences or we think about how we're about to act. And a whole host of other pieces. Involvement in a protracted divorce or custody case. There's a lot of partner violence that goes on in divorce proceedings, especially when we're talking about children and who the children are gonna live with. There's a lot of psychological aggression that occurs and it's an especially risky time. Your client's going through that. Partners abuse of children, pets or other people. One of the most fascinating findings from the danger assessment, which was originally developed by Jackie Campbell, which is an assessment that looks at homicide risk from partner violence. So it's basically an assessment looking at potential of femicide or killing of women by a partner. What's the risk? Abuse of pets, of animals is one of the most highly distinguishing factors between someone who's violent and someone who actually will end up killing their partner. So it's a severity marker, which is very interesting and important to keep in mind because I think a lot of times we would think, wow, that's a really mean person. He must hate dogs. But the idea of abusing and hurting an animal on purpose really separates people in terms of their ability to actually kill someone in an intimate relationship. Restricting access to family finances is a very common act of psychological aggression. So when someone has less money, less ability to access financial means and they talk about things like that. My partner says, we don't have money for my healthcare or he's saying that it's too expensive or I don't know if I can use the money for that reason, anything like that. Sudden absences or changes in plans for care. Of course, again, those of us who are involved in clinical work know that absences must be addressed, right? We need to figure out why people don't show up. We need to figure out why in one session people are gung-ho for a plan and they change their mind by the next session radically why. And sometimes we, in wanting to respect autonomy, we just accept these things. It's actually very important to try to understand is there an abusive piece here? Is there a partner wanting to restrict your access to care? Because you may disclose the violence. In terms of screening for IPV, there is a long list of assessments for IPV. And I'm not gonna go through a specific one today for a very, I think, important reason. But the CDC has published information on IPV assessments, specifically that are short, user-friendly, that can be used in healthcare settings. So I encourage you all to look at this resource, but I'm gonna take you through why I'm not gonna go through a specific assessment and why we're gonna focus instead on questions and the discussion around IPV. So the reason we're not going through an assessment is, unfortunately, the assessment measures on IPV are varied. They're drastically varied. Some of them really focus on physical violence. Some focus on sexual violence. Some try to incorporate psychological violence. And none of them are great. None of them are great when you look at sensitivity and specificity, especially when you try to look across different populations. What's interesting is there is a recommendation currently put out from, those of you who know, Futures Against Semitic Violence. There's a recommendation and understanding among many in the field that being able to have a conversation about relationships, the health of your romantic relationship actually may get us much closer to positive disclosures than a single assessment instrument. This is not to say that assessment instruments are not helpful. So I do recommend that you choose an instrument if you don't have one already that makes this process consistent. But it's even more important, it seems like from the research, that you're able to engage in a conversation where you are not uncomfortable and where you're able to get context about how that relationship is functioning. So questions to ask to get this conversation started can include things like, how are things at home? It's important for you to understand my patient or my client's safety in close relationships. Have you ever felt humiliated or emotionally harmed by your partner or ex-partner? Do you feel safe in your current or previous relationships? Have you ever been physically threatened? Why are we talking about ex-partners here? Because we know suicide risk is elevated, right? If we have experienced IPV, it doesn't have to be current IPV. Some of those people who are at highest risk are out of those relationships, but their suicide risk is still higher. Okay, so it's not just present time. Have you ever been physically threatened or harmed? Have you ever been forced into any kind of sexual activity? Do you feel your partner over-controls you in your relationships with family and friends or in financial matters? These are questions that are very positive to have as part of your conversation that can lead you to wondering, hmm, maybe I should be using a formal assessment with this person, or maybe I need to delve deeper in terms of the questioning. Really important with IPV that you do not appear uncomfortable with the reactions. The same thing is true for suicide risk. The same thing is true for suicide assessment. You need to practice this and know very clearly what you would do if someone did this positively, based on your processes, so that you are not uncomfortable, because people will feel that, especially in these very sensitive topics. In terms of suicide risk assessment, the American Psychiatric Association recommends screening all IPV survivors for suicide risk. It's important. This is done in a private confidential space, as is true, of course, with the IPV assessment. It's important to provide interpreters, discuss the reasons for the suicide assessment, just like we did for the IPV, right? We said, it's important for me to know about the health of my patients' relationships. And we're looking for as much description as possible about what's happening or going to happen in the course of your assessment. So just being very clear, I'm gonna ask you some questions about your suicide risk now, because I wanna gauge, if you're safe, I wanna make sure you're safe. Debrief with staff who might be involved in the process, depending on what level of risk you identify people. You're gonna need to know what the triage process is. Working with your patient on a safety plan will increase a sense of comfort and collaboration. One of the stark things we've heard in the experience of those who've experienced partner violence and have been assessed for suicide is, if after the suicide assessment, the provider says, okay, I'm gonna bring someone in to help. It really raises the ante in terms of anxiety in that client or patient. Being able to figure out a safety plan, go through a safety planning intervention with someone and bring in that triage is extremely helpful. So any, if you do find risk, any risk, any indication of risk, going through a safety planning intervention is an incredibly collaborative, empowering and calming process for most people. And then you bring in the triage, if they're at high risk. Focusing on coping strategies for risky situations, also very important, right? So when someone discloses IPV and someone discloses suicide, focusing on, okay, what are some things that you've done to keep yourself safe in both areas, right? What are the things you've done? What are the people in your life? And this is part of that, those plans, those safety plans. Who are those people? What are the motivations that keep you going, right? And who can you reach out to for help? So a little bit of a brief tutorial on suicide screening, okay, and then we're gonna bring them both together and really focus on the combined screening. The Columbia, the CSSRS, Columbia Suicide Severity Rating Scale is a bold standard scale to assess for suicide. The first two questions are things we ask of everyone, okay? And the timing, of course, is the past month, right here is your hint. So we ask everyone, have you ever wished you were dead or wished you could go to sleep and not wake up? This is a passive suicidal ideation question, passive. Question two, have you actually had thoughts of killing yourself? This is more of active suicidal ideation, okay? So we're looking to see, is there any cognition, any thinking about dying here, wanting to die, all right? If both are no, fantastic, you go on to question six. So you ask questions one, two, and six of everyone, okay? And this yellow just corresponds to low risk. If they do indicate one or both, they're at a minimum low risk and you continue on to the next questions. Question three, have you been thinking about how you might do this, right? How you might die? If yes, so meaning they have been thinking about the means, how they would go through taking their life. If they indicate yes, that bumps them to moderate risk. Okay, have you had these thoughts and had some intention on acting, of acting on them? So, this is bringing intent into play. If the answer is yes, this is a high-risk person. Have you started to work out or worked out the details of how to kill yourself? This is, do you have a plan? Do you have your plan? What you would do first? What would have to happen next? Absolutely high risk, right? Either of these or both of these. Everyone gets asked this last question. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Okay, yes, so that means, you know, suicide attempt or very nearly suicide attempt. We're automatically at moderate risk, no matter at what point in our lives, but if it was in the past three months, we are at high risk, okay, so we know that past suicide attempts are the greatest predictor of future suicide attempts. Okay, and if that was recent, as in the last three months, this is someone who needs immediate intervention, and depending on, you know, your process, where you're situated, your health system, you're going to have a process for that, right?, so low, moderate, high are the three triage levels. Intervening after an IPV disclosure. So, important thing to remember, it's essential to be non-judgmental, essential. Ask a client about their safety. If they're safe, do not ask questions that are curiosity-based or that can be laced with judgment. Why don't you just leave? Very unhelpful. You'll shut the person down. Empathize with the challenges. Do not appear afraid or uncomfortable, okay?, and provide resources. There's an intervention. The World Health Organization terms LIBS, or LIBs, where they're reminding us to listen empathetically and non-judgmentally. Inquire about the needs and concerns that the person might have within this situation of partner violence. Validate their feelings to show you believe and understand kind of what they're going through, or not necessarily that you understand their particular situation, but you understand why they're feeling the way they're feeling. Enhance safety and discuss how to protect. This is safety planning. This is what have you done so far? What kinds of things have helped? You can ask them, what do you want to do? What do you think would be helpful? You can ask them, what do you want to do? What do you think would be helpful?, and if they talk about wanting to be safer in the home, staying with the person, you help them figure out, how can I be safe?, right?, and if they say, I was thinking about leaving. I don't know what to do. You help them with that. You help connect them to those services. We all know about the suicide safety planning intervention. The Stanley Brown safety plan is a gold-standard example where we walk the person through, what are the warning signs for you that you're going to start thinking about suicide or that you're at higher risk for suicide? What are the internal coping strategies you have, things that you can do to help? What are the internal coping strategies you have, things that you can do to take your mind off the negative situation, let's say, or the thoughts you're having? If that doesn't work, what are people or places that can provide distraction for you? If that doesn't work, who are the people close to you who can offer help, who you can actually disclose the suicidal ideation to and get support from? If that doesn't work, who are the professionals or agencies that can support you if you're in a crisis, and how do we make the environment safe, right?, so if you are thinking about killing yourself with a gun, what do we do with that gun to remove it so that you can't access it quickly, right? The important thing to remember about that suicide safety planning is, when you have someone who is experiencing partner violence, you're doing something similar, right?, to the suicide safety plan. You're trying to help them think of things that can lower their risk and help them think through options that are going to keep them safe, right?, so the idea is completely the same, and there are many sources of this to look at those safety plans, but the important thing to remember, the really important thing to remember about the intersection here is that the plans have to be consistent. If we're not thinking about both the IPV risk and the suicide risk, we can add information to the safety plan, the suicide safety plan, that could increase the level of IPV risk. If that partner is not a safe person, they shouldn't be number one on the contact list, right? It's so interesting if you think about that case that's been in the news a while ago of the friend or the partner, I believe they are actually dating or had been dating, who was encouraging his girlfriend to kill herself, and their case is the other way around, encouraging the young man to kill himself, you've got to make sure that that support system is actually a support system, right? If the person is thinking of killing themselves with a gun, having their partner be the ones to hold the gun while their suicide risk is high might not be a good plan, right?, if that person is prone to getting violent, angry outbursts, and now has the gun clearly at his disposal. True, you may not know about all of these risk factors, right?, if you haven't had the conversation, if you haven't been able to have that open discourse about the health of their intimate relationship. Are there people or places that might otherwise be safe, except in this case, right?, so thinking about the safety, not assuming someone's partner is safe. Are there activities that might not be safe? So, what kinds of things may end up hurting you? So, again, things like, I'll have them hold on to my medication because I'm at heightened suicide risk. Well, what if they withhold that medication in order to bully you or in order to push you to do something, you know, at some point, so just keeping in mind these are all possibilities. How might the person store or keep their safety plan if they're monitored, right? It might not be safe for the person using violence against them to find their suicide safety plan. This is something that the domestic violence field has made huge strides in, in terms of IPV safety plans. There's all kinds of ways of disguising them in lipstick cases, you know, in key chains, in, like, secret pockets, so that all of the key information is there, but it's not something that's easily found, right?, by the partner, and safety planning for lethal means might look very different, right?, so keeping in the back of your mind, just because someone's a partner does not mean they're a safe person in terms of supporting a suicide plan and in terms of supporting patients or clients in general, right?, and we tend to think, we tend to say things like, let's call your partner right now and see if they can help us think through a safe way to administer your meds or let's see if they can, they have ideas. We need to be careful, and we need to have had that conversation first about the relationship. All right, and I think we are to the question period. All right, thanks very much, Dr. Carr. We do have some time now to answer a few questions from participants, and let's see, yeah, about nine minutes or so, so there's sort of, like, a couple about data, a few on, like, risk factors. I'll try to kind of compile them into the clusters here for you, so the first one that came in earlier is sort of more straightforward. There was a slide you mentioned earlier on. The data point on it was that intimate partner violence indicated as a precipitating factor in 25.6 percent of suicides with known circumstances. Was that just specific to adults? I do believe so, yes. I'll go back to that slide really quick, so everyone is anchored. Yes, I believe that is adult-focused, and actually, a really good question. Oops, I went past it, because I think my assumption would be that number is higher in young adults and adolescents based on just kind of where we are, developmental level of romantic relationships and what it means to people. Yeah. Okay. You know, for these data sources, you know, many from the CDC or otherwise, particularly in this space, looking at male versus female and sex in a dichotomous way, are there ways that, you know, data collection structures are thinking about what this looks like or what the impact is across gender identities and how they're gathering those data and some differential impacts that there may be emerging? I know if we don't have those data yet, it's mirroring to be seen, but I think it's an interesting point that was raised. Very important point. It's a very important point. There are attempts where we don't have great data yet, and we're not doing a good enough job. I'll go so far as to say, I mean, there is data from same-sex relationships in terms of occurrence and prevalence, but even that data is not appropriate. I mean, that's very strict gender identities, right, still in that data. So, bottom line, we're not doing a good enough job at looking across sexual identities, gender identities, and, you know, part of the reason for that, I'll be quite frank, is there has been a tension oftentimes in the domestic violence field with the use of gender identity, because the power and control way of looking at gender differences has been used to explain, in many cases, why men often use more severe violence against women. It's this idea that, you know, something that goes with masculinity is this kind of violent personality, and based on, you know, a lot of different factors, this, that has been challenged. I certainly don't think that that is enough information to guide our understanding, so that's one reason. I think that the research has been very slow in identifying gender in that dichotomous way, but it's a problem. Okay. Another thing that came in is related to, you know, the change from the term domestic violence to IPV. One of our participants said, you know, it's taught that intimate doesn't mean that the experiencers are actually the ones who are experiencing the violence, but it does mean that, you know, it's taught that intimate doesn't mean that the experiencers are actually, are perpetrated, I think is probably what they're referring to, the perpetrating and the person experiencing this, that doesn't mean they're actually intimate or even know each other, but maybe they live in the same environment as theirs, so I guess it's a bit of unpacking that terminology for what it means for, you know, clinical purposes or data collection or otherwise. Yeah. It's a great question and it highlights the definitional problems that we have, so the way that I use the term and the way that the vast majority of research is using that term when we're reporting, the statistics is intimate, meaning in an intimate relationship or were in an intimate relationship. It's very interesting. I mean, domestic violence itself for many of us is also the same thing as IPV, however, that term is also broadened in many circles to include anyone within the home, so actually Lauren, your feeling about the IPV definition for many people is actually how they see the domestic violence definition, so there is a problem in kind of clarifying who is in what group, but the vast majority of research that calls out IPV is talking about intimate partners, current or past. Great. Thanks, Dr. Carr. Another risk factor-related question, so thinking back to when you mentioned that women who are exposed to IPV are five times more likely to attempt suicide, I just think about if that's someone who also is experiencing serious mental illness, like how do these things stack up either next to or on top of each other, and we're sort of then talking about the middle of the middle of a Venn diagram of risk, but I wonder if there's some relationship we can speak of around individuals with a serious mental illness and the likelihood of them experiencing IPV or otherwise. It's a good question, and I have not seen good data that can answer that definitively. I think that the way I would come at that is whenever we have a source of vulnerability, be it severe mental health symptoms or a physical disability or we are completely new to a culture and don't know the language, whenever there is something that makes us more dependent, that makes us really need someone else to kind of lead us through, we're vulnerable. We're vulnerable to however that support is going to treat us. We're much more able to be taken advantage of. Now, I think one of the most startling lessons learned for me from the evidence and the data in the field is this, and maybe I'll leave you with this, is when you look at men across romantic relationships, men are much more able, much more likely to have, let's say, a relationship in which they were violent, the next relationship in which they're not violent, the next one in which they're violent, not, or where they're the recipients of violence, but they're able to shift across partners, whereas women don't do that as much, and again, this is a dichotomous gender research base, but women who are in relationships where IPV is present are much more likely to have all relationships or most of their romantic relationships include IPV. That is fascinating to me, and we don't have a good answer for why, but there is something very impressionable in some way that when a woman experiences IPV, that can become a frame, so to say, and men don't have that same experience, not at the population level, at least. I wonder, just in the last 60 seconds, if we sort of flip the camera around and say, you know, for clinicians who are doing these assessments looking at IPV or IPV and suicide together, what should self-care look like in this scenario? And it's, you know, a lot of, it can be a lot of trauma exposure. I'm just curious about, you know, what you might say there. It's a great question. Vicarious trauma, very common when we are listening to violent experiences of other people, and one of the most important things is, to be quite honest with you, to not allow yourself to get to a burnout point, so being able to take vacation, being able to make sure you are not so focused and overworking, that so much of your waking time is focused on the trauma, is important. Another very important thing is supervision and making sure you have professionals in your network who you discuss cases with, that act of disclosing of the clinician, of, this is something I heard, this is something I was told, and getting support is extremely positive in preventing vicarious trauma, so I would say taking time off, that work-life balance we're all striving for, but also making sure you are able to share, communicate these things, so it's not just sitting in your brain. Thanks very much, Dr. Carr. If you wouldn't mind flipping us forward, I just want to make sure to take a few final housekeeping things for our participants around accruing credit and so on and so forth. So if you advance us forward, I'll let everyone know just in a moment how to claim credit for today's webinar, and I think it's just the next one here. Perfect. Thank you. So to claim credit for today's webinar, please see these instructions. You submit an evaluation, you go to the claim credits tab, choose the number of credits, which is one for this, and you click claim. You can email learningcenteratpsych.org for questions. The next couple of slides, Dr. Carr, you can flip forward. These are related and relevant resources and references you can access in greater detail by, again, going to the PDF in the handout section in the control panel. And aside from that, that will conclude today's webinar. So thank you very much for joining. On behalf of SPRC and Dr. Carr, we really thank you for taking the time to attend. It was a pleasure, Dr. Carr. Thanks for your time, and we'll close it for today. Thanks again. Thank you. Thank you.

Dr. Heidi Carr

Intimate Partner Violence

IPV

Suicide

Assessments

Interventions

Trauma Exposure

Risk Factors

Safety Planning

Non-judgmental