Family violence: Towards a holistic approach to screening and risk assessment in family support services
Who should screen for/assess family violence?
There is little in the literature that specifically discusses the issues inherent in whether the best approach to screening and assessment is to separate out the tasks and have them undertaken by two separate people, or whether one person should do both. The Framework for Screening, Assessment and Referrals in Family Relationship Centres and the Family Relationships Advice Line (FRC & FRAL Framework) (Winkworth & McArthur, 2008) provides guidance around establishing a "first point of contact" worker, who identifies (screens) whether or not the client requires a more in-depth assessment, which would normally be undertaken by another practitioner, or whether the client's needs can be met through information provision and/or early referral elsewhere.
In some cases, assigning the screening and assessment processes to two separate workers may generate efficiencies; in other cases it may produce fragmentation of effort. It cannot be assumed that a second worker will be able to simply build on where the other left off. Revelations, even at the screening phase, are made by a client within the context of some level of trust in the competence and integrity of the individual conducting the screening. This dynamic will not always repeat itself with another individual. Difficulty in re-establishing trust and rapport is also likely to be greater if there is a delay between the screening and the assessment phase and/or if there is no active handover or facilitated referral between workers. It can indeed be argued that the very fact of beginning a screening process brings clear ethical and professional obligations on the part of the practitioner and the organisation to ensure that risks that are thought to be there even at this phase are acted upon and not "left" to the assessment phase.
This leads in turn to questions about the level of professional skill and knowledge needed to undertake these processes effectively. According to the FRC & FRAL Framework, significant skills are required by the professional undertaking screening to respond sensitively and respectfully to clients or callers, while supporting or "holding" clients and simultaneously not engaging in a deeper conversation about their concerns. Spangaro, Zwi, and Poulos (2009) also suggested that screening itself can be a therapeutic experience, but insensitively or incompetently handled, it can be traumatising and increase the risk that was present at the outset. So, should screening be regarded as a less specialised task than the task of assessment? Can it be effectively accomplished mainly by the use of validated self-reporting instruments administered independently? If used, should a validated self-reporting instrument be administered only in the presence of an empathically engaged worker, or is it acceptable to invite an individual to complete the task in isolation from such support? And whether or not an instrument is used, should other problems that frequently co-exist with family violence - especially substance abuse and certain forms of mental illness - also be screened in or out from the outset?
We suggest that there are considerable dangers associated with the use of a screening instrument in isolation from empathic engagement with a worker. Such a procedure would not, for example, pass an ethics application for a research project. This is because once begun, even for the purposes of research, there can be no guarantee that screening can be neatly concluded. The problem of decoupling early screening interventions from knowledge of and accessibility to "what comes next" has been addressed in the context of family law by Jaffe, Crooks, and Bala (2006). According to Jaffe and colleagues, safety concerns need to be given higher prominence at the early stage of intervention, the very stage at which "adequate information to evaluate the safety of children and adults" is more likely to be lacking (p. 47).
There are no easy solutions to these service delivery issues, which are essentially problems of triage. It can be argued that the person at the beginning of the triage process bears the greatest responsibility because a failure to detect violence or associated issues at this stage can reverberate throughout the service delivery system. At the same time, such an individual usually cannot take on the full burden of the case. Does this person need to have the assessment skills to be employed when a client passes a screening threshold? If not, should there always be a formally facilitated referral to an individual more formally trained in assessment? If so, when and how should these referrals be made? Should that person, who may be inside or outside the organisation, also have skills in the next phase of the intervention, whether it is safety planning, education, counselling, or mediation? Answers to these questions cannot be universal. They will, for example, depend on local conditions and availability of staff. But the governing principle, we suggest, should be high levels of skill at all stages, combined with the minimum number of new interventions possible.
Returning to the question of formal assessment, there is a clear emphasis in the literature on the need for the exercise of professional judgement to be part of the process (Kropp, 2008). Kropp calls for the following skills:
- expertise and experience in interviewing and assessing offenders and victims;
- considerable knowledge of the dynamics of domestic violence; and
- completion of assessments with the assistance of risk assessment guidelines or tools that have some acceptance in the scientific and professional communities.
This links in turn to the need for ongoing training related to family violence and the use of screening and assessment tools - another issue highlighted in the literature. In the NSW Health pilot project (Irwin & Waugh, 2001), all staff members were expected to undertake training in the use of the screening tool. In Victoria, an extensive state-wide cross-sectoral training program in the use of the Family Violence Common Risk Assessment Framework (CRAF) has been undertaken. An evaluation, including impact on practice, has been completed, although not publicly available at the time of writing. An emphasis on skills and knowledge in family violence is also evident in accreditation standards for family dispute resolution practitioners in Australia.5 Family dispute resolution practitioners who were included in the Family Dispute Resolution Register6 before 1 July 2009 must demonstrate competency in three specific units of study, one of which is "Responding to Family and Domestic Violence in Family Work".
There are strengths and weaknesses in the institutionalisation of screening and assessment procedures. On the positive side, these procedures formalise the process of determining the nature of the issues being presented by clients. They increase the chances that the service offered would be the most appropriate one. The CRAF, however, states that "assessment of risk based on a single tool alone will not deliver the desired outcome or guarantee victim safety. In fact, such an approach may endanger a victim because no tool currently available is 100% accurate".(p. 30). This raises the question of the possible link between assessment tools and the generation of too many false positive findings (that violence occurred when in fact it did not) or false negative findings (that violence did not occur when in fact it did). There is a risk of becoming complacent about false negatives when too much focus is placed on formal procedures.
As Gould (1981) has demonstrated with respect to the measurement of "intelligence", the results of formalised and institutionalised assessment procedures can too easily be seen as truths or "entities" that become fixed in time. An assessment of risk may be seen to have been "completed", at which point a practitioner or a service might remain less alert to the possibility that from a statistical point of view, past or present violence must always be regarded as a possibility. As such, the assessment process by practitioners must be ongoing. Although the principle of continuous assessment is also well established in the literature, putting it into clinical practice once a formal screening and assessment phase has "ended" can feel counter-intuitive, especially to the novice practitioner.
But like a pilot who seeks take-off clearance once all systems have been checked, a practitioner cannot simply assume that there are no dangers ahead simply because screening and risk assessment have been attended to. Like the pilot who continues to check systems in flight, the practitioner is required to focus on the task now at hand (for example addressing relationship tensions, attending to parenting issues, assisting in the resolution of a dispute) whilst simultaneously having an "ear open" to the possibility that these matters may be secondary to questions of more critical importance that have not been revealed (see Box 1: Case Study).
Box 1 - Case study - Attuning to violence in a Family Dispute Resolution (FDR) session
Towards the end of three sessions of FDR (mediation), a woman wanted to make adjustments to a draft agreement. Her ex-partner was not willing to make the change and a stalemate ensued. When the woman held her ground, her former partner quietly "reminded" her that this might not be in her interests. The FDR practitioner felt uncomfortable about the atmosphere that had developed in the room and called a private session. At that session the woman revealed an incident that had occurred shortly after their marriage. She recalled that during a dinner party, her then husband asked to see her in the kitchen. He had been angered by a remark she had made about him in front of the dinner guests. He put his fist through a wall and told his wife that she should be very careful in future. The woman had lived in fear of a recurrence of this incident and in fear of her own safety for many years.
This revelation significantly changes the nature of the work of a practitioner. Suddenly, the FDR practitioner is faced with many challenging decisions, and must slow the process down to allow himself/herself as well as the clients to adjust to this new situation. The revelation is likely to have placed the woman in a more vulnerable position, at least in the short term. Some questions that need to be addressed include:
- How is her immediate safety to be ensured?
- Can the changed circumstances, with respect to if and how FDR might continue, be communicated to the former husband in a way that ensures the safety of the wife?
- What further input is needed from the wife and what further assistance may she need before the husband is engaged further?
- How will the FDR practitioner deal with the possibility (perhaps likelihood) of denial or minimisation?
- Can parts of the draft agreement about future parenting arrangements be salvaged?
- In the event that the husband acknowledges the impact of his behaviour, how can the children's need for healing be incorporated into the parenting plan?
- What are the wife's views on continuing with a parenting plan and who else should she speak with about this?
Another set of questions arises when other professionals and their possible roles are considered. For example:
- Is there somebody who can advocate clearly for the wife in a way that is not punitive towards the father?
- Who can advocate for the children in a way that prioritises their safety without necessarily "removing" them from the care their father might provide?
- What services may be of assistance to the husband at this time?
- What other community-based referrals should be considered?
- Who should facilitate engagement with services such as those above, in what sequence and how?
- Do the circumstances warrant calling the police?
- What role can or should the legal representatives now play?
- If there are no legal representatives for one or both the parties, should they be advised to seek such representation?
- How active should the FDR practitioner be in promoting legal representation if it does not exist?
- If the woman has a legal representative, should the FDR practitioner consider seeking the client's permission to call her?
- Should the FDR practitioner ask the client if the legal representative has been told of this or similar incidents? If not, what might this say of the current relationship between the client and her lawyer. If so, how can this be reconciled with the fact that the legal representative appears to be supportive of FDR?
- Should the FDR practitioner seek permission to also speak to the former husband's legal representative, or if he does not have a legal representative, advise him to seek one?
The above list is not exhaustive. These and other possible actions require careful contextual analysis. They call for consideration and "judgement calls" regarding not only what to do and not do, but as noted, the sequencing of actions. Decisions at such a critical moment should not be rushed, and whenever possible should be made in consultation with a colleague or supervisor. On the other hand, action may need to be taken to ensure immediate safety. The former wife for example may need to be escorted when she leaves. A safety plan may also need to be devised for both the mother and her children. The former husband may need to be linked in quickly with a men's relationship or similar service.
5 Family dispute resolution practitioners need to have met accreditation standards based on new competency-based qualifications developed specifically for the family relationships sector (Vocational Graduate Diploma of Family Dispute Resolution).
6 Established by the Attorney-General’s Department, see: Family Dispute Resolution Register <http://fdrregister.familyrelationships.gov.au/Search.aspx>.