STANDARDS OF CARE FOR DOMESTIC VIOLENCE
PERPETRATOR TREATMENT


JEFFERSON COUNTY, KENTUCKY
OFFICE FOR WOMEN


MARCIA ROTH
Director

DAVID L. ARMSTRONG
County Judge/Executive


To assist in reaching the highest standards, we are proposing the following for all therapists and programs who wish to provide court ordered treatment of perpetrators of domestic violence.

I. Value Standards

A. Domestic violence is clearly defined as criminal behavior.

B. The primary goal of treatment services for domestic violence perpetrators is the cessation of the violence which will provide for the safety of victims and their children. This goal takes priority over all other issues including family reunification or the resolution of "relationship issues," and should,be the foundation on which all treatment decisions with perpetrators are made.

C. Perpetrators of domestic violence are to be held accountable for their violent behavior. Violence is considered to be the responsibility of the individual who perpetrates it.

D. Similarly, treatment services for victims of domestic violence should be predicated on the value that victims do not control and cannot be held responsible for their own victimization.

E. Domestic violence is understood to be a pattern of coercive control which includes physical, sexual, emotional, and environmental abuse.

F. The safety of therapists who provide services to perpetrators is also a value which is of high priority, and should be taken into consideration during and following the assessment and treatment process.

G. The effectiveness of services to victims and perpetrators of domestic violence is increased when approached as a community response rather than one provided by an agency/provider-working in isolation.




II. Personnel Standards

A. Domestic violence programs operated by Community Mental Health Centers (CMHC) must be staffed by mental health professionals as delineated in the Department for Mental Health and Mental-Retardation Services "Standards of Care for Domestic Violence Programs".

B. Individual therapists providing domestic violence perpetrator treatment may include the following:
1. Psychiatrist - board certified or board eligible
2. Psychologist - licensed or certified clinical or counseling psychologists licensed for independent practice

3. Clinical social worker licensed for independent practice

C. Group practices or other for-profit treatment entities providing domestic violence perpetrator treatment may include the following:
1. Psychiatrist, psychologist or social worker as described above.
D. Non-profit agencies which provide domestic violence treatment may include the following: 1. Psychiatrist, psychologist, or social worker as described above:
2. Certified psychologist or psychological associate under supervision of a licensed psychologist;

3. Certified social worker under supervision of a licensed clinical social worker;
4. Psychiatric nurse or registered nurse with one of the following combinations of education and experience:
a. Master of Science in Nursing with specialty in psychiatric/mental health nursing;
b. Four-year educational program, with a Bachelor of Science in Nursing and a minimum of one (1) year of experience in a mental health setting.
4. Professional equivalent, as defined by the Kentucky Medical Assistance Program., under supervision of a licensed mental health professional as defined in IIB.


E. Clinicians who provide domestic violence services must receive a minimum of 15-hours of specialized training before beginning to provide services. This training shall address all forms of interpersonal violence, specifically including the following: 1. Philosophical orientation related to the delivery of domestic violence services
2. Assessment of lethality
3. Impact of victimization on primary victim
4. Impact of victimization on secondary-victims, including children who witness the crime 5. Treatment modalities appropriate in domestic violence cases
6. Legal and ethical responsibilities
7. Laws and procedures of the criminal justice system relevant to domestic violence cases
8. Co-occurrence of domestic violence and chemical dependency.

F. Clinicians who provide services to perpetrators of domestic violence must receive continuing education of 5 hours per year in the area of domestic violence.



III. Treatment Standards

A. The programs,operated by Community Mental Health Centers must act in compliance with the service definition and standards for outpatient services as provided within the Instructions Manual (III-9, III-24).

B. The treatment programs and therapists must develop written policies in compliance with KRS 209 and KRS 620 which specify procedures for reporting child or adult abuse and procedures for documentation in client records of reports made.

C. The treatment programs and therapists must develop written policies in compliance with KRS 202A.400 which specify procedures for warning intended victims of violence when threats are made by program clients.

D. The treatment programs and therapists must incorporate methods to address the treatment and support needs of children in the home. Children's needs may be met by providing services directly to children or by establishing a formal referral mechanism to other treatment from which children's services may be obtained.

E. The treatment programs and therapists must implement methods of programmatic evaluation which include measuring rates of drop-out, dismissal rates and program completion.

F. Until the perpetrator acknowledges responsibility for the violence and evidences steps to control his/her behavior which are verified by the victim, the therapist should not encourage family or couple counseling to take place.


IV. Perpetrator Services

A. The program must begin with an evaluation of the perpetrator which should include a mental status examination and other assessments for the presence of a mental illness; risk and lethality assessment; social and psychiatric history; specific information regarding the history of violence in his current and past relationships; criminal history, including review of the police report associated with the most recent violent episode; assessment of chemical abuse/dependency; and assessment of the perpetrator's amenability to treatment. An interview with the victim should be conducted to receive collateral information and to verify the disclosures of the perpetrator.

B. The treatment must be violence specific rather than generic. components of the individual or group therapy should include cognitive restructuring, anger management, stress management, sex-role stereotyping, power and control issues, conflict resolution, the cycle of violence, chemical abuse/dependency, empathy for the victim's experience, and personal abuse history. The treatment should address cognitive, behavioral, and emotional processes.

C. Treatment modalities used in the treatment of perpetrators include individual and group therapy and psychoeducational groups. Concurrent groups for partners of the perpetrators in the treatment should be offered by the treatment program or therapist or should be coordinated with another victim services agency in the community.

D. The treatment program or therapist must review' cases routinely as a means of monitoring progress in treatment, including the degree to which the perpetrator has taken responsibility for the violence, lethality, and the current safety and status of the victim.

E. The treatment program or therapist must document any evidence of significant changes in the perpetrator's lethality or dangerousness. It further must establish procedures for alerting both the victim and law enforcement should threats be made by the perpetrator or should the safety of the victim become a concern in compliance with Kentucky statute 202A.400.'



V. Court-Mandated Perpetrator Programs

A. Perpetrators who enter treatment should sign a treatment contract which requires attendance, participation, and payment for treatment services and a statement that they will cease the violence. Contracts should also include a broad release of information to allow treatment providers to maintain contact with the victim of the abuse and others who would provide essential information or who have a legitimate need to be informed of the perpetrator's progress in treatment. Failure to sign proper releases will constitute grounds for dismissal from the program.

B. In the event that the therapist determines that the perpetrator should not be in the treatment program due to failure to keep the treatment contract or for other clinical reasons, a written report must be made to court for judicial determination.

C. Treatment programs or personnel should provide written reports to the court and the prosecutor related to the perpetrator's course of treatment at the midpoint and at the conclusion of the treatment.." Dismissal guidelines as recommended by the treatment program
should include 1. Serious recidivism of violence or any recidivism of violence which is not self- reported
2. Failure to attend scheduled appointments
3. Failure to actively participate in groups
4. Failure to complete assignments

5. Failure to assume financial responsibility for treatment services in accordance with the established fee schedule of the provider agency

D. The court-mandated treatment must designate a minimum number of sessions for a perpetrator to complete the program. Each session should last no less than one hour and the sessions must continue for at least sixteen weeks.

E. The court-mandated treatment program or therapist must operationally define completion of the program.


Domestic Violence Programs" are defined to
include organized individual, group and family
services provided to victims and perpetrators
are designed to- focus specifically on the
cessation of violence and the mental health
issues which are associated with the
experience of violence and abuse.

Value Standards

A) Domestic violence is clearly defined as criminal behavior.

B) The primary -goal of treatment services for domestic violence perpetrators is the cessation of the violence which will provide for the safety of victims and their children. This goal takes priority over family -reunification or the resolution -of "relationship issues", and should be the foundation on which all treatment decisions with perpetrators are made.

C) Perpetrators of domestic violence are to be held accountable for their violent behavior. Violence is considered to be the responsibility of the individual who chooses to.perpetrate it.

D) Similarly, treatment services for victims of domestic violence should be predicated on the value that victims do not control and cannot be held responsible for their own victimization.

E) Domestic violence is understood to be a pattern of coercive control which includes physical, sexual, emotional, and environmental abuse.

F) The safety of counselors and therapists who provide domestic violence services is a value which is highly prioritized, and should be taken into consideration throughout and following the assessment and treatment process.

G) Services to victims and perpetrators of domestic violence lose an element of effectiveness when provided by agencies in isolation. Thus, a community response rather than an individual agency response is prioritized.



Personnel Standards

A) Domestic violence programs funded by the Department for Mental Health and" of spousal Domestic Violence Programs

Mental Retardation Services must be staffed by qualified mental health professionals as defined in Section III-2 of the Program Policies and Billing Instructions Manual:
1. Psychiatrist - board certified or board eligible
2. Psychologist - licensed clinical psychologists, -certified psychologists, and psychological associates

3. Psychiatric nurse or registered nurse with one of the' following combinations of education and experience:
a. Master of Science in ' Nursing with speciality in psychiatric/mental health nursing. No experience.
b. Four-year (4) educational program, with a Bachelor of Science in Nursing and a minimum of one (1) year of experience in a mental health setting.
c. Three-year (3) educational program Diploma Graduate with two (2) years of experience in a mental health setting.
d. Two-year (2) educational program Associate Degree in Nursing with three (3) years of experience in a mental health setting.
4. Psychiatric social worker (MSW or MSSW) from an' accredited school of social work.
5. Professional equivalent, as defined by -the Kentucky Medical Assistance Program.

6. Mental health associate -.an individual with a Bachelor's degree in a mental health related field, working under the supervision of a' qualified mental health professional.

B) Clinicians who provide domestic violence services must -receive specialized training which addresses all forms of interpersonal violence, specifically including the following.-
1. Philosophical orientation related to the delivery of' domestic violence services
2. Assessment of lethality
3. Impact of victimization on the primary victim
4. Impact of victimization on secondary victims, including children who witness the crime
5. Treatment modalities appropriate in domestic violence cases
6. Legal and ethical responsibilities
7. Laws and procedures of the criminal justice system relevant to domestic violence cases

8. Co-occurence of domestic violence and chemical dependency

C) Clinicians who provide services to victims and perpetrators of domestic violence must receive continuing clinical supervision;

D) Clinicians who provide services to perpetrators of spouse abuse must have experience in working with or maintain a small caseload of domestic violence victims. This is not intended to require that a clinician must work with the specific victim of any perpetrator seen in treatment.'


Program Standards

A) The programs funded by the Department must act in compliance with the service definition and standards for outpatient services as provided within the Instructions Manual (III-9,111-24);

B) The program must develop and maintain at each service site, written policies in compliance with KRS 209 and KRS 620 which specify procedures for reporting child or adult abuse, and written procedures for documentation in client records of reports made;

C) The program must develop and maintain at each service site, written policies in 'compliance with KRS 202A.400 which specify procedures for warning intended victims of violence when threats are made by program clients;

D) The program must incorporate methods to address the treatment and support needs of children in the home. Methods may include providing services to children or establishing formal referral mechanisms to other programs for this purpose;

E) The program must implement methods of programmatic evaluation ' which include measuring rates of drop-out, dismissal rates and program completion;

F) The program must adopt maximum caseload guidelines for each therapist providing domestic violence services to victims or perpetrators;

G) Couple and family counseling or therapy must be restricted until the perpetrator, in the course of participating in the program, acknowledges responsibility for the violence and evidences steps to control violent behavior which are verified by the victim and documented in the client file of the perpetrator.


H) Victim Services
1. Services for domestic victims should be voluntary, unlike perpetrator services which are frequently mandated by-the court. The only exception are those rare instances in which the victim suffers from a mental illness and is a danger to self or others (KRS 202A) or where the victim -is unable to provide self care (KRS 209).

2. Services for domestic violence victims should begin with an assessment of her or his immediate level of safety.- the safety of any children in the home; and the status of any medical needs of the victims or the children;

3. The program must review with the victim on a routine basis, the level of lethality and dangerousness of her' or his case and. the degree to which she or he is in need of protective services;

4. As appropriate, the program should develop a "protection plan"- with the victim which addresses concrete steps to take when the perceived degree of dangerousness in the home is high, including how to access the key protective resources of local law enforcement, the Department for Social Services, and the regional Spouse Abuse Center;

5. The program should emphasize empowerment of the victim in the process of establishing goals for treatment and by support the individuals decision-making skills;

6. Services provided must be violence-specific rather than generic in content. Components of individual and group services for victims should address the cycle of violence., the causes of violence, cognitive restructuring around the victim's interpretation of the cause of the violence; power and control issues; the impact of domestic violence on primary and secondary victims; sex-role stereotyping-, appropriate conflict resolution; past abuse I, history, and other appropriate issues;

7. The program should begin with an evaluation of the victim which includes assessments for the presence of a mental illness or chemical abuse/dependency; risk and lethality assessment; social and psychiatric history-, and specific information regarding the history of violence in past and current relationships;


8. The program must incorporate methods of addressing chemical abuse and dependency among victim-clients, either through referral or by providing substance abuse services.



I) Perpetrator Services
1. Services for perpetrators of domestic violence must begin with an evaluation of the perpetrator which should include a mental status examination and other assessments for the' presence of a mental illness; risk and lethality assessment; social and psychiatric history,- specific information regarding the history of violence in current and past relationships; criminal history.. including review of the police report associated with the most recent violent episode; assessment of chemical abuse/dependency; - and assessment of the perpetrator's amenability to treatment. If the. victim is willing, an interview with her or him should be conducted to receive collateral information and to verify the disclosures of the perpetrator.,

2. Services provided must be violence-specific rather than generic. Components of the group program should include cognitive restructuring., -anger management, stress management, sex-role stereotyping, power and control issues, conflict resolution, the cycle of violence, chemical abuse/dependency, empathy for the victim's experience, and personal abuse history. The program should address cognitive, behavioral, and emotional processes;

3. Treatment modalities used by the program for perpetrators include individual and group therapy and psycho-educational groups. If groups are provided, concurrent groups for partners of the perpetrators in treatment should be offered by the program or should be coordinated with another victim services agency in the community;

4. The program must review cases routinely as a means of monitoring progress in treatment, including the degree to which the perpetrator has taken responsibility for '-he violence, lethality, and the current safety.and status of the victim;

5. The program must document any evidence of significant changes in the perpetrator's lethality or dangerousness. ' It -further must establish procedures for alerting both the victim and law enforcement should threats be made by the perpetrator or should the safety of the victim become a concern. (KRS 202A.400).



J) Court-Mandated Perpetrator Programs
1. The court-mandated perpetrator treatment program operated by the CMHC should develop a new committee or designate an existing committee of community representatives to serve in an advisory capacity. At a minimum, advisory committees should include representatives from the local court system, law enforcement, the 'Department for Social Services, and the regional Spouse Abuse Center;

2. Perpetrators who enter treatment should sign a treatment contract which requires attendance, participation, and payment for treatment services and a statement that they will cease the
violence. Contracts should also include a broad release of information to allow treatment providers to maintain contact with the victim of the abuse and others who would provide essential information or who have a legitimate need to be informed of the perpetrator's progress in treatment;

3. Entry into a court-mandated treatment program should be predicated on a ' guilty plea or follow an adjudication of guilt, that is, treatment programs should be post-conviction in order to emphasize consequences and accountability,-


4. Decisions regarding the acceptance of a perpetrator into a court-' mandated treatment program should be made following referral from the court and an initial evaluation by the treatment provider. The final authority to admit or reject any perpetrator into or out of the program should remain with the treatment program. Ineligibility guidelines may include:
a) cases in which there has been commission of a felony offense by the perpetrator which involves violence
b) cases in which the perpetrator is actively dependent upon alcohol or drugs (referrals for substance abuse treatment should be made prior to domestic violence treatment)
c) cases in which the perpetrator is actively psychotic or suffers from a significant organic impairment
d) cases in which there are indications that the perpetrator. is inappropriate for outpatient treatment, including criminal lifestyle or a continuing unwillingness to accept responsibility for the violence
e) cases in which there has been previous dismissal from,the treatment program;
5. Treatment programs should provide regular reports to the court and the prosecutor related to the perpetrator's course of treatment. Dismissal guidelines as recommended by the treatment program should include:
a) serious recidivism of -violence or any recidivism of violence which is not self-re reported
b) failure to attend scheduled appointments
c) failure to actively participate in groups
d) failure to complete assignments
e) failure to assume financial responsibility for treatment services in accordance with the established fee schedule of the provider agency;
6. The court-mandated program must designate a minimum. number of sessions for a perpetrator to complete the program, not requiring less than sixteen weeks of one-hour sessions per week or its equivalent.


7. The court-mandated program must operationally define completion of the program to include objective measures of acquired knowledge related to issues discussed in treatment.



Funding Standards

A) While the program may seek reimbursement for services provided from the Department for Mental Health and Mental Retardation Services, the primary reimbursement source for perpetrator treatment should be client fees (either structured as a flat fee or on a scale sliding). Payment for services should be included in the treatment contract and in the court order for the perpetrator to attend treatment.

B) When Advisory Committee meetings address specific cases or the coordination of the -services of the program, participation by CMHC- staff may be billed under Consultation and Education services.