A Brief Motivational Intervention to Address Intimate Partner Violence Victimization: A Pilot Study

Abstract

Purpose:

Intimate partner violence (IPV) is public health crisis that often goes unrecognized. Victims often report ongoing long-term physical and mental health consequences; however, health-care responses to address IPV have not been maximized. The standard of care of screening and referring to community organizations is not enough to help victims.

Method:

This mixed-methods pilot study enhanced the screening and referral standard of care by offering a brief motivational intervention (BNI-V) to six patients in an obstetrics and gynecology clinic.

Results:

Preliminary results indicate improved engagement into care and improvements in quality of life, trauma symptoms, and self-efficacy. Participants expressed high satisfaction with the intervention and improved perception of self.

Discussion:

This study demonstrates a feasible way to build on the screening and referral practices typically found in the health-care system.

Keywords

intimate partner violence motivational interviewing social work practice intervention

Intimate partner violence (IPV) is a fundamental human rights and public health crisis. National data suggest IPV victimization is more prominent for women than men, with one in four women reporting a lifetime prevalence (Breiding et al., 2015; S. G. Smith et al., 2018). Eighty-one percent of victims report significant and ongoing adverse repercussions, such as physical injuries, chronic disease or pain, and significant mental and behavioral health, which often lead to increased health-care utilization (Bonomi et al., 2009). In fact, 38–59% of women seeking health care report current or past IPV (Sprague et al., 2016). As a result, multiple professional organizations recommend in their best practices guidelines that medical providers screen for IPV (Nelson et al., 2012). While clinical practices that address IPV vary, the standard of care for most health-care environments with and without social workers is to screen and provide referrals to various community (e.g., hotlines, advocates, shelters) and/or legal resources (Nelson et al., 2012). IPV screening is effective in identifying victims in health-care settings (Trabold, 2007) and recommended by the U.S. Preventive Task Force (Moyer, 2013); however, simply providing referrals to IPV resources is insufficient to engage victims with services. IPV screening studies report poor follow-up rates (4–15%) using the screen and refer method (Klevens et al., 2012; MacMillan et al., 2009; Miller et al., 2014). The complexity and emotional impact of repeated IPV leaves many struggling to understand their victimization and feelings of fear, shame, and guilt that accompany IPV tend to normalize perpetrator behaviors, and the pathological relationship dynamics impact women’s readiness to engage in care (Chang et al., 2005; Cluss et al., 2006; McCaw et al., 2001). Moreover, IPV resources are heterogeneous and may not be appropriate for each situation (e.g., legal vs. counseling). Failing to make an appropriate recommendation further impedes effective engagement into care, can compromise safety, and allows for the cycle of violence to continue. Thus, merely offering referrals after screening is insufficient to engage most patients in IPV care.

Currently, there are numerous IPV interventions ranging from legal interventions (e.g., orders of protection) to advocacy/case management, shelter, and mental health/behavioral therapy. These IPV interventions improve well-being, depression, and post-traumatic stress disorder (PTSD) symptoms and reduce reoccurrences of violence (Trabold et al., 2018); however, many women do not engage with these effective interventions, allowing the sequela of IPV to continue (MacMillan et al., 2009). IPV screening and referral is necessary but not sufficient, leaving an important gap in how care is provided to IPV victims within health-care environments. Additional strategies are necessary to improve engagement with IPV care, which are cost-effective and sustainable. To augment the screening and referral to treatment for IPV victims, we adapted and tested whether adding a brief motivational intervention after screening would improve engagement into care and as a result well-being would improve.

This pilot study adapted and tested the preliminary effectiveness the Brief Negotiated Interview (BNI), a brief motivational intervention. The BNI, initially designed for substance abuse acute care settings, was adapted to address IPV victimization. BNI has demonstrated effectiveness in health promotion studies. Specifically, study participants seeking care in an emergency department who received BNI had increased contact with primary care, behavioral health, mammograms, and smoking cessation programs (Bernstein et al., 1997). BNI was selected and adapted (BNI-V) due to its demonstrated effectiveness with similar populations, its portability, and ease in use and potential for integration into health-care environments.

The adapted BNI-V intervention was guided by self-determination theory (SDT), a theory of human behavior focused on the psychosocial factors that enhance or inhibit individual’s behavior change based on fulfillment of three client-centered basic psychological needs: competence (ability to achieve a certain outcome), relatedness (social connection to others), and autonomy (desire to control one’s own life; Ryan & Deci, 2017). SDT is often helpful for understanding human motivation and is frequently applied to motivational interventions such as BNI due to their overlapping conceptual frameworks on behavioral change (Britton et al., 2008; Patrick & Williams, 2012); Vansteenkiste & Sheldon, 2006).

Motivational interventions focus on resolving ambivalence and increasing efficacy (competence), facilitating autonomy by identifying needs, wants, and choices (Bernstein et al., 1997), to motivate behavioral change by increasing insight and awareness about targeted behaviors. While the use and effectiveness of motivational interventions (MI) to engage high-risk populations is well-established (Battaglia et al., 2012; Carroll et al., 2001; Interian et al., 2010) and is used in numerous fields, the use of MI within the IPV field remains relatively novel. Three recent studies of MI-focused interventions with diverse samples of women (Hegarty et al., 2013; Saftlas et al., 2014; Wahab et al., 2014) found improvements in self-efficacy.

The purpose or this pilot study was to gather preliminary evidence on the feasibility, acceptability, and preliminary effectiveness of BNI-V for improving engagement into IPV care. Specifically, the research aims are to:

explore whether BNI-V improves engagement into IPV care in a sample of women seeking medical care,

explore changes in the health and well-being of women who receive BNI-V, and

explore the satisfaction, barriers, and facilitators of BNI-V among patients seeking medical care.

Method

Research Design and Procedures

We employed a mixed-method design to assess acceptability, feasibility, and preliminary effects of the BNI-V intervention. The sequential (quantitative followed by qualitative) mixed-methods design was employed to explore and understand preliminary outcomes and implementation potential to inform a larger pragmatic trail. A mixed-methods design was employed due to the complex aspect of the health-care delivery system and to facilitate translation into care but gaining preliminary data on both intervention effectiveness and implementation elements (Fetters, Curry, & Creswell, 2013). We recruited participants from a community-based obstetrics and gynecology (Ob/Gyn) office. The office provides routine and specialty Ob/Gyn care and is a part of academic medical center. The office has approximately 23,000 visits annually to patients who largely meet the federal poverty guidelines.

Prior to determining study procedures, the principal investigator (PI) met with the medical director, nurse manager, and social workers from the Ob/Gyn office to understand office policies and practices around IPV. In addition, the PI followed multiple medical assistants during office hours to understand office procedures (i.e., check-in, screening for IPV, exam rooming procedures). The standard of care was universal IPV screening in the exam room. The medical provider initially addressed a positive screen and made a social work referral if deemed necessary by the provider. The social work role involved further assessment and referrals to community/legal resources as deemed appropriate, but they did not engage in any MI-based interventions.

Recruitment

Prior to recruitment, the PI obtained institutional review board approval from the affiliated institution and trained the research assistant (RA) on IPV, crisis/safety protocols, how to approach participants, and the ethical conduct of research. Based on information and observations during study procedure planning, recruitment occurred using two different methods. First, the RA approached patients waiting for their appointment and asked if they would be willing to complete a few questions to determine eligibility for a research study about relationships and community resources. This process included IPV screening questions. Second, the RA received direct referrals from clinic staff (providers and/or social workers). If a patient reported IPV during an office visit via screening or self-disclosure, the clinic staff inquired if the patient would be interested in the research study. The RA asked for verbal assent to conduct study-screening questions. We invited potential participants to a private office for a formal request to participate in the study. After deemed safe, patients received an IPV information brochure and a brief assessment for safety as needed regardless of their decisions to participate in the study.

Inclusion Criteria

Participants were eligible for the study if they (1) reported any IPV (physical, sexual, emotional, or psychological) within the past 3 months, (2) were >18 years, (3) were able to speak and understand English (assessed during the screening process), and (4) were active patients of the OB/Gyn practice. Individuals were excluded from participation if (1) there was a serious and untreated substance use problem assessed using the alcohol use disorders identification test and the drug abuse screen test (Bohn et al., 1995; Westermeyer et al., 2004), (2) the person was unable to understand the consent process, or (3) the individual reported currently engagement with IPV interventions. Those who met the inclusion criteria were invited to participate in the study. We employed best practices for longitudinal studies including obtaining detailed contact information after potential participants signed proper releases (Leonard et al., 2003). Safety was considered in all aspects of obtaining detailed locator and contact information and preferred methods of contact. After eligibility was confirmed, a follow-up appointment was set to review the informed consent and complete the pretreatment measures. To verify participants understood the consent process and were able to converse in English, multiple questions were asked, such as “Can you tell me the purpose of this study?” “Can you explain the risk/benefits of the study?” After this process was successfully completed and the participant was able to answer all questions, the pretreatment measures were administered.

Screening and Enrollment

During a 10-week time frame, 151 women from the Ob/Gyn office were screened for eligibility via waiting room screening or direct referral. A total of 20 women were eligible and 6 participants enrolled. Of the participants who did not enroll, time, childcare, and delivery of a newborn were some of the common reasons for lack on enrollment. Of the enrolled participants, all six participants completed three sessions of the BNI-V with the PI, pre/post measures, and a semi-structured interview following completion of the intervention (see Figure 1). One participant had numerous work and childcare conflicts, thus the third intervention session was delayed.

Figure 1.

Study procedures.

Intervention

The original BNI is a one-session intervention comprised of five stages: building rapport, discussion of pro/cons, information and feedback, discussion of readiness to change behaviors, and development of an action plan focused on steps/options desired to make changes (Bernstein et al., 1997). Guided by SDT, the BNI-V was adapted for use with IPV victims, and two brief follow-up sessions using MI principles were added. The first session, similar to the original included multiple stages. First, establishing rapport and discussing the participant–clinician relationship and asking permission to discuss the relationship. This was followed by a general discussion of IPV and its personal impact via a personalized information pamphlet specialized to each participant based on responses from the pretreatment measures. Next, the positive and negative aspects of the relationship, readiness to address IPV, and/or engage in IPV services were addressed. This was followed by a discussion of personal strengths, resilience, and support. Upon completion of these stages, an action plan is offered to outline goals and a plan to achieve these goals. Two additional in-person follow-up sessions followed at 1 and 3 weeks from the first session. These sessions utilized MI principles, for example, open-ended questions, reflections, summary statements, and affirmations (OARS/FRAMES, see Miller & Rollnick, 2012) to discuss progress toward the action plan. In addition, all participants received their usual course of care from the clinic. The PI, who is a licensed social worker, conducted all sessions. The first two sessions took 30–45 min to complete, and the follow-up sessions were shorter in duration, usually lasting 15–30 min. All intervention sessions and assessments took take place in a private office at the clinic at a mutually agreed upon time.

Measures

Measures were administered using a computer-assisted data collection program called research electronic data capture (RedCap; Harris et al., 2009). After informed consent, the pre-intervention measures were completed and post-intervention assessments were administered 12 weeks later. All follow-up measures assessed symptoms since their last research assessment. In addition, within 12–14 weeks from the pre-intervention assessment, a semi-structured interview to explore experiences, perspectives, and acceptability of the BNI-V was conducted with all study participants.

Demographics

Self-reported items including age, race, income, education, and employment were also asked to further describe sample characteristics.

Timeline follow back (TLFB)

To obtain nuanced frequency data, we used the TLFB to measure engagement into IPV services. The TLFB (Sobell & Sobell, 1992) is a reliable and valid way to measure individual behaviors using a calendar where participants are asked to reconstruct their behaviors using events to facilitated recall (Donohue et al., 2004; Strong et al., 2012; Weinhardt et al., 1998). The TLFB was used to measure and understand utilization patterns of services over a defined time frame. Use of IPV services was defined as self-reported contact and/or attendance to a predetermined list of IPV services within the surrounding geographic area.

IPV

The Conflict Tactics Scale Revised (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) was used to measure IPV physical, sexual, and emotional abuse/violence victimization. The CTS2 has good reliability and validity in various populations (Straus, 2004). Responses range from 0 (this never happened) to 6 (happened >20 times in the past year) and 7 (happened but not in the past year). To understand the nuances of IPV, each item was explored individually. Each item was recoded into currently experiencing, history of, or never experienced form of IPV. To contextualize the IPV into a larger pattern of power and control and to assess for psychological abuse (see Johnson, 2006), the women’s experience with battering (WEB) was used to measure power and control aspects of a relationship (Smith, Tessaro, & Earp, 1995). The WEB has good construct validity and internal consistency (Smith, Tessaro, & Earp, 1995; P. H. Smith et al., 2002). Scores range from 1 (strongly disagree) to 6 (strongly agree) and are summed for a total score.

Danger assessment (DA)

DA was used to elucidate safety concerns and understand risk of homicide. The DA has good sensitivity and specificity (Campbell, Wester, & Glass, 2009). Responses are yes or no. There is a weighted scoring procedure after summing all the yes responses. Scores fall into a range of three categories from increasing, severe, to extreme violence.

Post-traumatic stress symptoms

The Post-Traumatic Checklist (PCL-C) is frequently used to screen, diagnose, or monitor PTSD symptoms before and after treatment, and the PCL-C also allows for symptom reporting for multiple traumatic events (Weathers et al., 2013; National Center for PTSD). Responses range from 1 (not at all) to 5 (extremely). Item are summed for a total severity score, where the higher number indicates more severe PTSD symptoms.

Depression symptoms

Using the Patient Health Questionnaire (PHQ-9; Kroenke, Spoitzer, & Williams, 2010), depressive symptoms were measured based on diagnostic and statistical manual of mental disorders symptom criteria. Responses are scored on a scale of 0 (not at all) to 3 (nearly every day), and individual items are summed to create a total score measured. A score of 10–27 indicates moderate to severe depression.

Self-efficacy

The General Self-Efficacy Scale was used (Schwarzer & Jerusalem, 1995) to measure self-belief, coping with adversity and commitment to behavior change. It is a widely used measure, translated into 30 languages, and has demonstrated reliability across diverse populations (Scholz, Dona, Sud, & Schwarzer, 2002). Responses range from 1 (not at all) to 4 (exactly true), and items are summed for a total score, with a higher score indicating higher efficacy.

Quality of life

Two questions from the World Health Organization Quality of Life Instruments Brief (WHOQOL-BREF) were used to get an individual global self-report perspective on quality of life and satisfaction with life; they are (1) How would you rate your quality of life, measured on a 5-point Likert-type scale from very poor to very good; and (2) How satisfied are you with your health on a 5-point Likert-type scale from very dissatisfied to very satisfied. The WHOQOL-BREF was developed by the World Health Organization. It has good validity and reliability and is widely used across various populations (Group, 1998).

Qualitative semi-structured interview

A nine-question, semi-structured interview was developed for this study focused on perceptions of the intervention, helpful or not helpful aspects, person-centeredness of the intervention, and perceptions of self before and after. An example of questions and probes include (1) How did you feel about the discussions? Thoughts on the information provided during the first session? (2) Did the sessions meet your needs? (3) Describe yourself before participating? Describe yourself now.

Data Analysis

Quantitative Data Analysis

Using SPSS Version 25, standard data cleaning procedures were completed, and basic univariate analyses such as frequencies, means, and standard deviations were calculated to explore changes in frequency and average scores on violence (CTS-2/DA), quality of life (WHOQOL-BREF), and mental health measures (PHQ-9 and PCL-C). There was limited missing data, which was deemed to be completely missing at random. Thus, to maintain the sample size and improve precision, we imputed the mean on all missing items to complete summed scores (Gelman & Raghunathan, 2001). A total of 3 items were imputed across all cases and measures. Paired t tests were conducted to explore differences in health, mental health and well-being outcomes, mean scores and standard errors for quality of life (WHOQOL-BREF) depression (PHQ9), trauma symptoms (PCL-C), self-efficacy, and the WEB were computed and compared between pretreatment and follow-up.

Qualitative Data Analysis

Semi-structured interviews were completed at 12–14 week from the pretreatment by the interventionist. All interviews were audiotaped and transcribed verbatim and verified for accuracy by randomly listening to sections of the audio files while reviewing the transcripts. In addition, the audio files and transcripts were compared to in vivo notes taken during each interview. Each transcript was read by the PI for initial understanding, and a conventional content analysis was used to analyze the data (Hsieh & Shannon, 2005). Codes emerged during the analysis, and after all transcripts were coded, cross-case analysis was used to determine prominent patterns and themes within and between participants (Miles et al., 1994).

Results

Quantitative Results

The average age of the participants was 34.1 (8.5) years, with an age range of 24–48 years. The majority (n = 5) identified as White, and all of the participants had completed or attended some college. One third (n = 2) were working full time, one third were working part-time, and one third (n = 2) reported staying home with children. The majority (n = 5) received some form of federal assistance (e.g., public assistance, women, infants, and children, supplemental nutrition assistance program; see Table 1). In the 3 months prior to study enrollment, all participants experienced emotional and psychological abuse (N = 6), 66.7% (n = 4) reported physical violence, and 50% (n = 3) reported sexual abuse, and 66.7% (n = 4) needed to seek medical care after a violent episode. Further 66.7% (n = 4) were considered in an extremely dangerous relationship (see Table 4 for details on IPV). Upon initiation of the study, four of the participants were already receiving ongoing behavioral health care through their Ob/Gyn office focused on symptoms management of anxiety and/or depression.

Table 1.

Demographics.

N = 6	M
Age	34
	Range
	26–48 years
	% (n)
Race
White	83.3 (5)
Education
Some college	33.3 (2)
Completed college	67.7 (4)
Employment
Full time	33.3 (2)
Part-time	33.3 (2)
Home with children	33.3 (2)
Income
Federal assistance	33.3 (2)
Living with partner	16.7 (1)
IPV
Physical	66.7 (4)
Sexual	50 (3)
Emotional	100 (6)
Psychological	100 (6)
Danger assessment
Extreme danger	66.7 (4)

Note. IPV = intimate partner violence.

To answer our first research aim, we used the TLFB calendar to recall use of IPV services. At pretreatment, we asked the participants what IPV service they used, if any, and how often they used these services within the 6 months prior to enrollment into the study. Upon initiation of study procedures, 33.3% (n = 2) of participants had previously contacted an IPV service. One participant made two hotline calls, and the other had one hotline call and five advocacy appointments, with approximately 4 months since the last contact with IPV services prior to enrollment into the study. Upon completion of the 3-month follow-up, 66.7% (n = 4) participants engaged in IPV services (see Table 2), for a total of 19 contacts. Further, the type of services was different relative to services prior to enrollment. At the 3-month follow-up, the majority of service contacts were IPV counseling-oriented (n = 15) one hotline call, one advocacy visit, and one legal/order of protection visit. One participant engaged in a pain intervention, per her preferences, and the other participant who did not engage in IPV services explained she had a negative experience with the mental health system, thus was not planning to follow up with any services.

Table 2.

IPV Service Engagement.

IPV Services	Pre 6 Months	3 Months Post
Type of IPV services
Hotline/phone	3	1
Counseling	0	15
Advocacy	5	2
Legal/order of protection	0	1

Note. IPV = intimate partner violence.

Using paired t tests, mean improvements were found when comparing pretreatment to the 3-month follow-up scores (Table 3). Statistically significant improvements and large effect sizes were detected on the PCL-C (t = 3.2, p < .05, d = 1.2), self-efficacy (t = −3.6, p < .05, d = 1.7), and WEB (t = 2.7, p < .05, d = 1.1) measures. The 1-item quality of life measure also reflected self-reported improvements (t = −0.32, p = .025, d = 1.3) with a large effect size; the other quality of life measure did not reflect any significant difference demonstrating a small effect size (d = 0.2). There were no significant changes for depression (small effect size d = 0.3). There were no statistical differences in the number of IPV services; however, there was a moderate effect size noted (d = 0.7). Additionally, frequencies of individual IPV items were calculated pre and 3 months post. In comparison, no participant reported any physical or sexual violence since the pretreatment assessment; however, emotional abuse continued, and five participants reported they were shouted or insulted at the 3-month follow-up (see Table 4).

Table 3.

Descriptive Statistics and t Test Results for Outcome Measures.

Outcome	Pretreatment		3-Month Follow-Up		n	95% CI for Mean Difference	R	t	df	d
Outcome	M	SD	M	SD	n	95% CI for Mean Difference	R	t	df	d
TLFB	1.3	2.4	3.3	3.4	6	[−4.8, 0.8]	.62	−1.8	5	0.7
PHQ9	16.7	7	15.5	8.5	6	[9.5, 22.8]	.85*	0.75	5	0.3
PCL	65.5	18.2	47.3	19.2	6	[3.4, 33.0]	.72	3.2*	5	1.2
Efficacy	24.3	8.11	28.5	6.8	6	[−7.3, −1.2]	.94*	−3.6*	5	1.7
WEB	47.8	11.3	35.5	8.5	6	[0.65, 24.0]	.40	2.7*	5	1.1
QUAL (1)	2.8	1.6	3.5	1.2	6	[−1.2, −0.13]	.97**	−3.2*	5	1.3
QUAL (2)	2.8	1.6	2.7	1.3	6	[−0.96, 0.62]	.89*	−0.54	5	0.22

Note. TLFB = timeline follow back; PHQ9 = Patient Health Questionnaire; PCL = Post-Traumatic Checklist; WEB = women’s experience with battering.

*p < .05. **p < .01.

Table 4.

Intimate Partner Violence.

IPV	Past Year % (n)	Pretreatment % (n)
CTS2
Destroyed something/threat hit	66.7 (4)	0 (0)
Insulted/shouted	83.3 (5)	83.3 (5)
Sprain/bruise/cut	50 (3)	0 (0)
Pushed/shoved/slapped	66.7 (4)	0 (0)
Punch/kick/beat-up	33.3 (2)	0 (0)
Went to doctor/needed to see doctor	66.7 (4)	0 (0)
Used force for sex	16.7 (1)	0 (0)

Note. CTS2 = Conflict Tactics Scale Revised.

Qualitative Results

Overall, there was high satisfaction with the BNI-V intervention sessions and participants reported positive self-perceptions after completing the intervention. Participants also noted numerous aspects of the BNI-V as helpful.

Acceptability of BNI-V

All participants found the BNI-V was a useful and helpful intervention, for example, one participant stated, “it was awesome. It was a lot of I don’t even know how to say it, like perfect. It was what I needed to hear and see I guess” (Participant 6). Another participant acknowledged the BNI-V was at times hard but was worth it.

I found the whole process to be almost as difficult as it was to be more enjoyable toward the end. Like in the middle of the process it is definitely overwhelming and embarrassing at times and things like that, but once you get over the hump toward the end I found it very helpful. (Participant 1)

Motivational interviewing attributes

The participants expressed how the various MI attributes of the intervention were useful and influential in the overall experience.

Feedback

Specifically providing personalized feedback was viewed as helpful and something participants would use beyond the intervention. One participant stated,

…it’s been really enlightening and helpful. Just really got a lot out of it and I’m so glad I got to be part of it. I got a lot of information that I’m going to keep using…I don’t know you just provided me with a lot of useful information and I needed to hear that. (Participant 6)

Another participant indicated, “…it’s good to get feedback cause it can kind of help you put your thoughts together…” (Participant 1).

Well talking about everything to you, and you saying that you hear it from other people and knowing I’m not alone and actually seeing looking at the [Power and Control] Wheel and talking about it just that was so helpful. It was at the very beginning and that made me want to come back and talk and find out more. (Participant 6)

In particular, the participants found the discussion around the power and control wheel (Domestic Abuse Intervention Project/https://www.theduluthmodel.org) to be useful. “The wheel, I think about that wheel all the time” (Participant 6). Other participants stated, “yeah the abuse cycle…I thought that it was a very helpful tool to see things…I didn’t know there were so many different varying types of abuse other than physical” (Participant 2) and “I think it’s spot on. You’re talking about the circle…Spot on. Yeah it’s good. I mean it’s very truthful in those stages. That’s what I mean by spot on” (Participant 4).

Affirmation or self-efficacy

It was also recognized by the participants as being useful in motivating and believing in their ability to seek change.

I think these sessions helped me identify what my needs are. So again for me this was my first point of contact dealing with this type of situation, so in our conversations it made me gain that self-awareness of these needs that I do have and I have not addressed them, I didn’t realize they were needs so they opened up that door. (Participant 1)

Another participant stated that “[BNI-V] gave [her] more intelligence in making future decisions. [I] know what I am looking for, looking for red flags, and things like that” (Participant 2). Participant 5 stated,

It actually helped me in a lot of ways trying to figure out what it was I was accepting, what I was dealing with, and what I need to do as an end result and this helped me stay kinda strong and stay on guard and keep my guard up with staying focused and keeping my eye in the prize of where I want to be with my goals…(Participant 3)

Menu/advice

An important aspect of a MI-based intervention is providing a menu of resources and an understanding how each resource potentially would help. This was a key aspect of the BNI-V at the first session, and overall the participants responded favorably to understanding options for help, but maybe more importantly, there was acknowledgement there was no pressure to follow-up one way or another. One participant stated, “It was nice to know that there is resources out there and that are available to people in situations like myself or relationships like myself” (Participant 3).

I think keeping the community resources part and the encouragement…I had really no interest in that and then just listening to you kind of talk about where I should go type of conversation but not being like judging me if I didn’t go, that was very helpful. (Participant 1)

“Oh the information, yeah it was definitely helpful. Just to know like there are resources, you’re not alone” (Participant 5).

Summarizing

Summarizing is another aspect of MI-based interventions, which involves collecting, linking participants comments to help move the conversation forward was helpful during the BNI-V sessions.

Yeah a lot of the times I would say something and you would kinda repeat back to me and paraphrase things, and I was very impressed by the way you were able to sum up things like I had never had that experience before…you were able to spin it back to me and a lot of times you taking all of this thought and making it a confined thought, and I was like yeah, that’s where I was going with that. (Participant 1)

Positive self-perception

All participants reported positive improvements in how they described themselves after the three-session BNI-V. Prior to beginning, participants described themselves as an “emotional hot mess,” “hopeless,” “distraught,” and “weaker.” After receiving the three-session BNI-V, all participants described a positive self-perception. For example, one participant stated, “well I am standing on my own two feet…I guess I have a little bit more appreciation of myself” (Participant 1). Another participant stated, “I am more confident and I have things under control” (Participant 2) and another participant expressed “I’m slowly starting to get my spark back” (Participant 3).

Discussion

This mixed-methods study explored the acceptability, feasibility, and preliminary effectiveness of a brief motivational intervention delivered in an Ob/Gyn office. Overall, this small pilot of six participants yielded acceptability with favorable trends in the amount and type of engagement with IPV services and improvements in health and well-being. Prior to receiving BNI-V, two participants had previous contact with IPV services, but none of these services were current. Interestingly, the majority of these contacts were either to an IPV hotline or advocacy focused (psychoeducation on IPV or safety planning). After the BNI-V, four participants engaged with IPV services, and one participant with complex pain, significant childhood trauma in addition to IPV prioritized pain-focused therapy and engaged with a pain therapist. One participant who did not engage with any service after the intervention stated she had apprehension to seek any type of services, due to a negative experience with a mental health provider as a child. This participant expressed she learned a lot from the intervention itself and did not need to engage with other services.

What is also notable from the results is the amount and type of services engaged with at the post measure. Prior to the BNI-V, the IPV services utilized were largely nonspecific hotline phone calls and advocacy, but after the BNI-V intervention, participants engaged most often with IPV-specific therapy and one participant sought legal services. There are numerous types of IPV interventions, some are empowerment focused and provide psychoeducation on IPV or safety planning, typically called advocacy; others are legal interventions like protective orders, and there are individual or group therapies providing behavioral, cognitive, and other therapeutic treatment options. There is no “one-size” fits all approach for IPV services. The most beneficial intervention will depend on victim’s experience. What is unique about providing BNI-V after screening for IPV is that the intervention provides a summary of the relationship (what type of IPV and severity of danger) and the potential impact of IPV on victim’s health and well-being. This process generated change talk regarding IPV services each participant felt would be potentially useful. This allowed the opportunity to focus on resolving ambivalence and increasing efficacy (competence), facilitating autonomy by identifying needs, wants, and choices. These techniques have been proven effective in increasing behavior change, linkage, and retention in care across various health and mental health care domains (Carroll et al., 2001; Carroll et al., 2006; Lundahl et al., 2013; Rubak et al., 2005; Swogger et al., 2016; VanBuskirk & Wetherell, 2014). Recent studies of MI with diverse samples of women who experienced IPV noted improvement in self-efficacy or belief they could change when compared to referrals to community resources only (Hegarty et al., 2013; Saftlas et al., 2014; Wahab et al., 2014). Beyond changes in engagement with IPV services, participants indicated that BNI-V was acceptable and the foundational aspects of MI were viewed as helpful and supportive. The results of the qualitative and quantitative data taken together suggest providing feedback; a menu of options and summary were helpful to behavior change talk.

What is also notable are the preliminary improvements in self-efficacy, trauma symptoms, perceived quality of life, and experience with abuse/violence even. While this study design does not allow for conclusions of direct or indirect effects of BNI-V on these outcomes, it does provide a foundation for further research to explore these pathways. We hypothesize the changes in engagement to care (amount and type) are a result of the improved self-efficacy. The intervention was guided by SDT, a theory focused on competence, relatedness, and autonomy. The results suggest these factors were enhanced. Motivational intervention in the IPV field is relatively new, and this small pilot further supports the promise of brief MI interventions, enhancing engagement into care and improvements in health and well-being outcomes and warrants further investigation.

Limitations and Future Directions

The results of this pilot study are preliminary and should be interpreted in the context of the small sample size and lack of a comparison group. Further, the sample included only women who identified as primarily White. It is unclear whether this intervention would be acceptable to men and/or a more diverse sample of women. While BNI-V demonstrated preliminary effectiveness, future research that includes randomization with larger samples for enough power to accommodate statistical methods to test pathways to improved outcomes is needed. In addition, while the TLFB enables a nuanced assessment of incident details, future research should consider objective measuring of IPV services to augment self-report data. In summary, future research using a randomized trial design to evaluate uptake, integration, and outcomes seems feasible and clinically important to understand whether BNI-V is an adjunct to how social workers and/or medical providers approach victims seeking health care.

Implications

There is a vital need to address IPV within a health-care environment due to its fiscal, emotional, and physical impact on the health and well-being of victims (Bonomi et al., 2009; Bonomi et al., 2006). While numerous health organizations advocate and recommend IPV be addressed at medical appointments, guidelines often lack details. In fact, the National Association of Social Work Women and domestic violence: implications for social work intervention, practice update (Webb & DCSW, 2010) provide limited recommendations on how best to intervene. The health-care system is an important conduit to identify individuals who experience IPV, and its co-occurring issues and social workers are important in identifying and addressing IPV. If efforts to address IPV are not maximized, evidence-based/informed services will be underutilized and victims will not receive the support necessary to address IPV and improve their health and well-being. Systematic approach to addressing IPV within health care has been outlined and recommend client-centered IPV assessment that connects patients to support and services regardless and, if possible, integrating on-site IPV services (Miller et al., 2015). Expanding this recommendation to include a brief motivational intervention such as BNI-V is interesting to consider for maximizing engagement into care.

This study provides pilot data for a brief motivational intervention, BNI-V, to address an opportunity to enhance the health-care systems response for IPV victims. By improving victim engagement with IPV services, we can improve the well-being and health of victims and reduce debilitating ripple effects of trauma for families and societies. Social work practice within health-care setting can be modified to include BNI-V. It is important for social workers to consider their own practices within health-care environments, but also consider their role as leaders in health-care systems and how to influence system-level change to augment screening and referral approaches to care. In summary, the adaptions to BNI for use with victims of violence were relatively simple. The intervention is portable and shows potential for uptake into busy medical office workflows.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Mental Health T32 under Grant 2T32MH020061 and the Susan B. Anthony Center, University of Rochester.

ORCID iD

Nicole Trabold

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