THE CHICAGO WOMEN’S HEALTH RISK STUDY RISK OF SERIOUS INJURY OR DEATH IN INTIMATE VIOLENCE A COLLABORATIVE RESEARCH PROJECT New Report, Revised June 2, 2000 Collaborators Though most of the collaborators of the Chicago Women’s Health Risk Project were silent partners in writing this report, they were equal partners in the project They include Olga Becker, Nanette Benbow, Jacquelyn Campbell, Debra Clemmens, James Coldren, Alicia Contreras, Eugene Craig, Roy J Dames, Alice J Dan, Christine Devitt, Edmund R Donoghue, Barbara Engel, Dickelle Fonda, Charmaine Hamer, Kris Hamilton, Eva Hernandez, Tracy Irwin, Mary V Jensen, Holly Johnson, Teresa Johnson, Candice Kane, Debra Kirby, Katherine Klimisch, Christine Kosmos, Leslie Landis, Susan Lloyd, Gloria Lewis, Christine Martin, Rosa Martinez, Judith McFarlane, Sara Naureckas, Iliana Oliveros, Angela Moore Parmley, Stephanie Riger, Kim Riordan, Roxanne Roberts, Martine Sagan, Daniel Sheridan, Wendy Taylor, Richard Tolman, Gail Walker, Carole Warshaw and Steven Whitman Principal Author: Carolyn Rebecca Block, Illinois Criminal Justice Information Authority, 120 South Riverside Plaza, Chicago, Illinois 60606 Contributions by: Christine Ovcharchyn Devitt, Michelle Fugate, Christine Martin and Tracie Pasold, staff of the Chicago Women’s Health Risk Study, Illinois Criminal Justice Information Authority, 120 South Riverside Plaza, Chicago, Illinois 60606 Sara Naureckas, MD, at Erie Family Health Center, contributed to the sections on children, medical help-seeking and pregnancy Dickelle Fonda, Chicago Women’s Health Risk Study project counselor, wrote the section on interviewer debriefing and support Barbara Engel, Sara M Naureckas and Kim A Riordan contributed to the sections on collaboration, and Judith M McFarlane and Gail Rayford Walker contributed to the sections on proxy field strategies The CWHRS was supported by grant #96-IJ-CX-0020 awarded by the National Institute of Justice, Office of Justice Programs, U.S Department of Justice Points of view in this document not necessarily represent the official position or policies of the U.S Department of Justice Printed by the State of Illinois ACKNOWLEDGMENTS The collaborators of the Chicago Womens’ Health Risk Study include people who represent each participating site However, many other people at the sites made significant contributions to the project They include Bonnie Noe of the Chicago Department of Public Health; Lois Furlow and Peggy Martin of the Chicago Department of Public Health Roseland Clinic; Jan Alroy, Gloria Becerra, Rebecca Estrada, Caroline Makere and Proshat Shekarloo at the Hospital Crisis Intervention Program of Cook County Hospital; Sue Avila and Rob Smith of the Trauma Unit of Cook County Hospital; Louis Hirsch of the Chicago Abused Women’s Coalition; Denise Djohan, Hazel Pernell and Bernice Haines of Erie Family Health Center; and Felicia Grey at the Office of the Cook County Medical Examiner Without the generous cooperation of the many agencies that allowed us access to their facilities, the Chicago Womens’ Health Risk Study would not have been successfully completed We would like to acknowledge the following people in particular: at the Illinois Department of Corrections, Steve Karr, Planning and Research Unit, Warden Dan Bosse, and Assistant Warden Gwendolyn Thornton at Logan Correctional Center, and Warden Donna Klein-Acosta and Assistant Warden Janice Burns at Dwight Correctional Center; at the Office of the Cook County Circuit Court Clerk, Associate Clerk Gerard Sciaraffa; at the Illinois State Police Research Support Center Metropolitan Chicago, Captain William Davis; at the Chicago Public Library Harold Washington Main Branch Interlibrary Loan Department, Valerie Samuelson The design and implementation of the proxy study part of the project greatly benefitted from the advice, suggestions and encouragement of those researchers who had pioneered this methodology We would especially like to thank Joyce Banton, David C Clark, Arthur Kellermann, Judith McFarlane and Harold Rose A cornerstone of the Chicago Women’s Health Risk Study was the culturally sensitive Spanish translations of the questionnaires and other instruments, as well as the sensitive interviewing procedures, which were made possible by the Erie Neighborhood Advisory Board, a group of people who met with Eva Hernandez over several months to work on translation and advise us on methods The project owes a special debt to Nanette Benbow, Alicia Contreras, Eva Hernandez, Laura Safar and Luis Cavero, who generously spent long hours on the translations Finally, we would like to thank the many people at the Illinois Criminal Justice Information Authority who understood the importance of this project and went above and beyond to find ways to make it happen Some of the people who contributed significantly to the project’s success were Hank Anthony, Carrie Bluthardt, Robert Boehmer, Maureen DeMatoff, Tamlyn Hawthorne, Candice Kane, James Oas and Gerard Ramker ii DEDICATION This project is dedicated to the women and their families who allowed us into their lives and were willing to overcome fear and grief to share their stories with us iii iv TABLE OF CONTENTS ACKNOWLEDGMENTS DEDICATION iii THE PROBLEM I GOALS and OBJECTIVES Questions Explored Risk Factors History of Violence Stalking and Other Harassment Controlling Behavior Type of Union Estrangement; Leaving the Relationship Age and Age Disparity Children Physical and Mental Health Pregnancy Alcohol or Drug Abuse Suicide Attempts or Threats 11 Partner’s Suicide as a Risk Factor for Homicide11 Suicidal Feelings and the Risk of Homicide Victimization Firearm Availability 12 Strengths and Protective Factors 12 Social Support/ Helping Network 12 Income, Education, and Employment 13 Help-Seeking and Interventions 13 Health Care 13 Community Services 14 Alcohol Treatment or Counseling 14 Police Intervention 14 Court Intervention; Orders of Protection 15 STUDY DESIGN AND METHODOLOGY 15 Project Methodology: Overview 16 Major Tasks 18 Changes in Study Design 18 Inclusion of same-sex intimate partner relationships 18 Decision not to collect public record data (clinic/hospital sample) Change in respondent fees and their administration 20 Decision to double the comparison group 21 Decision to interview more than one proxy respondent22 Decision to interview women homicide offenders 22 Additional consultants and staff 23 v 11 18 Re-conception of the proxy study methods 24 Assuring Subjects' Safety, Privacy and Confidentiality 24 Safety 24 Follow-up Safety Issues 27 Closure 28 Proxy Study Safety Issues 29 Procedures to Preserve Confidentiality 30 Collaboration Methodology 31 CLINIC AND HOSPITAL STUDY METHODS 33 Clinic and Hospital Sample 33 Site Selection 34 Screening Instrument 36 Sample Screening Process 36 Screening Results 39 Was There an Interview Selection Bias by Age or Language? Woman’s Age 42 Woman’s Language 43 Screening Status Versus Interview Status 44 Did the CWHRS Meet its Sample Goals? 46 Questionnaire Design 51 Spanish Translation 52 Calendar History of Incidents and Events 52 Measures and Scales Built into the Questionnaire 54 Violent Incident Severity 54 Danger Assessment 58 Type of Union 59 Abusing Partner (Name, Name2, Name3) 61 Relationship and Co-Residence 61 Estrangement and Leaving the Situation 64 Length of Relationship 65 Racial/Ethnic Group 68 Physical Health 68 Pregnancy 69 Drug and Alcohol Use 69 Mental Health: PTSD 70 Mental Health: Depression and Suicidal Feelings 72 Partner’s Physical and Mental Health 73 Occupation and Income 73 Immigrant Status and Public Aid 73 Resources and Social Support Network 74 Stalking and Other Harassment 79 Controlling Behavior 79 Intervention and Help-Seeking 84 Initial Interview Methods 86 Clinic Interviewers 88 vi 42 Interviewer Selection 88 Interviewer Training 88 Interviewer Support 89 Follow-up Tracking Methods 89 Follow-up Retention 90 Length of the Follow-up Period 91 Was there Retention Bias in the Follow-up? 93 HOMICIDE STUDY METHODS 95 Homicide Sample 96 Data Collection and Field Strategies 96 Sources of Potential Proxy Information 97 Analysis of Official Data Sources to Provide Proxy Leads 97 Case File Information 99 Field Work Strategies 100 Setting Priorities Among Potential Proxy Respondents 100 Support of the Proxy Respondents 102 Organizing and Interviewing Skills 102 Proxy Respondent Interviewers 103 Hiring and Training 103 Interviewer Support 103 Payment Plan 104 Homicide Case Completion 104 Combining Rules for Cases with Information from Multiple Sources 106 Homicide Cases with no Interview Data 107 Characteristics of Proxy Respondents 109 Quality of Proxy Respondent Information 111 Missing and Incomplete Data in Proxy Respondent Information 111 Demographics 111 Children 112 Estrangement or Separation 112 Firearms 112 Woman’s Physical Health 112 Woman’s Substance Use 112 Woman’s Mental Health 112 Support Network 112 Power, Control and Stalking 113 Violence in the Past Year 113 Help-Seeking and Interventions 114 ANALYSIS METHODS 114 Data Management 115 Management of Name, Name2 and Name3 Information Management of Incident-Level Data 115 Individual versus Incident Level Data 116 Aggregating Incident-Level Data for Each Woman vii 115 117 Variable Follow-up Period 117 Prospective Account of Abuse and Events Incident Date 118 Statistical Analysis 118 118 CLINIC AND HOSPITAL FINDINGS 119 Sample Characteristics 120 Place of Birth and Language 121 Employment, Education and Income 123 Age and Racial/ Ethnic Group 124 Type of Union, Relationship, and Co-Habitation126 Same-sex Relationship 128 Age Disparity between the Woman and Name 129 Pregnancy and Children 130 Mental Health 134 Depression 134 PTSD 135 Firearms in the Home 136 Summary: Clinic/Hospital Sample Characteristics 137 Differences Between Women Who Interviewed AW Versus NAW 139 Age and Race/Ethnicity 139 Type of Union and Relationship 139 Same-sex Relationship 141 Co-residence, Estrangement, and Leaving the Relationship 141 Length of Relationship 143 Disparity between Woman’s Age and Name’s Age 144 Children 145 Controlling Behavior 145 Stalking and Other Harassment 146 Physical Health 149 Overall Health 149 Pregnancy 149 Drug or Alcohol Use 150 Mental Health 151 Depression 151 PTSD 153 Name’s Suicide Risk 153 Presence of a Firearm in the Home 153 Social Support Network and Other Resources 154 Social Support Network Scale 154 Employment, Education, and Income 154 Place of Birth and Language 157 Divorce 157 Having a Home 157 Summary: AW versus NAW Comparison157 Characteristics of Violence in the Past Year 160 viii 312 Appendix IV Interviewer Hiring Material Clinic/Hospital Interviewers: Job Description First Interview Schedule for Job Candidates Second Interview Schedule Proxy Interviewers: Job Description Interview Schedule for Job Candidates 313 314 Appendix V Interviewer Debriefing by Dickelle Fonda L.C.S.W The designers of the Domestic Homicide Study wisely built into its design a debriefing component The purpose of this component was to offer the research staff the opportunity to "debrief" or process the emotional impact and aftereffects that hearing women's stories could have on them personally The training segment included some of the anticipated emotional effects inherent in this type of interview, as well as an introduction to stress management techniques to address them Debriefing sessions were structured in a group format and planned weekly in the early stages, then biweekly, then resuming weekly meetings when the proxy interviews began The format for the debriefing sessions was generally a combination of experiential stress reduction and relaxation techniques and verbal processing of the emotional, psychological and sometimes somatic reactions the interviewers were experiencing During our initial training session the group identified a list of anticipated concerns, questions and areas of discussion that they wanted to address during debriefing sessions Those topics of discussion were as follows: · Understanding the range of emotional and somatic reactions · How to be with survivors and respond appropriately · How to help people open up , tell their stories and answer the questions on the document · How to get the information needed without further exacerbating the respondent's trauma · When to push and probe · When to let it go or lay back · What to if respondent "blows up", disintegrates, or disassociates · When to terminate the interview · Differences between phone and in-person interviews · How to listen to painful material, difficult stories and graphic details · How to protect yourself psychically, energetically and emotionally · How to empathize with respondents, yet maintain research objectivity · How not to carry the emotional pain of the respondent's stories within yourselves · How to address interviewer reluctance to initiate process due to anticipatory anxiety · How to put the respondent at ease · How to not personalize rejection and resistance on part of respondents · How to feel comfortable in unknown areas of the city and maximize personal safety · How to avoid being perceived as part of an oppressive judicial and social systems by respondents with negative experiences with same During the course of the study, all of those areas were addressed, some several times from different perspectives, depending upon what issues arose from experiences in the field It should also be noted that in order to find respondents, the interviewers frequently went into very dangerous and unfamiliar neighborhoods in Chicago in the 315 process of doing their field work They went in pairs whenever possible, but generally by themselves There was a high-risk element to this piece of their work, which was often processed in debriefing The debriefing sessions provided a forum and opportunity for the interviewers to both discuss and process shared experience from their field work and to bond as a group in ways very reminiscent of a clinical support group By the final months of the study, this group of women had forged bonds and relationships, which will last long beyond the end of this particular project The debriefing time became an important and prioritized piece of this study for the interviewers in this group, as it became a safe haven to unload the residual emotional aftereffects from listening to the painful stories of the respondents on an ongoing basis From a clinical perspective, this scheduled "unloading" was an effective preventive strategy It helped keep the researchers physically and emotionally healthy by preventing the buildup of unreleased chronic stresses, which could have resulted in varied post-stress symptomatology The original intent, to provide that safe, confidential space for the interviewers, met and exceeded the designer's objectives The CWHRS design also incorporated a provision for interviewers to meet individually with me in my role as a clinical social worker, in order to process confidentially whatever aspects of this work may have triggered past trauma or unresolved issues of grief and loss in their personal lives Interviewers took the opportunity to use these individualized sessions as needed and, particularly at the end of the study, to bring closure to this work and to its personal impact The positive residual benefits for each of the interviewers personally also exceeded anyone's imagination As the study came to a close, the last month of debriefings were spent bringing closure, for the group as well as for each interviewer individually One component of the closure process was to consider and share the impact of involvement in this project on each interviewer personally Interviewers appreciated the stress management tools that each took from that piece of our sessions, which each interviewer will be able to use on an ongoing basis, personally and professionally But, far beyond those practical benefits, were changes in the interviewers lives, such as career goals and plans, heightened awareness of the vulnerability of women in this country, adjustment in personal safety precautions for themselves and their children, and a sense of global connection to other women A summary of the debriefing component of this study would be incomplete without mention of the particular group of interviewers who carried out this study in the field This was a group of exceptional, strong, intelligent, creative, brave and tenacious women As the clinical facilitator of their debriefing process, I was continually in awe of their willingness to persevere under frequently trying and stressful circumstances and with their ability to connect with and engender trust among their respondents At the same time, they managed to maintain a healthy balance of empathy and objectivity They each brought their own personal qualities of excellent listening and interviewing skills and compassion to their interviews While it wasn't the intention of this research study to assist the respondents to change their lives in any way (the interviewers were not social workers or counselors, a point that was regularly supported in debriefing), the interviewers inadvertently did help many of the respondents This happened as a result of the interviewers’ ability to pro- 316 vide a caring, authentic presence in which respondents were allowed to give voice to their stories and to their inner pain in a safe, non-judgmental atmosphere No doubt, many women's lives have already changed in the process In summary, each interviewer found their debriefing experience to be meaningful and useful for them individually and also as a part of a bonded group The consensus of the interviewers was that the debriefing sessions were an invaluable and beneficial component of their experience on this project They provided the "glue" of continuity and support for this group of remarkable women interviewers It was my honor as a clinician and facilitator to have been associated with them and with this very important research project 317 318 Appendix VI Proxy Study Training and Field Work Record Forms Daily Activity Log Potential Proxy Decision Form Problem and Contacts Form 319 320 Appendix VII CWHRS Reports and Publications Collaboration paper ICJIA collaboration research brief Proxy field work strategies paper 321 322 Appendix VIII Miscellaneous 1995 Intimate Partner Homicides Map 1996 Intimate Partner Homicides Map Women’s Health Risk Project Contact Letter Women’s Health Risk Project Poster Selected Proxy and Clinic/Hospital Respondent Support Materials 323 324 Endnotes Source: Chicago Homicide Dataset, annualized 1990-1992 data; Block & Block, 1993 For 16 interviewed women, we not know how they screened, because the screener is missing In addition, one woman told us at follow-up that she had falsified the initial interview and the screener The question about whether the woman was in a current relationship was in the preinterview screener, not the abuse screener Women who screened NAW were not always asked for their consent to speak to an interviewer Only women who were asked for consent were asked to complete the pre-interview screener Therefore, for many women who screened NAW, we not know if they were in a current relationship These 14 women include only those for whom we have that information Screener figures for Cook County Hospital Obstetrics/Gynecology are an estimate, because the completed screeners for non-interviewed women were accidentally destroyed before they were collected for data entry Screener figures for Cook County Hospital Trauma Department are preliminary, based on Trauma Department logs In addition, the screener is missing for 16 interviewed women, and one interviewed woman signed the screener but refused to answer any of the screening questions We cannot reliably differentiate between women who denied consent and women who were not asked for their consent, especially for women screened as NAW For almost all cases where the woman screened as AW and did not sign the consent, the person administering the screener noted that the woman did not want to be interviewed, or in a few cases, that the woman was not asked to sign For many cases where the woman screened as NAW, however, she was not asked to sign the consent form We were not trying to interview 100% of women who screened as NAW For these women, an unsigned consent form does not necessarily indicate that the woman would not have consented to an interview In addition, one of the 705 women who refused to answer questions about her household This woman was probably homeless, based on things she told us in other parts of the interview She refused consent for a follow-up Source: Demographic Characteristics of Chicago’s Population: Community Area Profiles Chicago Department of Planning and Development, March, 1994 The City of Chicago, in pending litigation, is challenging these figures In addition, several women identified a person who had harmed her, but was not an intimate partner, for example, a father or a brother In these cases, we added this information about violence against her to the calendar history, but we did not consider these instances to be “abuse by an intimate partner.” One woman responded to the questions by saying that “Only God” was there for her For the Acceptance and Support subscale, we counted these answers as a no 10 However, for nine of the 104, a second follow-up interview was actually conducted 11 Five additional third follow-ups were conducted even though they were not necessary (We already had a year of data.) 12 Sadly, there were some intimate partner homicides of women under age 18 These were not included in the study, because they would not have been comparable to the clinic/hospital sample 13 The Chicago Homicide Dataset project began in 1968 with the collection of 1965 data and 325 continues today with the advice and close cooperation of the Crime Analysis Unit of the Chicago Police Department The Authority has supported and maintained the data since 1979 The Joyce Foundation currently supports collecting 1991-1994 data and archiving prior years The National Archive of Criminal Justice Data, ICPSR, has 1965-90 data on its violence CD-ROM See Block and Block (1993) for details and bibliography 14 Source: conversation with Harold Rose, 12-7-94 15 Communication with Joyce Banton, who was in charge of fielding the Kellermann team study, and who kindly lent her advise and suggestions to the CWHRS 16 In addition to the ten cases of suicide at the scene, CWHRS investigation found that three men offenders committed suicide much later In one case, proxy respondents told us that they had heard that the offender, who had not been charged because of a bar to prosecution, had committed suicide many months later in another state We not know if his suicide was in any way related to the homicide One man was found guilty, and hanged himself in jail A third man had never been linked to the homicide until he committed suicide seven months later, left a note citing his despondency over another woman who had left him, and the police investigation then determined that he had been the offender in the earlier homicide 17 In one of the cases cleared exceptionally, the man offender fled the country, and in the other case, the offender was already dead when the police linked him to the homicide 18 These figures are based on the woman’s principal occupation If she had a job and was also a student, she is included under “full or part time job” for this analysis 19 In the “hot coffee” incident, the man first beat her up and kicked her, then threw a pot of hot coffee on her as she lay on the floor 20 Remember that there were very few white or other women in the sample This finding is based on the 20 who were aged 18 to 30 21 The CWHRS questionnaire allowed women to give multiple answers to this question Some women mentioned both domestic violence and other types of counseling 22 Eight women made both types of response In these percents, these eight are included with the women who said that their injuries were not serious enough for medical care 23 In some choking incidents, the woman had a weapon threatened or used against her, in addition to being choked or grabbed around the neck 24 Note that the Hamilton data not include men who killed their ex-girlfriend 25 About half of these women had answered the help-seeking questions themselves 326 ... women at greatest risk, the Chicago Women’s Health Risk Study (CWHRS) explored factors indicating significant danger of death or life-threatening injury in intimate violence situations A collaboration... examine risk factors that would place a physically abused woman or her partner in immediate danger of death or life-threatening injury Immediate was defined as within a year Serious injury was... 114 Data Management 115 Management of Name, Name2 and Name3 Information Management of Incident-Level Data 115 Individual versus Incident Level Data 116 Aggregating Incident-Level Data for Each