4
Prevention and Intervention

This chapter examines the types of responses society has made to violence against women. There are a number of ways to define and characterize prevention and intervention. This report uses one that best identifies the kinds of responses society can take and the research that can inform those responses. First, however, it notes several other classifications.

The public health perspective classifies ''interventions" into primary, secondary, and tertiary prevention. The goal of primary prevention is to decrease the number of new cases of a disorder or illness. The goal of secondary prevention is to lower the prevalence of a disorder or illness in the population. The goal of tertiary prevention is to decrease the amount of disability associated with the disorder or illness. Although these three categories seem conceptually distinct, in practice there is disagreement over their use (Institute of Medicine, 1994). Another classification is Gordon's (1983, 1987) proposal for universal, selected, and indicated preventive measures. Universal preventive measures are desirable for everyone in a population; selected preventive measures are desirable for those in the population with an above average



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--> 4 Prevention and Intervention This chapter examines the types of responses society has made to violence against women. There are a number of ways to define and characterize prevention and intervention. This report uses one that best identifies the kinds of responses society can take and the research that can inform those responses. First, however, it notes several other classifications. The public health perspective classifies ''interventions" into primary, secondary, and tertiary prevention. The goal of primary prevention is to decrease the number of new cases of a disorder or illness. The goal of secondary prevention is to lower the prevalence of a disorder or illness in the population. The goal of tertiary prevention is to decrease the amount of disability associated with the disorder or illness. Although these three categories seem conceptually distinct, in practice there is disagreement over their use (Institute of Medicine, 1994). Another classification is Gordon's (1983, 1987) proposal for universal, selected, and indicated preventive measures. Universal preventive measures are desirable for everyone in a population; selected preventive measures are desirable for those in the population with an above average

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--> risk of acquiring a disorder; and indicated preventive measures are desirable for individuals who are identified as being at high risk for the development of a disorder. Because of frequent confusion over the meaning of the public health classifications, the Institute of Medicine (1994) recommended the use of a combination of it and Gordon's: preventive interventions, broken into three categories modeled after Gordon's; treatment intervention, which includes identification and standard treatments; and maintenance intervention, which aims at reducing relapse and recurrence and promoting rehabilitation. This report adopts the Institute of Medicine's (1994) use of preventive interventions, but considers treatment and maintenance interventions together under the rubric of treatment interventions. Treatment interventions are separated into individual and community-level interventions: individual treatment interventions are those, such as counseling, that are targeted at the individual; community-level interventions represent more system-oriented interventions, such as criminal justice reforms, rape crisis centers, and battered women shelters. Following this classification, the chapter first discusses preventive interventions. Second, it considers treatment interventions, both the services available to women victims of violence and those, including criminal justice interventions, for offenders. Preventive Interventions School-Based Preventive Programs Preventive intervention efforts have largely consisted of school-based programs on conflict mediation, violence prevention in general, dating violence, sexual abuse, and spouse abuse. There are few data available on how widespread these programs are or to whom they are offered. Sexual assault and rape education programs seem to be increasingly common on college campuses; conflict resolution programs have been in-

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--> stituted in thousands of middle and high schools (Webster, 1993). The programs vary in length, in content, and in degree of theoretical underpinning. Evaluations are rare. The few evaluations that have been done of these programs generally test students' knowledge about and attitudes on relationship violence before and after the prevention program, as well as personal experience with dating violence (Jones, 1991; Jaffe et al., 1992; Kantor and Jasinski, 1995). In Minnesota, the Minnesota Coalition for Battered Women developed a secondary school violence prevention program and trained secondary school teachers in the use of the curriculum. The approximately 200 teachers who were willing to participate in the evaluation were stratified by junior or senior high, and by rural, suburban, or urban location. Teachers were randomly selected from each of the six subgroups, and their students became the sample for the evaluation. Control groups from the same or nearby schools were also tested. Both groups were given preprogram and post-program tests to assess their knowledge about battering, their attitudes, and their knowledge about the resources available for help in addressing relationship violence. Students who were given the 5-day prevention program improved their knowledge scores significantly more than the control group. However, attitudes among both experimental and control groups showed very little change. There was a posttest significant difference between girls' and boys' scores, with the girls' scoring more in the desired direction. The experimental groups also became more knowledgeable about general resources available for help with relationship violence, such as a hospital or mental health center, although they could not name specific local services (Jones, 1991). Other studies have found attitudinal changes following school-based intervention programs. Students in four secondary schools in London, Ontario, were involved in a dating violence prevention program (Jaffe et al., 1992). The program involved a large group presentation followed by classroom discussion led by trained facilitators. Questionnaires were

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--> administered to 737 students—selected by means of stratified classroom-level sampling—both 1 week prior to the intervention and 1 week after; at two of the schools, a delayed posttest was also given 6 weeks after the program. Overall, the evaluation showed significant positive changes after intervention on knowledge, attitudes, and behavioral intention. A small group of males, however, showed change in an undesired direction. Significant decreases in attitudes justifying the use of dating violence were found in a study of a prevention program in a Long Island, New York, high school (Avery-Leaf et al., 1995). The intervention consisted of five weekly sessions incorporated into a health class. The experimental group of 196 students were tested before and after the five-class program, and there was a control group of students whose health classes did not include the dating violence prevention program. While all of these programs may change knowledge or attitudes about physical and sexual violence between intimates, no longitudinal studies exist to document whether they have any short- or long-term impact on the commission of dating violence, date rape, or intimate partner violence later in life. A review of evaluations of a broad array of prevention programs aimed at adolescents—including pregnancy prevention, drug abuse prevention, delinquency prevention—found that curricula that only provide information about risks and use scare tactics have little or no positive impact and may even result in more of the undesired behavior (Dryfoos, 1991; National Research Council, 1993). Intensive programs that include social-skill training and follow-up booster sessions may hold more promise, particularly if classroom efforts are part of a more comprehensive, community-wide strategy (Dryfoos, 1991; Webster, 1993). Media Roles Public education campaigns, such as those mounted against smoking and drunk driving, are a universal preventive

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--> intervention that have been part of other successful community prevention projects (Institute of Medicine, 1994). The Advertising Council, in conjunction with the Family Violence Prevention Fund, in June 1994 began a public education campaign against intimate partner violence. The campaign consists of television, radio, and print public service announcements "designed to increase public awareness of battering and to motivate individuals to take action to reduce and prevent abuse" (Family Violence Prevention Fund, 1995). The advertising campaign is being evaluated. A preadvertising survey that measured attitudes toward battering was conducted; there will be several postadvertising surveys that will look at advertisement recognition and changes in attitudes about battering, willingness to intervene in battering, and knowledge of community resources (Lieberman Research Inc., 1995). Separate from public service announcements and other advertising, television programming has the potential to convey antiviolence messages. The recent National Television Violence Study (Mediascope, 1996) suggests that television could be used to send more prosocial messages about violence by showing the negative consequences of violent behavior and nonviolent alternatives to solving problems and by emphasizing antiviolent themes. There has been no research on the effects of such television programming. Deterrence To the extent that the threat of criminal justice sanctions deters people from engaging in violent behavior, they can be thought of as preventive interventions. The theory of deterrence is well established in the field of criminal justice (for reviews, see Zimring and Hawkins, 1971; Geerken and Gove, 1975; Gibbs, 1975; Cook, 1977; Blumstein et al., 1978; Tittle, 1980; Paternoster, 1987; Klepper and Nagin, 1989). The theory suggests that increasing the certainty of sanctions increases their deterrent effect (Reiss and Roth, 1993). From this per-

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--> spective, mandatory arrest for intimate partner violence, increasing rates of prosecution for rape and intimate partner violence, and stricter enforcement of protection orders could be considered preventive interventions. (For a more complete discussion of these types of interventions, see the section on Criminal Justice Interventions, below.) Other Issues in Rape Prevention The literature on rape prevention includes strategies for rape avoidance and rape resistance, which are considered by some—particularly in the criminal justice field—to be prevention through reduction of opportunity. Rape avoidance entails strategies to be used by women to minimize their risk of sexual assault. These strategies include avoiding dangerous situations, not going out alone at night, keeping doors and windows closed and locked, and other precautions to be taken by women. Although these avoidance techniques may reduce a woman's risk of being sexually assaulted by a stranger, it is not clear they would reduce acquaintance attacks (Koss and Harvey, 1991). These strategies are also criticized as restricting women's activities and as potentially placing the blame on women who are sexually assaulted for not taking adequate precautions (Brodyaga et al., 1975, as cited in Koss and Harvey, 1991). The extent to which a woman chooses to use any particular avoidance strategy may depend on the importance she attaches to the perceived costs and benefits of the strategy (Furby et al., 1991). An emphasis on rape avoidance may actually increase the fear of rape (Koss and Harvey, 1991). Furthermore, avoidance strategies may do little to lower the overall rate of sexual assault; they may simply displace the assault from one potential victim to another. Rape resistance strategies involve recommendations to women on what to do should they be attacked. Storaska (1975) popularized among law enforcement agencies the theory that women should remain passive in the face of an

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--> attack to avoid angering the attacker and increasing her risk of serious injury or death. The majority of the research on resistance strategies, however, suggests just the opposite. Women who actively resist attack are more likely to thwart rape completion without increasing their risk of serious injury (Javorek, 1979; Bart, 1981; Quinsey and Upfold, 1985; Levine-MacCombie and Koss, 1986; Siegel et al., 1989; Ullman and Knight, 1991, 1992). The success of resistance strategies also appears to be linked to situational factors, such as the proximity of others to the attack site, and offender traits (Koss and Harvey, 1991). This report does not consider rape avoidance or rape resistance to be preventive interventions, the goal of which should be reduction in rates of perpetration. Some researchers also consider rape prevention to mean minimizing the psychological impact of sexual assault; this report considers that topic under interventions for victims, not as prevention. Interventions For Victims There is no universal system of services available to victims of battering or sexual assault; they vary from community to community. Interventions may occur in the criminal justice system, the health care system, the social service system, the mental health system, or some combination of systems. As noted above, the discussion of interventions is divided into those whose main focus is on the individual and those whose focus is institutional or community based; individual-level interventions seek to ameliorate the consequences of individual victimization; community-level interventions seek to change systems' responses to victims. Individual-Level Interventions Individual counseling and peer support groups are probably the services most used by battered women. A survey of 250 victims of battering in New York City who called 911 for

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--> help found that 43 percent of the callers wanted counseling services and 42 percent said they wanted someone to talk to about their feelings (Taylor, 1995). However, few data exist on how many battered women actually seek counseling services: of those seeking counseling services in the New York City study, Taylor (1995) found approximately two-thirds actually received them. Although specific therapy elements have been recommended for use with battered women (e.g., Walker, 1994), the panel found no evaluation studies of individual counseling or support groups for battered women. Counseling services are also available for couples in which the woman has been battered or otherwise victimized, but there remains much debate in the field over the merits and advisability of couples counseling (Dobash and Dobash, 1992; Edleson and Tolman, 1992; Gondolf, 1993). Many practitioners and researchers argue that couples counseling is never appropriate when violence is present because it endangers women. Other counseling providers argue that couples counseling that is specifically designed to address the use of aggression may be beneficial for couples in discordant or mildly violent relationships (Pan et al., 1994; O'Leary et al., 1995). Because couples counseling is generally viewed as an intervention for the perpetrator, evaluations of it are addressed below in the section on interventions for batterers. Mental health interventions with rape victims have received more study than those with battered women. Treatment approaches designed to address the postrape psychological consequences have been developed, and in some instances evaluations were undertaken to assess their effectiveness. However, in a review of the rape treatment outcome studies, Foa et al. (1993) concluded that few studies used an approach that would permit drawing conclusions about effectiveness. In most cases, there was no control group so it was not possible to determine whether improvements were a function of the passage of time or the intervention. The early studies that randomly assigned victims to different conditions produced mixed results. Veronen and Kilpatrick (1982) devel-

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--> oped a brief, focused intervention implemented immediately postrape and designed to be prophylactic; they found that active treatment was no more therapeutic than assessment only. In contrast, a comparison of different six-session therapy approaches found that all three types of intervention produced improvement while victims on a naturally occurring waiting list did not improve (Resick et al., 1988). Two more recently reported studies examined the effectiveness of specific treatments for victims suffering from posttraumatic stress disorder (PTSD). Foa and colleagues (1991) compared stress inoculation training—a combination of cognitive-behavioral and relaxation techniques to teach clients to control their fear, prolonged exposure—reliving the rape scene in the imagination in order to confront fear, and supportive counseling. They found that all treatments produced improvements at posttreatment, but at a 3-month follow-up, exposure appeared to be the most effective for PTSD symptoms. A cognitive processing approach designed to address maladaptive beliefs, as well as rape-related fears, reduced symptoms compared to a waiting-list control group (Resick and Schnicke, 1992). These studies support the conclusion that treatment for rape victims can be helpful and that specific types of treatment may be more effective for certain symptoms. Community-Level Interventions Crisis-Oriented Services: Shelters, Rape Crisis Centers, and Advocacy A recent survey (Plichta, 1995) found 1,800 programs, of which approximately 1,200 were shelters, targeted at battered women in the United States. The programs offer a variety of services including hotlines, temporary shelter services, group and individual counseling, legal advocacy, social service referral and advocacy, services for children of abused women, transitional housing, child care, and job training. Public edu-

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--> cation and changing social norms with respect to battering are also an integral part of "the shelter movement." In addition to shelters, individual social workers, psychologists, and clinics that offer therapy and counseling services undoubtedly provide services to some victims of battering. Little data exist on how many clients are served by the various programs or who those clients are. It does appear that the services are inadequate to meet the needs of all victims of battering who seek them. For example, in New York City in March 1995, about 300 women and children a week were denied emergency shelter due to lack of space (O'Sullivan et al., 1995). There is some information on the women who do use shelter services. They tend to be from low socioeconomic groups, possibly because they have fewer resources available to them than women from higher socioeconomic groups. For example, in one study (O'Sullivan et al., 1995) 76 percent of the sample were on public assistance; another 1 percent had no income whatsoever. In another large sample of women using services in Texas (1,482 battered women in shelters and 650 battered women using nonresident shelter-based programs), Gondolf and Fisher (1988) found that a substantial portion lived in poverty. Over one-half of their sample had no personal income, and three-fourths of the women's husbands made less than $15,000 per year. The women who sought only nonresident services tended to be from higher socioeconomic groups than those who sought resident shelter services. In a sample from a shelter in a medium-sized Midwestern city, 81 percent of the women were receiving some type of government assistance, and 60 percent lived below the poverty line (Sullivan et al., 1994). It is often suggested that women with more economic resources may be able to pay for temporary shelter, for example at a hotel, and that they obtain other services through private means, such as individual counseling. Shelter service seekers also have low educational attainment. In the Texas sample, about one-half of the women had

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--> not completed high school, and only about one-fifth had some post-high-school education (Gondolf and Fisher, 1988). Similarly, 45 percent of the New York sample had not finished high school, 31 percent had a high school diploma, and 23 percent had attended some college. The racial characteristics of shelter users seem to depend on the location of the shelter. In Texas, 57 percent of the women were white, 15 percent were African American, and 29 percent were Hispanic. In New York City, 52 percent of shelter users were African American, 39 percent were Latina, and 9 percent were white or other (O'Sullivan et al., 1995). In the Midwestern sample, 45 percent of the participants were white, 43 percent African American, 8 percent Latina, and 1 percent Asian American (Sullivan et al., 1994). In preliminary data on shelters in the deep South, Donnelly and Cook (1995) found residents to be primarily white: only 2 of the 16 shelters they had surveyed (to date) targeted women of color. In recruiting a sample of abused women for a study in Newark, New Jersey, Joseph (1995) found more African American abused women in shelters for the homeless than in shelters for victims of battering. Since such characteristics as socioeconomic status, race, ethnicity, and educational level of all the women in a region who may need shelter services are not known, it cannot be determined if the shelter populations are representative of the battered women in an area. Race and ethnic origin may be important factors in assessing the needs of women who use shelter services and in understanding barriers that may exist to obtaining services. For example, in comparison with white and African American women, Hispanic women in Texas shelters had been married the longest, had lower education, employment, and job status, and tended to report the longest duration of abuse, thereby experiencing more socioeconomic barriers to ending victimization (Gondolf and Fisher, 1988). There are few descriptions in the literature of programs that are successfully serving minority communities (Norton and Manson, 1997). There has been little evaluation of the services offered to

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--> tionships. The focus of the program is as much on changing men's view of their entitlement to control their partners, through whatever means, as it is on stopping the actual physical battering (see, e.g., Pence and Paymar, 1993). A number of researchers have studied batterers' groups to see how effective they are in stopping physical violence (e.g., Purdy and Nickle, 1981; Edleson et al., 1985; Dutton, 1986; Hamberger and Hastings, 1986; Rosenbaum, 1986; Waldo, 1986; DeMaris and Jackson, 1987; Edleson and Grusznski, 1989; Tolman and Bhosley, 1989; Edleson and Syers, 1990; Palmer et al., 1992; Saunders, 1994). The findings are somewhat positive, but they must be cautiously interpreted due to many methodological shortcomings. Most of the studies did not use control groups, making it impossible to ascribe outcomes to the treatment; sample sizes were frequently small; and attrition in both the programs and the study follow-up periods was high. It is also difficult to compare results across studies because outcomes were measured differently: some studies relied on official records, for example, looking at rearrest rates; others relied on information reported by the batterers; still others gathered information from the partners of the batterers. The length of the posttreatment follow-up period varied from a few months to several years. Because of these many methodological shortcomings and differences, some analysts have concluded that there is little that one can conclude about the effectiveness of these treatment programs (Hamberger and Hastings, 1993). Others are more optimistic, noting that there are consistent findings that a large proportion of men stop their physically abusive behavior after involvement in a program (Tolman and Edleson, 1995). Studies that relied on partners' reports of physical abuse have found between 53 percent and 85 percent success rates in follow-up periods ranging from 4 to 26 months (Edleson and Tolman, 1992). There is little information about interventions for batterers who are racial or ethnic minorities. In a recent survey of 142 batterers' programs, the majority did not provide ser-

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--> vices that targeted minority clients. For example, only 25 percent of the programs provided education and training in minority communities. Even fewer programs incorporated specific program elements designed to encourage minority participation (Williams and Becker, 1994). Anecdotal evidence from programs designed specifically for African American men suggest that they are more successful with that population than other batterers' programs (O.J. Williams, 1992, 1994, 1995). The development and dissemination of culturally relevant programs and policies would benefit from program descriptions and outcome evaluations. Couples Therapy The use of couples therapy when there is abuse in a relationship is highly controversial. Many practitioners think that the dynamics of the battering relationship do not lend themselves to joint therapy, especially in court-referred cases (e.g., Dobash and Dobash, 1992; Kaufman, 1992). Most important is the potential of putting the woman in greater danger as a result of the therapy. Those who advocate profeminist approaches to batterers' treatment think that couples therapy, particularly if it focuses on the couple as a system, may allow the batterer to continue to deny responsibility for his violence (Breines and Gordon, 1983; Bograd, 1984). Little research has been done on the effectiveness of couples therapy in ending violent behavior. Several studies of couples counseling found a reduction or cessation of violence in a sizable proportion of the sample following couples counseling (Taylor, 1984; Neidig et al., 1985; Deschner et al., 1986). However, the samples were small (only 15 couples in one study), the follow-up time was short, and the studies did not specify how violent behavior after treatment was assessed. The last point is particularly important because it has been consistently found that men who batter often report their use of violence to be less frequent and less severe than is reported by their female partners (Szinovacz, 1983; Jouriles and

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--> O'Leary, 1985; Edleson and Brygger, 1986; Bohannon et al., 1995). A recent study comparing couples and single-sex group therapies with couples who had experienced physical aggression—none of it severe—and who wanted to stay together found significant decreases in physical aggression from both therapies a year after therapy ended (O'Leary et al., 1995). Similarly, Harris and colleagues (1988) found no difference in the level of violence or participants' level of psychological well-being between couples who participated in individual couples counseling and those in a group program that consisted of single-sex group sessions followed by couples group sessions. However, participants were four times more likely to drop out of individual couples counseling than the group program. Although there is some evidence that couples therapy may be effective in reducing violence, philosophical disagreements about its use are bound to continue. There is, however, agreement among most practitioners that couples therapy is not appropriate for court-mandated cases or for severely violent men (who are likely to be more violent) (Gondolf, 1995). Sex Offenders The question of treatment effectiveness for rapists is the subject of significant controversy. Reviews of treatment outcome studies arrive at different conclusions. An influential paper by Furby et al. (1989) concluded that the methodological problems with most available studies precluded drawing any definitive conclusions. They note that most studies did not carefully describe the treatments, included a mixed group of offenders, and, most importantly, did not have a comparison group of untreated offenders. A recent review had a more optimistic assessment of the available studies, but concluded that even effective programs "do far better with child molesters and exhibitionists than with rapists" (Marshall et al., 1991:481). The debate about whether the currently available body of

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--> treatment outcome literature is informative on the question of treatment effectiveness revolves around the scientific merit of the studies. It is argued that without formal controlled clinical trials with untreated comparison groups, recidivism rates cannot be attributed to the intervention (Quinsey et al., 1993). But there are moral and ethical constraints—as well as community objections—to withholding treatment from known sex offenders that argue against trying to achieve this standard of scientific rigor. Marshall (1993) contends that it is possible to accumulate knowledge about treatment effectiveness by identifying appropriate comparison groups among those who refuse treatment or for some reason do not receive the specified treatment. He believes that any reduction in recidivism is worthwhile because of the enormous cost of even a single repeat offense to the victim and society. There is one study that used a random assignment design with control groups that provides specific data on rapists (Marques et al., 1994). The treatment consisted of a comprehensive cognitive behavioral program that used a "relapse prevention" framework, in which offenders are taught to identify situations and emotional states in which they are likely to reoffend and the skills to avoid those situations and deal with the emotional states. Preliminary results for the 59 rapists (as opposed to child molesters) in the study revealed reoffense rates within 5 years of prison release (as measured by rearrest) for sex offenses of 9 percent for the treatment group, 28 percent for the offenders who volunteered but were not assigned to the treatment condition, and 11 percent for the nonvolunteer control group. The rates for other violent offenses were 23 percent for the treatment group, 33 percent for the volunteer controls, and 22 percent for the nonvolunteer controls. It is unfortunate that the total treatment sample includes so few rapists, and therefore, the power necessary for statistical analyses is reduced. It is worth noting that the overall reoffense rates are relatively modest considering current beliefs about the risk for recidivism among rapists. There was one striking finding: of the rapists who had to be re-

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--> moved from the treatment group for seriously disruptive behavior, 100 percent committed a new sex offense. It is possible that offenders with a particularly high risk of reoffending can be identified as those who are too disruptive to participate in treatment programs. Many questions remain about what treatment for rapists should entail and whether it is a worthwhile endeavor, as opposed to simply imposing long periods of incarceration. Efforts might be useful to identify those who are at highest risk for reoffending and imposing especially long sentences on them. An actuarial method for prediction of future sexual dangerousness has been developed (Quinsey et al., 1995): variables such as prior convictions, deviant sexual interests, and psychopathy have been shown to be associated with increased risk. However, there are major philosophical questions involved in sentencing on the basis of future predicted behavior. Conclusions And Recommendations There are few good evaluations of preventive or treatment interventions for either victims or perpetrators of violence against women. Existing evaluations are difficult to compare because different outcomes have been measured in different ways and at different times. One serious problem with studies of interventions is selecting and operationally defining outcomes to measure. For example, is the goal of a batterers' treatment program to reduce or completely stop batterers' violent behavior? Should prevention programs measure reduction in victimization rates or reduction in perpetration rates? Should services for battered women consider improvement in self-esteem, separation from the batterer, or physical safety as the outcome? Should treatment of rapists measure sexual arousal or behavior outside the laboratory as an outcome? At what intervals following the completion of the program should measurements be made? Are there unintended negative outcomes from prevention or treatment in-

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--> terventions? Close collaboration between researchers and practitioners is necessary to carefully specify the basic assumptions underlying the intervention and to determine what outcomes constitute success. Recommendation: Evaluations of preventive and treatment intervention efforts must clearly define the outcomes expected from the intervention. These outcome measures should derive from an explicit theory underlying each intervention. Defining outcomes requires close collaboration between researchers and service providers. Preventive Interventions School-based programs to prevent date rape and intimate partner violence, as well as programs on conflict resolution and general violence prevention, have become popular in recent years. However, these programs have seldom been evaluated, and the evaluations that have been done usually look only at short-term attitudinal change. Their longer term impact on behavior, arguably what these programs are trying to effect, remains unknown. In light of studies that have detected negative outcomes with some program participants, a better understanding of long-term outcomes and differential effects of preventive efforts is needed. Early childhood predictors have been identified for violence in adolescence and adulthood as well as for other undesirable behavior (e.g. substance abuse, teenage pregnancy). Some of the predictors that have been identified include impaired relationships with parents, witnessing violence, experiencing physical abuse and neglect, absence of prosocial role models, and early learning and behavior problems. It is possible that sexual and intimate partner violence have common precursors with other forms of violent and dysfunctional or undesirable behavior. Except for the few prevention programs targeted at preventing dating violence, most youth violence prevention programs have ignored the prevention of intimate

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--> partner and sexual violence. Inclusion of the consideration of violence against women in these studies would greatly increase understanding of possible links between various types of violent behavior and might lead to better designed prevention programs. Recommendation: Programs designed to prevent sexual and intimate partner violence should be subject to rigorous evaluation of both short- and long-term effects. Programs designed to prevent delinquency, substance abuse, teenage pregnancy, gang involvement, or general violence (including conflict mediation programs) should include evaluation of risk factors for and prevention of intimate and sexual violence. In addition, studies of at-risk children and adolescents should include an examination of the relationship of risk factors, such as poverty, childhood victimization, and brain injury, to outcomes of sexual and intimate partner violence. Interventions with Victims Services for victims of rape and domestic violence are available in many communities. Anecdotal evidence and the few evaluation studies that have been done seem to indicate that the services are helpful to the women who use them. Yet many women do not use those services. Research is needed to determine whether those women are unaware of the services; if the services offered fail to meet their needs; if they seek help from systems, either formal or informal, other than those specifically designed for victims of violence against women; if they do not want or need services; or if other factors play a part in their underutilitzation or nonutilization of services. Special attention should be paid to whether there are systematic differences in the types of services sought by different subpopulations of women, and, if so, the implications of those differences for providing services. A better understanding of both the effectiveness of current services

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--> and the service needs that remain unmet could lead to better program designs. Furthermore, studying women who do not seek services may yield information on factors that affect resiliency and obviate the need for services. An understanding of the social, economic, and institutional barriers that may prevent women from seeking services is important to designing these alternatives. For example, services might be made available in primary health care, community clinics, or educational facilities. In spite of the proliferation of training and screening protocols, particularly for professionals in medical settings, violent victimization is frequently overlooked. The effectiveness of training programs needs to be assessed to determine the training models that best equip professionals to identify and assist victims. Recommendation: Studies that describe current services for victims of violence and evaluate their effectiveness are needed. Studies to investigate the factors associated with victims' service-seeking behavior, including delaying seeking of services or not seeking services at all, are also needed. These studies should describe and evaluate innovative or alternative approaches or settings for identifying and providing services to victims of violence against women. Interventions with Offenders Interventions with sex offenders and batterers consist of a criminal justice response or specialized social service treatment programs for certain offenders, or both. Information is needed to determine the relative effectiveness of various interventions and to develop a means of matching offenders to interventions. Special attention should be paid to cultural and ethnic differences that may have a bearing on the effectiveness of interventions. Studies should not overlook possible informal surveillance and control mechanisms that may work independently or in conjunction with more formal con-

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--> trols to deter offenders from repeating their violent behavior. Efforts are also needed to find effective interventions for the large subset of offenders for whom current approaches are ineffective. The panel considers court-mandated programs for batterers to be ripe for randomized, controlled outcome studies. Such programs are gaining in number around the country. Criminal justice personnel, judges, and victims all seem to find mandated batterers' programs an attractive option. As these mandated programs proliferate, it is important to understand what features—including other community resources and concomitant sanctions, as well as program philosophy, structure, and length—make them effective, and for whom. Recommendation: Randomized, controlled outcome studies are needed to identify the program and community features that account for the effectiveness of legal or social service interventions with various groups of offenders. Criminal Justice System The crimes of rape and battery by intimate partners have historically been handled and perceived differently than other person-to-person crimes. Legal reforms have been proposed and implemented to treat sexual assault and intimate partner violence similarly to other crimes, but little is known about how these reforms have affected actual practices or what differences, if any, they have made for victims. For example, many changes have been made in rape laws and rape trial procedures, but little is known about the impact of those changes on investigation, prosecutorial decision making, or jury behavior. Similarly, the use of expert witnesses on the results of trauma (e.g., rape trauma syndrome, posttraumatic stress syndrome, and battered woman's syndrome) is becoming more widespread, but few studies have been done on the

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--> effects of such testimony on trial outcome. More broadly, there is little information on the way in which reforms interact with people and practices within the systems. The process by which reforms are implemented, or not implemented, may well be as important as the reforms themselves. Recommendation: Studies are needed that examine discretionary processes in the criminal and civil justice systems, including implementation of new laws and reforms, charging and prosecutorial decision making, jury decision making, and judicial decision making. Legal research, which supplies the theoretical basis behind legal interpretations and reforms, is also needed. Notes 1.   The advocates used in this study were trained undergraduates; some researchers and practitioners speculate that the impact of advocacy may have been greater if professional advocates had been used. 2.   A research grant from the National Institute of Mental Health supported the 1975 National Survey on Family Violence (Straus et al., 1980). The Law Enforcement Assistance Administration (LEAA) funded local criminal justice initiatives on behalf of victims during the 1970s. LEAA established a Family Violence Program to fund demonstration and evaluation programs in 1978 (see Fagan et al., 1984). The interests, knowledge, and concerns of victim advocates, researchers, and policy makers were heard in a 1978 consultation sponsored by the U.S. Commission on Civil Rights and later that year in hearings on battering before a subcommittee of the U.S. Senate Committee on Human Resources. See Schechter (1982) for a critical discussion of these developments. 3.   Mandatory arrest means that an officer must arrest if he or she finds probable cause that a crime was committed; a presumptive arrest policy allows the officer discretion, calling for arrest unless the officer believes that circumstances dictate some alternative.

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