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Healthy Relationships and Intimate Partner Violence
DHA is committed to providing all beneficiaries safe, effective, trauma-informed prevention and care for both intimate partner violence and other types of violence, to include non-intimate partner sexual assault.
DHA continues to address prevention and health care response to IPV and other types of violence in an integrated manner, and in partnership with other federal agencies. In addition to following VA/DOD clinical practice guidelines for screening and assessment in the primary and specialty care settings, DHA has made significant efforts to standardize treatment for patients who disclose trauma from violence. DHA implemented the DHA Forensic Healthcare Program to develop policy and guidance for providers and staff to ensure high quality trauma-informed response is provided when patients disclose trauma. DHA continues to develop trainings and monitor health care activities related to integrated violence prevention and intervention in the health care setting, and to make to improvements to address the health care needs of our beneficiaries. This includes continuing to provide additional relevant resources through our website, as well as beneficiary and provider education materials.
Definitions
- Integrated Primary Prevention: Refers to prevention activities that simultaneously address multiple self-directed harm and prohibited abusive or harmful acts or the inclusion of prevention activities across self-directed harm and prohibited abusive or harmful acts into a cohesive, comprehensive approach that promotes unity of effort, avoids unnecessary duplication, and lessens training fatigue. Selected areas of focus include prevention of suicide, sexual assault or harassment, workplace violence, substance misuse, domestic abuse, and child abuse.
(IAW DODI 6400.09 DOD Policy on Integrated Primary Prevention of Self-Directed Harm and Prohibited Abuse or Harm)
- Domestic Abuse: Domestic violence, or a pattern of behavior resulting in emotional or psychological abuse, economic control, or interference with personal liberty that is directed toward a person who is a:
- Current or former spouse.
- Person with whom the alleged abuser shares a child in common.
- Current or former intimate partner with whom the alleged abuser shares or has shared a common domicile.
- Person who is or has been in a social relationship of a romantic or intimate nature with the accused and determined to be an intimate partner (as defined in this issuance: IAW DODI 6400.06, December 15, 2021, Change 2, May 16, 2023).
- Intimate Partner Violence: Violence between intimate partners.
- Intimate Partner: Within the context of eligibility for DOD Family Advocacy Prevention services, a person who is or has been in a social relationship of a romantic or intimate nature with the alleged abuser, as determined by the length of the relationship, the type of relationship, and the frequency of interaction between the person and the alleged abuser. An intimate partner is informed by, but not limited to, the totality of factors such as:
- Previous or ongoing consensual intimate or sexual behaviors.
- History of ongoing dating or expressed interest in continued dating or the potential for an ongoing relationship (e.g., history of repeated break-ups and reconciliations).
- Self-identification by the victim or alleged abuser as intimate partners or identification by others as a couple.
- Emotional connectedness (e.g., relationship is a priority, partners may have discussed a future together).
- Familiarity and knowledge of each other’s lives.
(IAW DODI 6400.06, December 15, 2021, Change 2, May 16, 2023)
- Sexual Assault: Intentional sexual contact characterized by the use of force, threats, intimidation, or abuse of authority or when the victim does not or cannot consent. The term includes a broad category of sexual offenses consisting of the following specific Uniform Code of Military Justice offenses: rape, sexual assault, aggravated sexual contact, abusive sexual contact, forcible sodomy (forced oral or anal sex), or attempts to commit these offenses.
(DODI 6310.09, “Health Care Management for Patients Associated with a Sexual Assault,” May 7, 2019)
- Sexual Harassment: Refers to unwelcome sexual advances, request for sexual favors, and deliberate or repeated unwelcome verbal comments or gestures of a sexual nature by any member of the Armed Forces or civilian employee of the Department of Defense. Sexual harassment can occur through electronic communications, including social media, other forms of communication and in person.
(IAW DODI 1020.03, February 8, 2018, Change 2, December 20, 2022)
- Stalking: Includes but is not limited to a person who: wrongfully engages in conduct directed at a specific person that would cause a reasonable person to fear death or bodily harm (including sexual assault) to him/herself, to a member of his or her immediate family or to his or her intimate partner or when the conduct induces reasonable fear of death or bodily harm to the specific person, to himself or herself, member of their immediate family or to their intimate partner.
(IAW DODI 1020.03, February 8, 2018, Change 2, December 20, 2022)
- Workplace Violence: Any act of violent behavior, threats of physical violence, harassment, intimidation, bullying, verbal or non-verbal threat, or other threatening, disruptive behavior that occurs at or outside the work site.
(DODI 1438.06, “DOD Workplace Violence Prevention and Response Policy,” January 16, 2014)
Trauma-Informed Care
Protocols for Routine Assessment
Protocols for Addressing IPV in Click to closeDirect CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”Direct Care
Primary Care Screening
- Direct care guidance follows the Joint Commission requirements for organizations to screen for IPV and requires documentation of screening be completed within the electronic health record.
- Screening for IPV is also recommended as a standard part of women’s health screenings as recommended by the VA/DOD Clinical Practice Guideline: Pregnancy.
- There is a standard tool in the MHS GENESIS medical record for providers to document screening for intimate partner violence.
Specialty Health Care Services
- Behavioral Health services include trauma-informed treatment approach as a foundation to service delivery.
- Forensic Healthcare Program services provides policy and guidance for health care providers and staff who support patients who disclose trauma of any kind. FHP also provides forensic examinations and documentation of strangulation and other violence which may be related to intimate partner violence.
As best practices continue to evolve, DHA will update guidance.
Protocols for Addressing IPV in Click to closeprivate sector careNetwork and non-network TRICARE-authorized civilian health care professionals, pharmacies, and suppliers.Private Sector Care
- Screening for IPV is a standard part of good clinical practice and covered under TRICARE preventive services at no additional cost to the beneficiary.
- Private sector providers are expected to provide care consistent with CPGs such as those established by the U.S. Preventive Services Task Force and Bright Futures, which set current recommendations and standards for screening in the U.S.
- TRICARE also covers forensic examinations following sexual assault or domestic violence, as well as all medically and psychologically necessary and appropriate trauma-informed care.
- DHA provides guidance to the Managed Care Support Contractors through the TRICARE manuals, to include use of assessment tools, such as the PTSD Checklist (PCL) for assessment and treatment of trauma due to IPV or sexual assault. ·
Promotion of Trauma-Informed Care Plans
DHA is currently developing a mandatory training, Sexual Trauma: Trauma-Informed Treatment Training for Behavioral Health Providers, which includes a chapter providing guidance on implementation of trauma-informed care.
Strategies for Trauma-Informed Care Plans
The Department of Defense mandates screening of all patients for symptoms of trauma at both annual physical appointments and behavioral health intakes using the PTSD Checklist – Military Version (PCL-M). The PCL-M is a validated self-administered scale which can be quickly completed and is sensitive for the symptoms of trauma. Annually screening with this tool is mandatory for all active duty members of the Department of Defense.
- However, if symptoms of trauma are detected, the DOD recommends monitoring those symptoms with the Clinician-Administered PTSD Scale for DSM-5 (CAPS). As opposed to the PCL-M, the CAPS is clinician administered and is more accurate in determining the severity of trauma symptoms and response to treatment. The DOD discourages the use of the PCL-M for this purpose as it has not been found to be sensitive to changes in clinical condition.
- The DOD does not recommend empirical treatment following a traumatic event beyond referral for support. A review of treatment administered following traumatic events found insufficient evidence that either psychotherapy or medications were effective in prophylaxis of the development of traumatic stress symptoms.
- In the presence of traumatic stress symptoms of less than the one month duration required to diagnose PTSD, the VA/DOD 2023 guidelines recommend offering treatment with cognitive processing therapy. Cognitive processing therapy is the only modality with data supporting its effectiveness, when administered in this time frame, in preventing the development of PTSD. Other therapeutic modalities, including medications are not recommended due to a lack of evidence supporting their efficacy.
- In the presence of PTSD symptoms of greater than 1 month duration, the DOD recommends psychotherapy with Prolonged Exposure Therapy, Eye Movement Desensitization and Reprocessing therapy or CPT as the specific therapies having the greatest efficacy. If these modalities are unavailable or unsuitable to the traumatized service member, the VA/DOD guidelines make recommendations for Ehler’s Cognitive Therapy, Present Centered Therapy, Written Exposure Therapy and specific medications (Sertraline, Venlafaxine XL and Paroxetine).
- The DOD recommends mindfulness based practice as the alternative/complementary therapy with the best evidence should the service member decline conventional therapy or in addition to psychotherapy or medication.
Additional Resources
Relevant Health Care Policies and Guidance
- DODI 6310.09 Health Care Management for Patients Associated with a Sexual Assault (Published May 7, 2019)
Establishes protocol for the assessment of sexual assault, a type of IPV, promoting trauma-informed care strategies for such assessments.
- DHA-Procedural Instruction 6310.01 Healthcare Management of Patients with Interpersonal Violence and the Department of Defense Forensic Healthcare Program (Published August 10, 2023)
Establishes protocols for a patient-centered, trauma-informed healthcare response when: a patient discloses or a healthcare provider suspects interpersonal violence such as sexual assault, domestic violence, IPV, child abuse and neglect, or other acts of unwanted violence (excluding combat injuries).
- DHA-Administrative Instruction 6025.09 Walk-in Contraception Services at Military Medical Treatment Facilities (Change 2, Published November 16, 2023)
Establishes protocols following the identification of IPV including medical services, forensic healthcare services, and notification to the Family Advocacy Program and Sexual Assault Prevention and Response coordinator.
- DHA-AI 6490.01 Behavioral Health System of Care (Published February 22, 2023)
Establishes protocol for DHA’s standardized behavioral healthcare delivery system within MTFs, including evidence-based behavioral health treatment for trauma following IPV and sexual assault.
- DHA Policy Memo 23-005 Sexual Assault Prevention and Response (Published May 31, 2023)
Establishes the DHA requirement for all employees (clinical and administrative staff) to complete an annual training on sexual assault prevention and response.
Additional Resources for Providers
Education
- DHA Direct Care provider training is available on the DHA Joint Knowledge Online platform: Interpersonal Violence Response for Healthcare Personnel (all health care personnel are required to take this training)
Resources for Patients
TRICARE Resources
Department of Defense Safe Helpline
Launched in 2011, the DOD Safe Helpline is the Department’s sole secure, confidential, and anonymous crisis support service specially designed for members of the DOD community affected by sexual assault. Safe Helpline is available 24/7, worldwide. The Safe Helpline staff provides live, one-on-one support to survivors, their families, and other DOD stakeholders. RAINN (Rape, Abuse & Incest National Network), a national anti-sexual violence organization, operates the Safe Helpline, through a contract with the DOD Sexual Assault Prevention and Response Office.
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Last Updated: April 19, 2024