Vital Views

October is Domestic Violence Awareness Month. An expert in the field, Dr. Jacquelyn Campbell (Johns Hopkins School of Nursing) explains the different kinds of domestic violence that are not so obvious; how loved ones and health providers can talk to possible victims about seeking help; and how she came up with the Danger Assessment Tool used across the country to identify risks.

National Domestic Violence Hotline:
Crisis Support Services of Nevada:

Creators & Guests

Joseph Gaccione
Host, Writer, Producer
Jacquelyn Campbell
Professor, Johns Hopkins University School of Nursing

What is Vital Views?

Vital Views is a weekly podcast created by UNLV School of Nursing to discuss health care from a Rebel Nursing perspective. We share stories and expert information on both nursing-specific and broader healthcare topics to bring attention to the health trends and issues that affect us. New episodes every Tuesday.

Feedback? Questions? Episode Ideas? Email

Joe Gaccione 0:02
Welcome to Vital Views from UNLV School of Nursing. I'm Joe Gaccione, communications director for the School of Nursing. October is Domestic Violence Awareness Month. Domestic violence unfortunately has far too many faces and cases, both reported and unreported. There's a complexity to the act itself that has manifested not just physically, but mentally, emotionally, legally, and it can be difficult to understand even on a surface level. Joining us today to help break down domestic violence, from Johns Hopkins University School of Nursing, is Dr. Jacquelyn Campbell. She is known for her research on intimate partner violence or IPV, and health outcomes, including homicide, the danger assessment, which helps abused women more accurately assess their risk of homicide, and studies of IPV, contributing to health inequities for marginalized women. Her more than 300 articles and seven books and being PI of or co-PI of 10 major national research grants have provided major contributions to nursing and interdisciplinary science and policy in the US and globally. Dr. Campbell, thanks for coming by.

Jacquelyn Campbell 1:05
I'm delighted to be here.

Joe Gaccione 1:07
Now, we mentioned before IPV, what is the difference between IPV and DV, or domestic violence?

Jacquelyn Campbell 1:14
Well, it's interesting. The public thinks of IPV as domestic violence. But the problem is intimate partner violence, the more precise definition, does not involve other family members. So, intimate partner violence is violence toward or experienced by an intimate partner, someone you have dated someone, you are living with, someone you have sex with, someone you're romantically involved with, or married to. But domestic violence, although the general public says, “Well, what you just described is domestic violence, is it not?” unfortunately, in many of the technical definitions, like the police oftentimes would say, “If it's a domestic violence event, it could be any family member hitting, hurting another family member.” Domestic violence is therefore a broader term, legally a broader term in many policy initiatives. So, that's why as researchers we call it intimate partner violence, but when we're talking to the public, we oftentimes refer to domestic violence.

Joe Gaccione 2:25
So, although there's overlap, they're not exactly interchangeable.

Jacquelyn Campbell 2:28

Joe Gaccione 2:29
There are common types of abuse when it comes to domestic violence or IPV. We know the physical, we know mental, we know emotional, but when it comes to domestic violence, what are lesser known, but equally significant types? I've heard of digital, I've heard of legal and financial, can you describe some of those?

Jacquelyn Campbell 2:44
Some of those, and one of the ones that's incredibly important is physically forced sex as being a form of domestic violence. And that's one that for we would call it rape if it was between strangers, but because it's between intimate partners, we talk about it in terms of forced sex. So again, terminology sometimes gets complicated, the same thing with like, digital violence, so in this age of incredible technology, there's a lot of things that are done, get done. Stalking surveillance with digital means is a form of domestic violence, if one partner does it to the other, that is hard to measure, hard to recognize, when you're the person themselves. Like, for instance, if your partner, if you, when you first got together, you gave each other permission to get in each other's healthcare records, for instance, which makes sense that you would want your loved one to be able to see if there's a diagnosis of something. But then if the relationship becomes fraught, if there begins to be behaviors that are not healthy in the relationship, then if I, if I'm a woman, goes to my health care provider and wants to say, “Yes, I'm worried about this relationship, there's been some things that have happened that are scary,” then oops, if that health care provider puts it in the medical record, then my partner can see that I've disclosed to the health care person. And most of us, you know, I don't go into my partner's healthcare record, I will only have access in order to be able to tell if if something, you know, problematic happens, he's unconscious or something, I can at least get into the healthcare record from that point of view, but those kinds of things in terms of what gets said, one of the things that's characteristic of domestic violence is a partner being overly surveillant of like, the medical records. And so that's a form, and you wouldn't ordinarily say, “Well, that's domestic violence, when somebody gets electronically into your records, into your, where you've been on the internet, into looking at what websites you have looked at,” but abusive partners, that's often part of that pattern of abuse, is it goes along with the digital realm. There are ways that like, you can monitor doorbell camera. That seems like, okay, that's not a bad thing for you both to be able to monitor that doorbell camera. But if, for instance, a woman leaves her partner, because he's become abusive, he still has access to that doorbell camera, so he can see who comes and goes, including when she leaves. So you know, those kinds of things are just a realm of domestic violence, who haven't really thought about. Sexting is another one. When intimate portraits, pictures have been taken of each other, when you're in love, and it seems like a really good thing, and you promise never to ever share them with anybody and then all of a sudden, when you break up, then there's a picture on the internet, wildly accessible, that becomes a form of harassment and stalking.

Joe Gaccione 6:28
And we're talking about the public perception, there is that almost stereotypical idea of domestic violence being just physical being a man versus a woman, but there, it's so nuanced. It's almost like, to me, when you're talking about sexual assault awareness, it's not just the act, it's also that power, that feeling of control towards a partner.

Jacquelyn Campbell 6:48
Yes. And that is so often the case, is that the one person, that abuser, has power over and does all of these controlling actions. They may not be motivated by that, and that's one of the things that people that are experiencing violence from a partner, they're not sure what to label it, “Is this domestic violence, what's going on here?” And oftentimes, that being controlled, being afraid of what a partner might do is very much part of the picture, but it's not necessarily what the other person is intending. It's not necessarily their motivation, I mean, oftentimes, abusers, couples that are fighting a lot, you know, they talk about losing their temper, and oftentimes in the official domestic violence lingo, we say, “Oh, no, no, no. No such a thing. That's just an excuse.” But, the more we know about brain science, the more we know that that kind of action, especially in people who have been highly traumatized, who witnessed domestic violence as a child, who were abused themselves, have been through numerous traumatic experiences in their childhood, that there, there is, you can see it on brain scans, there is this place where somebody gets, and we call it triggered, where the, the emotional outburst, the angry outburst, is not mediated through the prefrontal cortex. So, where most of us when we get mad at somebody we decide it's not a good idea to hit them. They're either our boss or whatever. But if you've been highly traumatized as a child, and as an adolescent, that prefrontal cortex does not work. It's not doing that judgment thing, whether or not it's a good idea to hit that person. So, the sum of what we thought we knew about domestic violence, like there's no such thing as losing, losing your temper, you decide to abuse somebody, you're just trying to control them, isn't always what goes behind it. And I think the more I studied domestic violence, intimate partner violence, the health outcomes, the more I conclude that people are incredibly complicated, and there's not just one picture of what domestic violence is.

Joe Gaccione 9:25
And that leads right into my next question, you may have already answered it, when we talk about all these different types, are there general red flags that you can identify if you think or suspect someone that you know might be a victim?

Jacquelyn Campbell 9:36
Definitely, if, and, and hopefully, you're a good friend of this person, and can get them to disclose about just how are things going with, you know, the name of their partner. And we have to remember that abuse can happen from a man to a woman, it can also happen between two women that are in a relationship, it can also happen between two men that are in a relationship, and anywhere where people identify themselves, domestic violence can happen. So, you know, one of the things, as friends, is to check in on how things are going with your, your friend’s partner, and just listen to them and if you hear things that they are concerned about the, the partner, or if your friend says, “We're fighting a lot,” you know, okay, so how does that look, you know? So, you just listen carefully, but don't expect, at least at the beginning, for your friend to say, you know, “My partner has become abusive, they're definitely trying to control me,” or, or whatever we think domestic violence looks like, but much more, you know, there's, “We're not getting along, we're fighting,” those are the kinds of ways that people describe it to their friends, when they're trying to sort out, “Is this fighting? Is this kind of stuff that's happening, is this a sign that this relationship is not going to work?” You know, people, we, we, in academics, we talk about healthy relationships and unhealthy relationships, but ordinary people are like, “Okay, is this not going to work, is this something that's not good for me?” And, and that's the kind of thing you need to listen for. And what happens so often is that a couple that is having problems will go ahead and have children, and then when there's a child involved, then it becomes much more complicated.

Joe Gaccione 11:42
I've heard horror stories about custody battles, where one will use the child like the rights to have the child over the other, to say the very least, it's brutal.

Jacquelyn Campbell 11:51
Yes, absolutely. And that's one of the things that we find that our family courts are not very well equipped to deal with this. And they, they understand, you know, that if, if a couple, if there's any kind of domestic violence, it shouldn't be mediation, or it should be a very controlled kind of mediation process, but divorce, separation, custody decisions, are incredibly expensive. And that's where the legal system comes into play, and that's where you can see these forms of, we could call it legal abuse, or abuse through the courts, does happen. And oftentimes, especially when one partner has left the other one, it becomes very retaliatory if there's been prior domestic violence, and you can even see domestic violence start as part of those custody proceedings. So, family courts are paying a whole lot better attention to it now, but they don't have really good processes in place when both parents are saying, “No, it was him. No, it was her,” who has been abusive, and therefore should have limited access to the children.

Joe Gaccione 13:05
If you're a nurse or other healthcare professional, and you don't have that, that relationship, then you have to be even more perceptive if you have a patient and you suspect that something's wrong, correct?

Jacquelyn Campbell 13:15
Absolutely. One of the things we found in our study of domestic violence homicide was that 47% of the women who had been murdered had been in the healthcare system in the year before they were killed. And they were in prenatal care, or primary care, or mental health care, various parts of the mental health, of the healthcare system. And so, one of the things we realized, only 4% of those women who ended up being murdered had ever been in touch with domestic violence service organizations, the people that help women do, or any abuse victim, do safety planning, which is so incredible for staying safe, but only 4% of them had ever been in touch with that sector that can be the most helpful, and only about 27% had ever called the police or gotten the police involved with a protective order. So, the health care system was where we saw more women. So, that's led to that study and other important studies have led to the notion that nurses and physicians should do routine screening for domestic violence. Now, some people say, “No, it should be indicator based. It should be only when there's some red flag about this patient that makes you think they might be abused,” but the trouble is, we don't know that. There's nothing about a patient that comes to us that we would necessarily think was being abused. So, that's what's led to the notion of doing it routinely, asking every patient that comes in front of us, are they experiencing violence from a partner or anyone at home? Or the question that's oftentimes used is, “Are you safe at home?” but the problem with that is people oftentimes think we're thinking about smoke alarms, for instance, you know, that kind of safety versus safety from a loved one. So, the asking has to be skilled, and that's one thing that we have a lot of tools now and a lot of processes to help, but training nurses and physicians in their basic training is incredibly important in terms of how to ask and then what to do if somebody says, “Yes.”

Joe Gaccione 15:30
And talking about tools and training, let's talk about the danger assessment tool used by domestic violence advocates, health care professionals, even criminal justice professionals to measure the risks for abused women. Did you originate this tool?

Jacquelyn Campbell 15:41
I did. And I did it way back when, when I was a master's student, finishing up my master's thesis. I did a study of homicide of women and that's when I found out that when women are murdered, they're most often murdered by a husband, boyfriend, or ex, and there's most frequently domestic violence before they're killed. So, I was like, “Oh, my goodness, I have to, I need to get in this space, I need to help women see if they're abused, A, and then if they are, how dangerous that relationship is, how much risk there is that they could get murdered. And you know, fortunately, in terms of numbers, there's three to five million abused women every year in this country and only, although we'd like to prevent every single one, about 1200 women get killed. So, it's very rare that there's an actual homicide. But when a woman, and I did the study on women, it needs to be done on men who are abused to see if the risk factors for homicide are the same, but I'm like, “Women need to be able to see this for themselves, not be told, ‘Oh, you're at risk to be killed, so you ought to leave, or whatever you got to do,’ that women need to see the amount of danger there is for themselves, and then be able to factor that information into whatever decisions they're making about the relationship and where to go from there.” And so, I developed the danger assessment, originally, after my master's study, when I was doing my PhD, and then gradually used it more widely with women in all kinds of settings, in support groups and for domestic violence shelters, in various healthcare settings, and then we actually tested it in a big national study to see not only were these the right risk factors, but also how much they should be weighted? Like, should you count, you know, factor A, like forced sex, should that be counted as strongly if he's ever threatened you with a gun? Which one should be, you know, they're both red flags, but which one should we count the most, which is incredibly important. The other thing that, that I'm proud of with the danger assessment, it's using the words of actual victims of domestic violence, rather than, you know, we don't ask, “Does your husband ever rape you?” because women don't think of the sexual assault that sometimes happens in a marriage, an abusive marriage as rape, they just don't put those words on it. They don't put the words “sexual assault” on it. So instead, we ask women, “Have you ever been forced into sex that you did not wish to participate in by your husband?” So, and, and it was abused women that helped me see what kind of words to use.

Joe Gaccione 18:48
When we talk about using assessments to determine the risk and we talk about red flags, one of the easiest, easier said than done comments you'll ever hear is, “Why can't so and so just leave that person? Why do they stick around?” domestic violence shelters have probably asked multiple times, “Is this the time that you need to step away from this? Why do you go back to this?” Why is it so hard for people to escape?

Jacquelyn Campbell 19:13
Well, first of all, when they first enter into this relationship, they have no clue that this person is abusive. They haven't been taught what to, you know, what kinds of things you might want to look for, listen for, but they also, you know, they assume this is going to be a wonderful, they fall in love, “This is going to be a wonderful relationship. This is somebody I want to spend the rest of my life with. This is somebody I want to have children with.” And as I alluded to before, it's the children that's the complicating thing. And then oftentimes, if one of the partners realizes that the other one is becoming abusive, you have a lot more freedom to just step away or you, you may want to try and do some other things to take care of the issues et cetera and if they don't work, then you may say, “Okay, this is not working, we're calling it off.” But the more you're entwined, both in terms of your heart is entwined, where you live is entwined with this person, and so importantly, if you have children with this person, you really want them to change, to be different, to not abuse you. And there's, and it's not like this abusive person is evil, ugly, abusive, every day, all the time. It's occasional, although repeated acts of all the different kinds of violence we've, we've talked about, but it's not like this person has suddenly become an evil person, “That I don't care about, that I'm not attracted to,” it's that this behavior has become more and more problematic. And so, you know, and I've interviewed about 3000 abused women that I have track of, and so, I know that that's what they say: “I just want him to change.” And like I said, it's not always a him/her, but that's the most frequent, at least that I have interviewed. “I just want him to change, I want him to be different, he wants to be different.” And that is 90% of the time absolutely true. He doesn't want to act this way. He doesn't want these things to happen. And unfortunately, in our system, we don't have good programs to help people change abusive behavior. We do have some offender intervention programs that they're based through the criminal justice system, you have to be court mandated to go, they're very much on a model of, “This is a bad person, and they need to learn to do better,” kind of thing. So, it's all prefrontal cortex, and remember what I said about the prefrontal cortex not working very well if you've been highly traumatized? So, what we need to think more about is, “How do we have interventions for people who use violence against partners, that they can start early before the police are involved, that they can, that aren't punitive, that are actually are helpful, and that deal with healing that brain, that psyche of that person who's using violence?” Generally, and I know there's, you know, there’s psychopaths, and a few people that are totally evil and do want to be violent and use violence, but the vast majority of abusers, that, you know, if there's three to five million abused women every year, that means there's three to five million abusers every year, that aren't all psychopaths. There needs to be better ways that they can learn to do different.

Joe Gaccione 22:51
When this episode drops, we're going to have links in the episode for local resources, but are there any national resources that you recommend personally for victims or potential victims?

Jacquelyn Campbell 23:02
The National Domestic Violence Hotline is awesome, and there's both chat functions as well as phone functions. There is also a teen dating violence hotline that's equally awesome with trained people who can help on a variety of strategies. They also can connect the person back up to local resources. And the, there's also an app, it's called the My Plan app, Nancy Glass developed it, it's free in every app store, you have to be careful because it's small “m y” and then capital “P l a n,” it's also available on our website, but it helps people work through, you know, whether or not their relationship is abusive, and then if it is, that the danger assessment is embedded in there. And it's also, it's very astutely programmed so that you, the more information you get it, the more you have a plan, a safety plan that's contextualized to your realities, your situation, and then also puts you back in touch with your local domestic violence resources. So that's, you know, a real possibility that's exciting. The one other thing I wanted to mention is that Nevada has one of the highest rates of homicide of women and has over the past since 2001, when they've been keeping track. This year, it's no longer in the top 10, but it has been every other year, and this year, it's number 18 in the country, so that's just one thing that our listeners here need to know.

Joe Gaccione 24:51
Would that step be attributed to domestic violence, or would that just be in general?

Jacquelyn Campbell 24:55
Right, it's in general homicide of women, but more than half of those murders are domestic violence partners.

Joe Gaccione 25:05
Dr. Campbell, thank you so much for taking the time to talk to us today. Obviously, one month is not nearly enough to solve issues like this, but at least it puts a bigger spotlight on them. Thank you for listening, everyone. Hope you have a great day.

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