Gold Award: Integrated Psychiatric Treatment for Survivors of Intimate Partner Violence at the Bronx Family Justice Center

The decision to integrate psychiatric treatment at the Bronx FJC represented a shift in thinking about the most effective way to treat the psychological and mental effects of intimate partner violence. Some staff worried that blending the FJC’s traditional role by providing psychiatric treatment would stigmatize clients who were referred for services and could affect child custody issues.

But the difficulties in securing treatment for clients had become a real stumbling block to helping clients. According to data from the Family Justice Center Alliance, over 80% of respondents identified a high degree of untreated psychiatric symptoms and poor access to care among FJC clients. In 2015, a survey of 195 staff at New York’s five FJCs revealed widespread frustration with the lack of resources to help deal with the emotional and psychological aftermath of domestic abuse. The survey also identified numerous barriers to accessing care, such as geographic distance, lack of language fluency, lack of insurance, undocumented status, stigma, and a lack of training among mental health providers regarding intimate partner violence.

The survey also confirmed that there was a dearth of psychiatric and psychological treatment resources for FJC clients. Over 40% of counselors and case managers reported not knowing where to refer their clients for mental health services. When they did make a referral, waiting lists for services were long, or it was not possible for their clients to get to treatment.

What’s more, there was a general feeling among staff that poor access to psychiatric treatment was undermining clients’ efforts to improve their own safety and achieve personal goals. Although FJCs provide counseling as an essential service, they do not provide the type of specialty psychiatric care necessary to cope with the sometimes devastating consequences of trauma.

The problem was particularly acute in the Bronx, which in 2014 ranked last among all 62 counties in New York State in clinical care and socioeconomic factors. One out of every four family-related homicides occurred in the Bronx, although the borough was home to only 17% of the city's population. More than half of individuals presenting for services at the Bronx FJC were foreign born, a group that is particularly likely to have unmet need for treatment of intimate partner violence–related trauma.

Anna Chapman, M.D., a faculty member at Columbia’s Center for Psychoanalytic Training and Research, had become increasingly dismayed by the lack of psychiatric treatment for survivors of intimate partner violence and believed it was time for a new model. “For too long,” she said, “intimate partner violence has been approached as a social issue, and not from a mental health perspective.” Yet survivors of domestic abuse require the services of psychiatrists and psychologists, she said, who are expertly trained to interpret and help manage the complex psychodynamics surrounding domestic violence.

Fortunately, as president of the Chapman Perelman Foundation, Dr. Chapman was in a unique position to make a difference. Working with Dr. Lieberman, she entered into discussions with the city to provide funding for on-site, high-quality psychiatric and psychological services at the Bronx FJC.

Integrating psychiatric care at an FJC made sense, even though few, if any, models existed for colocation of psychiatric and psychological services in an advocacy setting. The New York City FJCs are a program of the OCDV and are funded by a combination of federal and local funds, as well as the Mayor’s Fund to Advance New York City, a not-for-profit organization established to promote partnerships between the city and the private sector. The centers provide criminal justice, civil legal, and a wide range of advocacy services, all in one location. Free colocated services already included civil legal assistance on immigration and family court matters, meetings with prosecutors, access to shelter, help in applying for housing and financial assistance, assistance with filing police reports, safety planning and risk assessment, counseling for survivors and their children, and language interpretation. A wide range of self-sufficiency services are also available at the FJCs, including English classes for speakers of other languages and financial literacy and computer skills classes.

Providing psychiatric treatment in the Bronx FJC allows clients to obtain psychiatric treatment in a caring, supportive environment where they already felt comfortable, according to former executive director Margarita Guzman, J.D. Children ages 3 and up can play in a safe and supervised children’s room while their parents receive services. Intimate partner violence survivors also receive assistance with transportation. No appointments are necessary, and all are welcome regardless of age, gender, sexual orientation, language, income, and immigration status. Spoken translation services are available and the Web site is translatable into more than 100 languages, befitting the high number of clients who are recent immigrants.

This collaborative effort makes the entire process less intimidating to survivors and their children and more efficient and effective for everyone involved, said Mayumi Okuda, M.D., who has served as the Chapman Perelman fellow since the beginning of the program. Rosemonde Pierre-Louis, former commissioner of the OCDV, agreed. “The DVI has gone a long way toward correcting a major gap in services,” she said. “It provides the psychological support needed by many of our clients and helps them take the next step in healing.” “The program is a prime example of what can be accomplished when public and private institutions work together,” added New York City First Lady Chirlane McCray, who serves as chair of the Mayor’s Fund to Advance NYC.

Staff concerns about the appropriateness of integrating psychiatric services quickly faded once the program hired Dr. Okuda, a native of Colombia who received her medical degree from the Pontificia Universidad Javeriana in Bogota, for the pilot program. Dr. Okuda completed her psychiatry residency at Columbia University, where she was trained in pharmacologic management of psychiatric illness and evidence-based psychotherapeutic approaches.

Each client who was referred to the DVI was evaluated by Dr. Okuda, who is bilingual in Spanish and English, for 90 minutes (120 minutes if translation was necessary). Treatments offered at the FJC include psychopharmacologic management and group and individual trauma-informed psychotherapy. The bulk of clinical treatment during the original pilot program was provided by Dr. Okuda and Rosa Regincos, an L.C.S.W. psychotherapist, who worked two days and one day per week, respectively, on site. The program also allowed clinical trainees from the CUMC Department of Psychiatry to receive training in noncombat trauma and its effects on mental health. The opportunity to engage psychiatric residents with this type of innovative setting attracted Uju Berry, M.D., a resident at the time, to focus her research career on the effects of trauma on women and their children. The clinicians collaborate closely with case managers, counselors, and legal staff from the many agencies that work at the FJC. Elizabeth Fitelson, M.D., and Catherine Monk, Ph.D., faculty of the women’s program in the CUMC Department of Psychiatry, codirect the DVI and continue to oversee the program’s expansion.

Between 2014 and 2017, the DVI received close to 200 referrals and served approximately 60 active patients per month, nearly all women. Patients ranged in age from 18 to 65 or older, with a mean age of 37. About half spoke primarily English, and about one-third spoke only Spanish. Other languages spoken include French, Fulani, Bengali, Ewe, German, Haitian Creole, Hungarian, Mandarin, Somali, Tagalog, and Twi.

Like many survivors of intimate partner violence, a significant proportion of DVI clients have a psychiatric disorder. A 2016 chart review indicated that major depression was the most common diagnosis among DVI patients, affecting 46%, followed by PTSD (44%), mood disorder not otherwise specified (37%), anxiety disorder (31%), and substance use disorder (10%). Comorbidity is common, with most clients having two psychiatric diagnoses and some having as many as four. Shockingly, 40% reported a prior suicide attempt, and of these, 36% never received mental health care, 7% discontinued treatment after one or two visits, and 5% received psychiatric care only after multiple suicide attempts.

Helping survivors of intimate partner violence gain access to treatment is essential, according to Dr. Fitelson, but the DVI is equally passionate about educating mental health care providers and policy makers about the impact of intimate partner violence on psychiatric illness and risk of suicide. Untreated trauma can have devastating consequences, said Dr. Fitelson, and psychiatrists and other health professionals need better training in trauma-informed care. To that end, members of the CUMC Department of Psychiatry conduct regular training on the intersection of domestic violence and mental health for the FJC staff and representatives of community partner agencies who provide services at the FJC. Feedback from training recipients has been positive, with respondents giving high marks for the importance and relevance of the training curriculum.

A third objective of the DVI is to harness the CUMC’s world-class research program to answer key questions about intimate partner violence and—hopefully—help prevent its transmission to the next generation. “The project hopes to foster a better understanding of how to help future generations affected by domestic violence,” explained Dr. Chapman. Key questions include, What are the consequences of intimate partner violence on clients and families? How does psychiatric treatment affect clients’ well-being? How can the program contribute positively to the overall health and well-being of troubled families?

Research on the intergenerational effects of domestic abuse is a particular area of interest for Dr. Monk, who is a pioneer in the effects of stress, including intimate partner violence, on pregnant women and their offspring in utero. Her research shows that maternal stress can cause changes in the development of the fetal and infant brain, exposing the child to a heightened risk of psychiatric illness. Even trauma experienced by women as children may affect in utero development of their own children.

Following the successful pilot program, in May 2015, Mayor de Blasio announced $54 million in additional funding to expand mental health and social services for the most vulnerable New Yorkers through the THRIVE NYC initiative, including funding to replicate the DVI pilot program at the FJCs in all five boroughs through NYC Health & Hospitals. Currently, the FJCs in all five boroughs are staffed with a half-time psychiatrist and full-time psychologist with administrative support.

The funding presents an exciting and unique opportunity for the DVI to partner with the city to enhance the well-being of many more FJC clients and their families. It also represents a strong endorsement of the original vision of Dr. Chapman and her partners at CUMC and the OCDV. Providing psychiatric services to survivors of intimate partner violence in nonmedical, community-based settings is both feasible and acceptable, according to Dr. Fitelson. It seems clear that survivors of intimate partner violence are more likely to seek services at FJC s or similar nonmedical settings than at traditional mental health care facilities, she added.

The CUMC team continue to work as partners with OCDV and NYC Health & Hospitals to implement DVI services at the other FJC sites, with Columbia providing technical assistance to the city agencies as well as clinical training in intimate partner violence, trauma, and specific mental health techniques for the clinicians. Acknowledging the toll of vicarious trauma and burnout in the treatment of this high-risk and highly traumatized population, the program also provides opportunities for peer support for the clinicians. The Chapman Perelman Foundation, Columbia Psychiatry, OCDV, and NYC Health & Hospitals continue to collaborate in this powerful model, aiming to optimize mental health services at FJCs across the city, according to Dr. Fitelson.

As a result of the support from this collaboration, the CUMC team has also been involved in the dissemination of knowledge on intimate partner violence and mental health through conference presentations, manuscript publications, and the creation of a best practices guideline for mental health providers.

Integration of psychiatric services in FJCs is likely to be implemented elsewhere, as more and more communities seek to colocate services for victims of intimate partner violence. When they do, the DVI hopes to help guide the way. “We are bringing the most advanced CUMC psychiatric care to some of the most vulnerable New Yorkers,” said Dr. Okuda. A powerful model indeed.