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The most critical red flag of domestic violence

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Joni E. Johnston :
October is Domestic Violence Awareness month. It's a sad reminder that what starts out with intimacy and love can become ugly and tragic. It's also a reminder that even among abusive relationships, some are deadlier than others. One of my jobs as a forensic psychologist is to estimate the violence risk of batterers so we can develop safety plans for victims and parole plans for perpetrators.
It's not easy; there are psychological barriers that get in the way. Many of us have a hard time admitting - even to ourselves - that we're being abused by spouse or partner. Even when we know it's abuse, it can be easy to make excuses for it: It was the alcohol, or poor role modeling, or a bad childhood.
Even when we recognize domestic violence, it's hard to predict it. As a group, mental health professionals tend to overestimate the risk of violence, which can result in the scarce available resources, and level of intervention, not being selectively targeted to the people most at risk.
On the other hand, as a group, law enforcement officers tend to underestimate the level of risk. A large 2019 study from the U. K. found that, even when front-line officers used a structured risk tool to evaluate a victim's risk of serious harm, their accuracy was barely better than if they had flipped a coin.  
Given the fact that a few perpetrators are responsible for the most serious domestic abuse harm and this harm is concentrated among a subset of victims, it is critical to sort out the wheat from the chaff when it comes to risk factors that make a difference. Recent research from Johns Hopkins School of Nursing indicates 20 factors that influence whether violence risk goes up or down - things like whether the abuser has access to a gun, whether they are threatening to kill themselves, or whether the behavior is escalating.    
There is one risk factor, though, that stands out above all the others: strangulation.  Batterers who strangle their victim are more likely to engage in other extreme acts of violence; it's a message that there are no limits to which he won't go. The odds are, he's willing to kill.    
A large case-control study in the United States found that previous domestic violence involving strangulation is a substantial and unique predictor of attempted and completed murder. Statistically, it multiplies the odds by seven.
Not only is this important for domestic violence victims to know, it is critical for the people who try to help them. Twenty percent of domestic violence homicide victims are friends, family members, neighbors, or others (including law enforcement officers) who attempted to intervene on a victim's behalf. It's not hard to imagine that a perpetrator who will choke his wife or girlfriend might also be willing to commit violent attacks on a police officer or well-intentioned bystander.
Fortunately, the word is getting out about this dangerous warning sign. San Diego County, for instance, just launched a campaign to teach health care providers how to spot signs of domestic violence strangulation. You might think they'd be easy: Look for red marks or bruises around the neck. But it's not.
More than half the time, there are no visible marks or physical signs of injury on a victim's neck, making detection impossible unless health-care providers know what kinds of questions to ask and what other symptoms to look for, such as hoarseness, a sore throat, lapses in memory, pain while swallowing, and shortness of breath. There are also longer-term effects, both psychological and physical, that are not so obvious.   
Multiple attempted strangulations are commonly reported by women in domestic violence shelters but were often missed by law enforcement and health-care providers.
That is changing. While there is no indication that the frequency of nonfatal strangulations has increased, strangulation felony charges have quadrupled in the last six years because police officers are increasingly referring victims for evaluation to forensically-trained clinicians who are asking the right questions, such as how the victim was choked, whether the victim was verbally threatened or physically assaulted in other ways, how often this has happened, whether drugs or alcohol were involved, and how the victim responded.      
Since 2017, four women a day have been killed by an intimate partner. Strangulation is often one of the last abusive acts a batterer commits before he kills; surviving strangulation is surviving attempted murder. From a violence risk perspective, nonlethal strangulation is as much a red flag as the odor of alcohol in a DUI investigation. In any domestic violence situation, it should be asked about, talked about, and, if present, acted upon. As the old proverb goes, better a thousand times careful than once dead.

(Joni E. Johnston, Psy.D, is a clinical/forensic psychologist, private investigator and cohost of the forensic radio show Thread of Evidence and author of three books).

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