MENTAL ILLNESS AND INTIMATE PARTNER HOMICIDE

SCHIZOPHRENIA NOT ASSOCIATED WITH VIOLENCE

An 18-year old man is implicated in the recent intimate partner homicide in Weymouth, MA.  He is said to be diagnosed with schizophrenia and had a history of violence.  Obviously this case is just coming into focus and little is known about the young man except that he was estranged from his mother and her boyfriend - both of whom were killed in their Weymouth home. 

People should not fear patients with mental illness.  In general, schizophrenia is not associated with violence unless paranoia is among the features of the chronic mental illness. A subset of patients with schizophrenia are paranoid that includes symptoms of suspiciousness, anger, and fear.  It is not clear to what degree the 18 year old experienced these symptoms but his mother was quoted as saying "he is going to kill me some day.."  That day, in fact, did occur on November 10th.  The alleged perpetrator has been arrested and is being held.  It is very likely that additional information about him and his motive will emerge. 

As in many cases of domestic violence homicide containment of those individuals who pose a significant threat is necessary.  In doing so, families who are at risk may be protected.  The information we have about the alleged Weymouth murderer suggests that his history was quite violent and unpredictable.  Treatment and containment is necessary especially when uncontrolled mental illness is suspected.  In order to reduce harm greater containment of abusers is neccessary when behavior becomes unpredictable.  In cases I have reviewed family members had direct knowledge that something terrible was going to happen.

THE ROLE OF VICTIMS

ANALYZE FACTS BUT AVOID BLAMING THE VICTIM

NEW BRAINTREE, MA December 3, 2011 Inevidably DVH is the sole responsibility of the abusive and violent spouse. It is never appropriate to lay blame on the victim. After interviewing scores of individuals regarding DV and DVH it becomes evident that an analysis of the facts must include the analysis of the behavior of the victim as well as the abuser. It is well known that commonalities exist in individual cases of DV that may be a source of education and intervention. For example, in this age of social media greater care must be taken to avoid humiliation through exposure. Daily postings about trips, weekend plans, and new friends can create a feeling of resentment if read by an estranged spouse. That is no fault of the victim but it happens and caution should be taken. There are cases where the social media postings of victims have alerted the abuser to changes in living situation including new address and other intimate knowledge that may impact her safety plan.


It is important that victims of DV be provided support for their decisions and be helped to understand the risk they face.  Domestic violence is an under reported crime.  It often takes years for victims to come forward and decide to leave an abusive man.  The risk is greatest when this happens because the abusive spouse suddenly feels he is loosing control.  Arguably when this occurs "the man becomes enraged with his loss of control at the attempt by the woman to "break the relationship" and engages in various acts of harassment which include stalking, threats, assault or other subtle forms of 'psychological warfare.'" (Brayden 1998)  As he becomes less significant to his spouse the risk of violence grows.  The extend of this violence depends on the cognitive and emotional stability of the individuals involved.  Some men become distorted in their belief of "ownership" of the victim.  The case from Dexter, Maine resulted in a sharply decompensated man first destroying the family home by removing the furnace and copper piping and next destroying the family in a despicable act of murder-suicide.

ANALYSIS OF FACTS HELPS REDUCE HARM

DOMESTIC VIOLENCE REVIEW BOARDS

NEW BRAINTREE, MA December 3, 2011  New Braintree Police Officer Michael Sefton was recently in Augusta, Maine providing testimony about the results of the psychological autopsy conducted by Officer Sefton, Brian Gagan of Scottsdale, AZ, and Ron Allanach, Ed.D. of New Westminster, BC, Canada and Chief Joseph Laughlin of Portland, ME.  Officer Sefton, who holds a doctorate in psychology provides education and forensic consultation on domestic violence including domestic violence homicide and assessment of risk. 

PUBLIC INFORMATION

The testimony provided details about a hideous case of family violence that ended with the homicide of 4 members of the same family and was culminated by an attempt to burn the bodies after the murders.  Their research was conducted over a 3 month period following the homicide deaths of Amy Lake and her children.  Most researchers agree it is nearly impossible to predict when DVH will occur.  However, the psychological autopsy provides many salient red flags that offer clues to the impending emotional conflagration. It is not uncommon that red flags are often present early in the relationship.  These include obsessional jealousy, threats, sexual aggression, unwillingness to integrate into extended family, any use of a weapon, and others.  In the course of their research Sefton and Gagan interviewed Dale Preston who was convicted of DVH in 1982 and served 18 years in Maine State Prison.  When asked what may have stopped him from killing his wife, Mr. Preston indicate "there was nothing that could have stopped me..."  In these cases a greater awareness of risk or dangerousness is essential.  In some cases the containment of risk requires direct contact with an abusive spouse including GPS monitoring, house arrest, or no bail imprisonment.

The case in Maine occurred in June 2011 exactly 1 year to the day after the victim obtained a protection from abuse order from her husband.  The murders occurred 2 weeks before the divorce was to be finalized and were likely triggered by the abuser's anger over not being permitted to attend his son's 8th grade graduation ceremony.  The Bangor Daily News presented details of the recent psychological autopsy presented recently in Augusta, Maine.  Over 30 states across America have formal homicide review boards. 

Officer Sefton writes a blog about DVH at enddvh.blogspot.com

'WE DIDN'T THINK HE WOULD TAKE THE KIDS'

SOME PEOPLE KNEW WHAT WAS COMING

NEW BRAINTREE, MA November 24, 2011 In the horror of the immediate aftermath of a domestic violence homicide everyone asks themselves could something have been done to predict the event.  Generally, people always say they never saw it coming in the days when people stop and take the pulse of a neighborhood or community.  Yet there are always people who are not surprised by the sudden paroxysm of domestic violence and could foresee what was to come.

Reasearch shows that DVH is the product of chronic manipulation and control among initimate partners.  Red flags are the subtle and no-so-subtle signs of abuse that preceed the physical and sexual aggression associated with DVH.  I have interviewed families after the most hideous cases and was not surprised to see that some people knew what was happening before it happened.  In one recent interview the relatives of a man who killed his wife and children admitted they knew the man was planning something but "did not believe he would take the children".  How can those people live with the knowledge that they might have been able to intervene?

It is encumbant upon human beings to reach out and protect those who may be in harms way.  If we see someone standing in front of a runaway car the majority of people would do whatever they could to warn that person.  When someone stumbles and bumps their head we stop what we are doing and lend a hand.  Why does this happen and why are victims often needlessly left in danger?  Abusers are resentful, angry human beings that often have a long history of sadistic cruelty and aggression.  There should be ways to contain their aggressive impulses as we might someone who makes threats against a political figure or celebrity. 

When people admit that they knew "something was going to happen" and did nothing it speaks to an unwillingness to take a moral stand and act.  As people in the helping profession are required to act on suspicion of child or elder abuse so too should all human beings who have direct knowledge about an impending human conflagration and death.  Otherwise, we loose that which makes us unique among animals.

THE PSYCHOLOGICAL AUTOPSY

      PSYCHOLOGICAL AUTOPSY PROVIDES HOST OF INDICATORS

The aggregation of facts – including both internal and external conflict, coupled with the enduring lack of empathy, denial of responsibility, and failed ability to compartmentalize anger and resentment imbued the abuser away from the margin into the nucleus of his own violent conflagration.

The perpetrator was a socially antagonistic man who sought public approval via social media postings in the last months of his life.  In the days before the homicide he was quick to “unfriend” anyone whose opinion was out of synch with his own musing.  He had begun to slip away and his girlfriend and family began to see just how chaotic and dangerous he was becoming.

To her credit, the victim was fine mother and respected teacher.  She loved her children more than anything.  There is consensus that she liked to take care of others – before herself.  But this way of living made her vulnerable to husband’s control and intimidation raising her self-doubt, guilt, and confusion as to how to move forward in life. 

The emotional and behavioral schema for the homicide resulted from the distorted cognitive belief that the laws of society and orders of protection (PFA) do not apply to the man and an overriding belief that none of this would have happened “if he could only see his kids.” His lifelong fascination with guns and access to at least 2 of his 20-plus gun collection granted him the means to act out his violent plan.

He claimed to love his children.  No one knows whether the man truly loved his children or not – but throughout evolution, over millions of years – a parent lived to safeguard his offspring from harm and not to destroy them. This innate set of rules assured for the continuation of the species and protection of the young.  As one of my research colleagues expressed early on, “You do not kill something you love…”

The tragic folly in the man’s distorted thinking is the magical denial of wrongdoing and epoch mystification of truth on which he obsessed. This “truth”, that he had done nothing wrong, suggests a profound lack fundamental, human conventionality and emotional detachment. These human elements are central to effective parenting and healthy living.  Regrettably, this lingering truth is shared  by many across the DVH literature.  It requires that society construct a perfunctory “safety net” or statewide DV system to measure risk and significantly limit the potential for the propagation of primal rage and entitlement that shunt cognitive reasoning in the minds of those with a proclivity to commit domestic violence homicide.  To say that nothing can be done to stop DVH miscarries the real truth – that risk and harm reduction may require the containment of high risk abusers as a protection for society.

Our research has brought us in contact with one man who served 18 years in prison for the killing of his wife.  His candor proved educational as the parallels with this case are eerily similar.  When asked pointedly “what could have stopped this incident?” He replied that “nothing” could have stopped it but agreed that if he were in custody the violent cascade of events may have been derailed. 

Finally, family members who are in the crosshair of these insidious events often see but lack the knowledge to stop the emotional and behavioral kinetics once they start.  Therefore, a continuum of interagency cooperation is needed to effectively measure risk and understand the pre-incident red flags that are common underpinnings of abuse and often forecast terminal violence.  As the totality of these red flags come into focus it becomes incumbent upon each of us to take action on behalf of those most at risk – as we are mandated to do in cases of child and elder abuse. 

In respect to victims of domestic violence it is vital that red flags and risk factors become the first of its kind “road map” to reduce harm to families who find themselves in the crosshairs and assure that safety plans are not abandoned, abused, or ignored. 

RISK IS INCREASED WHEN ABUSER MARGINALIZED

There is agreement among clinician's in the field of domestic violence that the risk to victims is increased when the abuser is "moved out" - physically and psychologically.  In some cases when the victim decides she is moving-on the risk to her safety is increased exponentially.  The decision to separate from a dysfunctional and dangerous relationship is a difficulty one that does not come easy.  In many cases when abuse trickles down to children or family pets a victim realizes she must act to protect her family.  Arguably when this occurs "the man becomes enraged with his loss of control at the attempt by the woman to "break the relationship" and engages in various acts of harassment which include stalking, threats, assault or other subtle forms of 'psychological warfare.'" (Brayden 1998)  By feeling marginalized an abusive man may feel insignificant and sometimes humilated - especially when police become involved in keeping the peace or responding to a violation of a stay-away order.  It is well known that abusers often experience feelings of deep resentment and anger.  At these times containment and intensive intervention may be necessary to assure for the safety of women and chilldren attempting to break free.

“Domestic violence homicides are predictable and therefore preventable,” says Jessica C. Brayden, Executive Director of RESPOND, Inc. in Sommerville, MA
VJ Geberth, (1998) Practical Homicide Investigation. Law and Order Magazine, Vol. 46 No. 112, November, pp 51-54

LEARNING FROM TRAGEDY - Well-being for EMS and Police

LEARNING FROM THE TRAGEDY OF DOMESTIC VIOLENCE HOMICIDE
The health and well-being of emergency service workers like police officers and paramedics requires the balance of physical and mental wellness. Greater attention is being paid to educating students in the emergency services to proper nutrition, the importance of exercise, lifestyle balance and proper stress management techniques. Wellness is not something that happens by itself. Many officers and medics alike believe they are just fine when everyone can see they are not. Why? Police officers and paramedics are exposed to a complete range of human experience and tragedy. Most “suck it up” and keep their feelings to themselves when unresolved issues percolate in their psyches. The resulting stress adds to career burnout and in the worst case – arguably, a frank psychosocial crash and burn. Enhanced training in personal and professional wellness is essential for optimal long term resiliency of the first responder.

GALLOWS HUMOR

        The camaraderie among EMS and fire service personnel is well documented. Similarly, police officers tend to “hang” together whenever they get the chance and share stories from their departments – big and small. There are usually plenty of laughs as stories are shared. These sometimes take on a “gallows humor” as cops and EMTs process and integrate the scenes they cover. I once sat at a local bar with a vice presidential secret service detail and it was no different with them. Humor is a coping mechanism to an otherwise woeful system that often fails its membership – especially when events exceed what is thought to be just an “average call.” Police, EMTs, and fire service personnel have high rates of alcoholism, drug abuse, suicide, and ironically, domestic violence. There is a high price paid when this brand of humor leaches into the professional conduct of front line practitioners and can affect the delivery of pre-hospital intervention.

CAREER BURNOUT

As the American population gets older the need for pre-hospital care and inter hospital transfers is likely to grow. It is unlikely that the demand for pre-hospital professions is going to decline in the coming generation. According to Bledsoe et al., a paramedic may find themselves providing a wider range of care in the future – including primary care (page 5). Therefore, paramedic training should include specific direction about post-incident debriefing in order to assure that medics remain healthy and focused.

It is well documented that the body responds to stress by a build-up of cortisol—a hormone that depresses autoimmune functioning and can contribute to hypertension, pain, and disturbed sleep. Continuing education also fails to address the cumulative effects of stress and the impact this has on personal health and wellbeing. The response to stress differs from professional to professional but many choose maladaptive coping mechanisms blaming the “job” or “company” for low wages, valuing profit over human capital, and other frustration unrelated to internal conflict – expressed as anger and resentment.

CONCLUSION

Paramedicine is an exciting and rewarding field. Nowhere else can an average person practice emergency medicine without having attended medical school. However, along with this lofty responsibility comes the awareness that an important price is paid when the paramedic believes he is above being human. Arguably, the profession needs to be accountable for the wellbeing of its membership including post-incident support. The tragic reality in Maine brings home the impact that we are all exposed to experiences that most human beings avoid or never witness. Most of us are able to cope and process the images in adaptive fashion. Following the horrific events of 9-11, the incidence of suicide among police officers, EMS and fire service personnel was excessive and unnecessary. Most did not receive the help they needed early on. Resiliency training has been shown to be a viable professional development and may better inoculate the police officer and paramedic against the range of emotional contagions faced on a regular basis. In Dexter, Maine at least one public service employee is at high risk for post-traumatic stress and its potential to corrupt long-term health and well-being.  When calls for service become solely a transaction between medic and customer it may be a sign that professional resiliency is over taxed and career burnout may be rising from the proverbial ashes of the calls we did before.

DVH LINKED TO A PATTERN OF SEXUAL AGGRESSION

POLICE NEED TO ASK TOUGH QUESTIONS

The continuum of domestic violence ranges from emotional abuse to physical battery, to sexual sadism, torture, and sexually motivated homicide.  As early as 1998 DVH has been linked to a chronic, egregious pattern of physical and sexual aggression among intimate partners (Gerbeth, 1998).  It is well known that law enforcement officers are the first responders for domestic violence calls across America.  Most agree that greater containment of abusers is necessary to prevent DVH - especially after an order of protection has been issued. “Protective orders in the state of Maine are written on paper and that’s about as much value as they have. We need to put some teeth in it” according to Maine Governor Paul LePage (quoted in BDN, July 2011). Arguably, it is encumbant upon the officer on the beat to ask the difficulty questions that may uncover the secretive pattern of aggression that belies too many households in America. Maine and much of New England has experienced a dramatic increase in DVH since 2009. A psychological autopsy is sometimes used to measure the prevalence of pre-incident "red flags" that indicate a higher risk of violence and DVH. These evaluations are conducted infrequently due to their cost but they are valuable tools in the fight against DVH.  Victims of domestic violence and surviving family members ask what can be done to help to reduce the risk of escalating physical and emotional damage on intimate partners.

According to Geberth, "Domestic violence murders are synonomous with Interpersonal Violence Oriented Homicide - now called Domestic Violence Homicide (DVH). The rationale for classifying domestic violence as sex related is due to the fact that murder serves as the ultimate form of sexual revenge. And, in many instances the homicides will include sexual assault or wound structures manifesting a sexual orientation."

Vernon Gerbeth was a supervising homicide investigator in Bronx, NY during the 1990's and published a paper on DVH after serving on the Governor's Commission on Domestic Violence Fatalities in 1996-1997.  37 states have DHV review boards whose task it is to review the circumstances of individual cases of homicide committed between intimate partners.  "Domestic violence is defined as a pattern of behaviors involving physical, sexual, economic and emotional abuse, alone or in combination, by an intimate partner often for the purpose of establishing and maintaining power and control over the other partner."  Review panels seek to make recommendations that are designed to lower the risks by enacting changes in response to DV across the board. 

Generally speaking, the reports generated are the culmination of months of investigation and testimony following an egregious killing.  The documents are frequently published and contain the intimate details thought to be the triggers in the case.  These details must become the substantive underpinning of change in the handling of new cases of DV in order to reduce the risk of DVH.  Police and social service agencies should work together and integrate the recommendations from review boards.  On going education and training may facilitate this risk reduction.


VJ Geberth, (1998) Practical Homicide Investigation. Law and Order Magazine, Vol. 46 No. 112, November, pp 51-54.

HARM REDUCTION IN DOMESTIC VIOLENCE

HUMAN FACTOR IN HARM REDUCTION

DVH results from the cascade of behaviors that evolve between victim and her abuser.  Women sometimes abuse their husbands but the problem of domestic violence homicide is largely attributed to men acting out against their female partners.  How can people begin to impact the human cost of domestic violence unless it moves up to the societal level?  Some believe greater recognition of red flags offer law enforcement a head start at reducing DVH.  As a police officer, I have been asked to investigate domestic violence calls and almost universally am met by the male spouse saying that "nothing happened" and "my wife has overblown this again". Denial of responsibility and emotional intimidation are among the most common red flags to early cases of domestic violence according to research.  These often begin as soon as husband and wife are married.  There is a strong push for secrecy and for decades police treated domestic calls as a "private matter" between husband and wife.

The most typical red flags have all been published in countless peer-reviewed journals and I will provide them shortly.  When the red flags are uncovered police need more tools to offer security for potential victims and containment of the abuser.  This requires greater communication between police and domestic violence social services.  Maine has had an upsurge in DVH in 2010 and there is a calling for changes in the bail requirements that will free an abuser for only $ 200 to $ 2000 dollars. 
Once a protection from abuse order has been filed it is essential that open communication be available between the police, judiciary, and probation.  If someone violates the PFA order than efforts to contain the abuser should be maximized.

Pre-incident Indicators - Red Flags

History of depression Threats to kill spouse or family Previous history of battery Threatens family with weapon Engages in stalking behavior Order of abuse filed Uses drugs and/or alcohol

                                                                                                              Fox et al, 2008         

"For domestic violence workers in Maine, who engage in activities ranging from lobbying the Legislature to providing training for law enforcement officers, the only way to eliminate domestic violence completely is to instill in society the fact that it’s a societal problem, not a private one. Brian Namey, a spokesman for the National Network to End Domestic Violence in Washington, D.C., said Maine has strong laws on the books to combat domestic violence — including protection orders that include pets and a victim notification law that alerts a victim if the perpetrator tries to buy a firearm — but those laws won’t convince enough people to report domestic violence when they encounter it." (Taken from Bangor Daily News)

Domestic Violence Review - When Containment Fails

 The fact is that greater containment of high risk abusers is needed.  Unfortunately, no one seems to believe that a person can be held on "high bail" simply because he held his family hostage and threatened them with a firearm.  Many believe there is a disconnect between the judiciary and the bail system.  The June 2011 case in Maine culminated after the abuser was released from jail on $ 2000 dollars bail.  After his death the money was returned to his family.  Some district attorneys have tried to withhold bail money when the defendant fails to appear in court due to death by suicide after DVH.  For many this seemed like a draconian response to families who were in pain.

What can be done to assure greater containment?

A Domestic Violence review panel conducted in June 2011 concluded that “there is nothing society can do for a despondent, abusive spouse whose obsession overrides the norms of society – even his will to live”.  If we believe this then we will erroneously surrender any creativity in domestic violence prevention and harm reduction.  When high ranking prosecutors say DVH cannot be prevented society is cheated out of taking steps toward containment of those who may violate protection from abuse orders.  Lois Reckitt, executive director of Family Crisis Services in Cape Elizabeth, ME is quoted as saying that the wrong people are in jail when violence-prone abusers are released from custody to stalk and terrorize their family, as was the case in the Dexter, Maine tragedy.  Containment and harm reduction should be the focus of the legal system and social service agencies alike.  The judiciary and political machinery in states throughout America must speak out about protecting victims and families and not say there is nothing that can be done to stop DVH.

ASSESSMENT TOOLS - FEATURED PRE-INCIDENT INDICATORS

THE CASE FOR DOMESTIC VIOLENCE REGISTRY

Domestic violence homicide is said to be excedingly difficult to predict.  If we could predict its occurence then perhaps a greater number of "intimate partners" could be better protected from the monsters with whom they live. When victims are able to escape their abusers often move on to repeat the pattern elsewhere and find new partners.

Police departments are largely responsible for responding to calls for help when domestic assault and battery occurs.  They need tools to effectively measure the risks faced by their citizenry including a measure of containment to reduce the likelihood of harm. The June 2011 massacre of Amy Lake and her children in Maine started and ended within 6-8 minutes of onset. The heroic officers at the scene could do nothing to stop the shooting already in progress when they arrived. Abusers are often slowly marginalized from supports and grow alienated and rageful. These cases need to be assessed for the potential for DVH long before the murderer looses control.

There are a number of assessment tools used throughout the country.  Jacqueline Campbell, Ph.D., R.N. developed the Danger Assessment while at Johns Hopkins University as a tool to measure risk factors.  Author Gavin deBecker has a lengthy list of risk indicators in his text The Gift of Fear published in 1997.  Most clinicians and researchers identify several key factors that are red flags for possible violence.  These include such things as the use of weapons, forced sexual contact, pathological jealousy, previous choking incidents, and increasing use of threats to control behavior. Any aggression during pregnancy is also a high risk indicator of a pattern of sadistic behavior.  In future essays I will feature what arguably may be an essential next step in abuse containment - a domestic violence registry.

PERSONAL BLAME - VICTIM CHARACTERISTICS OF DOMESTIC VIOLENCE

UNPREDICTABLE AGGRESSION ALTERS DEVELOPMENTAL TREJCTORY

Many victims of abuse believe if they could be more "perfect" then they would be free from the wrath of their spouse and yet in most cases a growing pattern of abuse may evolve no matter what happens.  Many blame themselves for the random acts of a violent, manipulating spouse.  It is often the randomness of the agression that contributes most to childhood fear and aggression (Sefton).  Many victims acknowledge a naïve hope that their spouse will ultimately change and become the "loving soul" he claimed to be.  This is extremely rare.  In most cases of domestic violence the female victim feels trapped.  She may have children with limited support.  Learned helplessness refers to the insideous resignation and emotional futility felt by the "victim" spouse.  She may believe that nothing she does can change her circumstances.   She may have no employment, limited access to family or friends, no access to the funds necessary to plan her escape – should this become necessary.  In families where domestic violence prevails, children grow up in a setting where physical aggression is condoned as a means of resolving conflict and asserting dominance.  In many families where abuse occurs a harsh, overly punitive parent may exhibit a pattern of sadistic abuse early on - often toward children.  This striking lack of empathy adds to the risk for serious violence.  The notion that violence begets further violence is true and often transcends one generation to the next. 

Sefton, M.  2005. The Evil that Kids Do. Philadelphia: Xlibris.

"It started when I said 'I do...'" - Victim of abuse

Intimate partner aggression is often hidden from family members and certainly from neighbors and friends.  I recently interviewed a 35-year old mother of two small children.  Her complaint was that her spouse of 7 years was emotionally abusive and intimidating.  When asked when the abuse had started she replied "it started as soon as I said I do". 

This is a common report when victims of physical and emotional abuse are interviewed.  Abusive partners sometimes seek "ownership" of a wife or girlfriend and wrongfully believe it is their right to manipulate and control them.  Police and social service agencies become involved depending on the frequency and pervasive quality of these behaviors.

In an effort to contain domestic violence homicide greater awareness of pre-incident indictors is essential.  The secretive nature of these dysfunctional families often will obscure high risk behaviors to all but the immediate family.  A sensitive and trusting relationship between victims and the community at large may reduce the isolation felt by victims of emotional and physical abuse. 

DVH results from the interaction of behavioral underpinnings including history of violence, substance abuse, and extent of alienation felt by the abuser.  The assessment of a potential for violence should be a routine component of domestic violence complaints received by police. 

The Need for Containment

A recent spate of domestic violence homicides in Maine and Massachusetts has led for the call for greater "containment" of abusers.  Since June 2011 there have been over a dozen domestic violence related killings in New England which brings up the issue of how to contain abusers and keep them from killing their families.  Police and social service agencies encounter cases of domestic violence on a daily basis.  The difficulty they experience is how to differentiate the cases of intimate partner aggression from those who go on to murder their spouses and often themselves.