Biopsychosocial Assessment

For this Assignment, imagine yourself as Ray’s social worker. Though you won’t be interviewing him, you have learned a great deal about his story in videos throughout the course. Now, in this Assignment, you apply that learning to identify, categorize, and record important information about Ray’s development in a bio-psychosocial assessment.

By Day 7

Using the template, submit bio-psychosocial assessment focusing on Ray. The assessment should be written in professional language and cover the following sections:

Presenting issue (including referral source)
Demographic information
Current living situation
Birth and developmental history
School and social relationships
Family members and relationships
Health and medical issues (including biological, psychological, and psychiatric functioning and substance use)
Spiritual and cultural development
Social, community, and recreational activities
Client strengths, capacities, and resources

At the end of the document:

Include a summary and analysis of the overall challenges experienced by the client and how the social environment has contributed to those challenges. Describe how this analysis of the social environment would be beneficial to treatment and goal-setting.
Then, describe two goals that you can work on with this client based on the assessment. Explain why these goals are appropriate and relevant to the case in addressing the presenting issue and challenges.

Please use the Learning Resources and additional research to support your analysis. Make sure to provide APA citations and a reference list

MeetRay. Age 17 to 18

Meet Ray. Age 17 to 18
Program Transcript

NARRATOR: Ray gains self-confidence from exercising, socializing with the other team

workers at his part-time fast-food job, and honing his woodworking skills he graduates

high school. Ray applies to college with the support of his teacher-mentor and gets a full

scholarship. He would be the first in his family to attend college.

However, his father George becomes sick with lung cancer the summer before his

freshman year of college. Ray doesn’t know where to turn. He is estranged from his

father’s side of the family due to a fight George had with his brother years ago. His

mother’s side of the family do not live in the area, and he’s never had a close

relationship with them. He feels a sense of obligation to George and guilt for what he’d

said about wishing him dead, ray never leaves for college, letting the scholarship lapse.

He stays and cares for his father until George dies four months later.

Now 18, Ray lives alone with a rescue pit bull named Daisy. He has maintained his fast-

food job, but after George’s death, he begins to show up at work late, unshowered, and

occasionally drunk. Ray’s boss tells him that he understands he’s grieving, but he can’t

show up in that state. The boss puts him on probation. If he is late, skips work, or shows

up inebriated again, he will be fired.

If Ray loses his job, his housing will be in jeopardy as well. Ray’s work friends

encourage him to see a social worker.

MeetRay

Meet Ray
Program Transcript

FEMALE SPEAKER: Meet Ray. Ray is a full-term baby of normal length and weight,

born to working-class Caucasian parents living in a suburban area. As an, infant he

stops breathing on several occasions, which the emergency room doctor says may be

due to the effects of secondhand smoke. Both Ray’s mother, Mary, and father, George,

smoke in the apartment.

In his early years, Ray forms a strong bond with Mary, who is loving and nurturing.

However, she works two part-time cashiering jobs to support the family and is not often

home. George is stern and often yells and loses patience with Ray.

At age 6, Ray regularly hears his parents fighting when he is trying to sleep, usually

over money and the demands of parenting. Ray interprets his father’s anger as not

wanting me. When Ray enters public school, the nurse helps Ray get an inhaler for his

breathing challenges, which have escalated to asthma.

MeetRay. Age 7 to 12

Meet Ray. Age 7 to 12
Program Transcript

FEMALE SPEAKER: As Ray grows, the family moves around a lot from short-term

rental, to hotel, to campground depending on the season. While this exposes Ray to a

diverse set of experiences and people, it also leads to lack of continuity in schooling and

social relationships as Ray transfers school districts. Ray does well academically,

particularly in math, but does not engage in after school activities preferring to be home

when his mother has a brief break in between her two jobs.

Ray and his mother Mary attend Catholic church services weekly. The family does not

have medical insurance or access to regular medical care aside from Ray’s inhaler

provided by the school. The only affordable and accessible food in their area is

processed and high in fat and sugar. Both of these circumstances affect the physical

health of a family with Ray being overweight and Mary obese. In Ray’s early

adolescence, Mary develops diabetes and cardiovascular disease linked at least part to

her history of obesity and smoking.

Johnson Family Episode 1

Johnson Family Episode 1
Program Transcript

ERIC: Ladies, what’s going on?

TALIA: Hi.

ERIC: I’m Eric.

TALIA: Talia

SHERRY: Sherry.

ERIC: Excellent. So I know some good-looking guys looking for some good-
looking girls.

SHERRY: You do, huh?

ERIC: We’re throwing a party Saturday night, and invitation only. I want you guys
to come. Lots of booze. You like to dance?

TALIA: I love to dance.

ERIC: Me too. You should dance with me. You better come.

TALIA: All right.

ERIC: Both of you.

SHERRY: Thanks.

ERIC: I’ll see you then? All right, see you later.

TALIA: Bye.

SHERRY: Bye.

TALIA: He’s hot.

SHERRY: You think?

TALIA: Oh, yeah. You gonna go?

SHERRY: Well, yeah, if you’re going to go.

TALIA: Yeah, I’m definitely gonna go.

Johnson Family Episode 1

SHERRY: OK, then we’re going.

TALIA: OK, it’s settled.

[INTERPOSING VOICES]

ERIC: Hey, there. How you feeling?

I’m drunk.

ERIC: Yes, you are. Here, have some more.

TALIA: I need to lay down. I don’t feel so good.

ERIC: Oh, no. No, no, no. Not here.

TALIA: Take me home.

ERIC: It’s my frat party. I actually– I’ll tell you what. I’ll take you upstairs. You can

use my bed, OK?

TALIA: Sure.

ERIC: All right. Come on, Talia. I got you.

SHERRY: Talia. Hey, are you OK?

TALIA: I’m fine.

SHERRY: You sure? Do you want to go with him?

ERIC: It’s fine. She likes me. Don’t you?

TALIA: Uh-huh.

Johnson Family Episode 1
Additional Content Attribution

MUSIC:
Music by Clean Cuts

Original Art and Photography Provided By:
Brian Kline and Nico Danks

MeetRay. Age 13 to 16

Meet Ray. Age 13 to 16
Program Transcript

NARRATOR: Ray’s mother Mary dies of a heart attack when Ray is 14. Ray is

devastated and retreats further into himself. He begins to experiment with his father’s

alcohol and likes how it makes him forget.

His father George goes from aggressive and argumentative to complacent after Ray’s

mother dies. He doesn’t care what I do, says Ray, who walks to the local park and

drinks and smokes at night. On one occasion, a police officer on patrol escorts him

home and warns that if he is out drinking in public again, he will be fined. Ray does so

again and is fined $500. When he tells the officer he can’t pay, he is instead enrolled in

an alcohol-awareness class and mandated community service.

A year goes by, and due to the loss of income from Mary’s death, he and George have

to move to subsidized housing in a different part of town. At this point, they are living on

Social Security and disability income. Ray signs up for a woodworking class at his new

high school, remembering how his father used to make household items with wood

scraps. The teacher sees promise in him and mentors Ray in woodworking and

cabinetmaking outside of class.

At the same time, Ray becomes interested in dating girls, but he is self-conscious about

his weight. He starts working out at the school gym. Meanwhile, he clashes with George

at home. He sees his father as useless because he hangs around the apartment and

drinks and smokes all day watching TV. Ray has to make dinner for himself, clean, and

so forth. He also has to get a part-time job.

One night, Ray says under his breath, I wish you had died and not Mom.

Biopsychosocial Assessment

Student Name

Walden University

SOCW 6200: Human Behavior and the Social Environment I

Instructor Name

Month XX, 202X

Biopsychosocial Assessment

Name:

Date:

Agency:

Demographic Information

Age:

Ethnicity:

Marital Status:

Date of Birth:

Presenting Issue(s)

This section should include the client’s self-assessment of the problems, reasons, or motivations for seeking treatment, as well as the onset, duration, intensity, and frequency of precipitating stressors or symptoms (in the client’s own words).

Referral Source

State who and/or what entity referred the individual for treatment. Also specify whether information was gathered from previous treatment records, court documents, etc.

Current Living Situation

Describe the client’s current living situation, including any of the following: others living in the home, dependents, employment or disability status, insurance, transportation, and daily living skills.

Birth and Developmental History

This section should include prenatal, birth, and early development history, including information about infancy, childhood, and early adolescence. Describe family of origin—parents, siblings, extended family; geographic, cultural, and spiritual factors of early development; and any history of abuse or trauma.

School and Social Relationships

This section should contain information about social development, particularly in the context of school and peer group experiences. Include current and past friendships, educational history (school attended, performance, education level, and extracurricular activities), and military history (if applicable).

Family Members and Relationships

Identify family members and relationship dynamics, as well as interpersonal/marital history. Include age of involvement in relationships, sexual orientation, length of relationships, relationship patterns or problems, and partner’s age/occupation (if applicable).

Health and Medical Issues

This section includes medical history and current physical health, mental status, history of psychiatric illness and previous treatment, and substance use history.

Medical History and Physical Health

State any history of traumatic injuries, chronic health problems, current illnesses, current health status, allergies, medications and vitamins/supplements, health habits (appetite, sleep, exercise, nicotine, alcohol, illicit drugs), sexual functioning, and risk behaviors.

Mental Status

Describe relevant observations about attitude, affect, mood, and appearance; memory, cognition, thought process, and speech; judgment, homicidal/suicidal ideation, and hallucinations/delusions.

History of Psychiatric Illness and Previous Treatment

Include previous mental health diagnoses, inpatient or outpatient treatment, and history of self-injury, suicide attempt, or suicidal ideation. Include history of aggression, violence, or homicidal ideation.

Substance Use History

State the type of substance use, onset, duration, pattern of use, and involvement in treatment.

Spiritual and Cultural Development

Describe the client’s spiritual beliefs and activities, including past and current involvement in organized religion and faith-based services and programs. Record cultural factors, such as cultural background, beliefs, and practices, that are relevant to assessment and treatment.

Social, Community, and Recreational Activities

Record leisure activities, involvement in the community, and available social supports.

Client Strengths, Capacities, and Resources

List the client’s personal strengths and abilities, as well as available family and social resources.

Summary and Analysis

Summarize the biopsychosocial assessment. Provide an analysis of the overall challenges experienced by the client and how the social environment has contributed to those challenges. Describe how this analysis of the social environment would be beneficial to treatment and goal-setting. Please use the Learning Resources and additional research to support your analysis.

Goals

Describe two goals that you can work on with this client based on the assessment. Explain why these goals are appropriate and relevant to the case in addressing the presenting issue and challenges. Please use the Learning Resources and additional research to support your analysis.

References

(Include full references here for any sources that you have cited within the Summary and Analysis and Goals sections of the paper. Note that the following references are intended as examples only.)

American Counseling Association. (n.d.). About us.

https://www.counseling.org/about-us/about-aca

Anderson, M. (2018). Getting consistent with consequences. Educational Leadership, 76(1), 26-33.

Bach, D., & Blake, D. J. (2016). Frame or get framed: The critical role of issue framing in nonmarket management. California Management Review, 58(3), 66-87.

https://doi.org/10.1525/cmr.2016.58.3.66

Burgess, R. (2019). Rethinking global health: Frameworks of Power. Routledge.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24(2), 225–229.

https://doi.org/10.1037/0278-6133.24.2.225

Johnson, P. (2003). Art: A new history. HarperCollins.

https://doi.org/10.1037.0000136-000

Lindley, L. C., & Slayter, E. M. (2018). Prior trauma exposure and serious illness at end of life: A national study of children in the U.S. foster care system from 2005 to 2015. Journal of Pain and Symptom Management, 56(3), 309–317.

https://doi.org/10.1016/j.jpainsymman.2018.06.001

Osman, M. A. (2016, December 15). 5 do’s and don’ts for staying motivated. Mayo Clinic.

https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/5-dos-and-donts-for-staying-motivated/art-20270835

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed.). Wiley.

Walden University Library. (n.d.). Anatomy of a research article [Video].

https://academicguides.waldenu.edu/library/instructionalmedia/tutorials#s-lg-box-7955524

Walden University Writing Center. (n.d.). Writing literature reviews in your graduate coursework [Webinar].

https://academicguides.waldenu.edu/writingcenter/webinars/graduate#s-lg-box-18447417

World Health Organization. (2018, March). Questions and answers on immunization and vaccine safety.

https://www.who.int/features/qa/84/en/

Bystander Intervention to Prevent Sexual Violence: The Overlooked Role
of Bystander Alcohol Intoxication

Ruschelle M. Leone
Georgia State University

Michelle Haikalis
University of Nebraska—Lincoln

Dominic J. Parrott
Georgia State University

David DiLillo
University of Nebraska—Lincoln

Objectives: Bystander training is a promising form of sexual violence (SV) prevention that has
proliferated in recent years. Though alcohol commonly accompanies SV, there has been little consider-
ation of the potential impact of bystander alcohol intoxication on SV prevention. The aims of this
commentary are to provide an integrative framework for understanding the proximal effect of alcohol on
SV intervention, provide recommendations to spark novel research, and guide the application of research
to bystander programming efforts. Method: This commentary begins with a review of existing bystander
training programs and the need to target alcohol use and misuse in these programming efforts. Next,
pertinent alcohol and bystander theories and research are drawn to develop a framework for the proximal
effect of alcohol on SV intervention. Results: The well-established decision-making model of bystander
behavior (Latané & Darley, 1970) and alcohol myopia theory (Steele & Josephs, 1990) are used to
identify potential barriers to SV intervention that may be created or exacerbated by alcohol use.
Additionally, the ways in which alcohol may facilitate intervention are discussed. Conclusions: Specific
recommendations are made for elucidating the relationship between alcohol and bystander behavior and
testing the impact of alcohol at each level of the presented framework. Methodological and analytic
concerns are discussed, including the need for more multimethod studies. Recommendations to guide the
application of the present framework to SV prevention programming efforts are provided, and consider
how the proximal effects of alcohol impact intervention.

Keywords: alcohol myopia, bystander effect, prevention, sexual aggression, sexual assault

Through the myopia it causes, alcohol may tie us to a roller-coaster
ride of immediate impulses arising from whatever cues are salient.

—(Steele & Josephs, 1990, p. 923)

. . . situational factors, specifically factors involving the immediate
social environment, may be of greater importance in determining an
individual’s reaction to an emergency than such broad motivational
concepts as “apathy”. . . .

—(Latané & Darley, 1970, p. 127)

Bystander training is a promising form of sexual violence (SV)
prevention that has gained widespread favor in recent years

(DeGue et al., 2014). These programs train witnesses to intervene
in risky sexual situations, which often involve alcohol (Abbey,
2002; Testa, 2002). Though bystanders, if also intoxicated in these
situations, are undoubtedly susceptible to alcohol’s cognitive and
attentional influences, there is little empirical data to inform
whether intoxication on the part of bystanders interferes with their
ability to respond effectively to sexual risk situations. As such, the
principal aims of this article are to (a) propose an integrative
framework for the proximal effect of alcohol intoxication on by-
stander intervention when witnessing SV behavior (hereafter referred
to as SV intervention), (b) provide recommendations to stimulate new
lines of research, and (c) guide the application of research to bystander
programming efforts. This article begins by reviewing bystander
training programs and discussing the need to target alcohol use and
misuse in these programming efforts. We then provide a framework to
understand how the proximal effects of alcohol may influence SV
intervention by integrating pertinent alcohol and bystander theories.
This framework is the basis for specific recommendations for future
research and is used to guide potential applications of findings to
prevention programming efforts.

Review of Bystander Training Programming

Bystander training programs have proliferated on college cam-
puses in recent years as a key approach to SV prevention. In

This article was published Online First October 19, 2017.
Ruschelle M. Leone, Department of Psychology, Georgia State University;

Michelle Haikalis, Department of Psychology, University of Nebraska—Lin-
coln; Dominic J. Parrott, Department of Psychology, Georgia State University;
David DiLillo, Department of Psychology, University of Nebraska—Lincoln.

Ruschelle M. Leone and Michelle Haikalis contributed equally to this
work and share first authorship. Preparation of this article was supported in
part by National Institute on Alcohol Abuse and Alcoholism Grants
F31AA024692 awarded to Michelle Haikalis and F31AA024369 awarded
to Ruschelle M. Leone.

Correspondence concerning this article should be addressed to Ruschelle
M. Leone, Department of Psychology, Georgia State University, P.O. Box
5010, Atlanta, GA 30302-5010. E-mail: rleone1@gsu.edu

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Psychology of Violence © 2017 American Psychological Association
2018, Vol. 8, No. 5,

639

– 647 2152-0828/18/$12.00 http://dx.doi.org/10.1037/vio0000155

639

mailto:rleone1@gsu.edu

http://dx.doi.org/10.1037/vio0000155

contrast to traditional prevention approaches that seek to educate
about SV and shift rape-supportive attitudes (Banyard, Plante, &
Moynihan, 2004; DeGue et al., 2014; Söchting, Fairbrother, &
Koch, 2004), these programs focus on activating individuals to
intervene in a range of SV behaviors (Bennett, Banyard, &
Garnhart, 2014). Bystander programs serve two main functions:
(a) to prevent specific instances of SV from occurring by encour-
aging bystanders to engage in intervention when witnessing risky
sexual scenarios and (b) to lead a cultural shift by establishing
healthy social norms and dispelling rape-supportive attitudes that
contribute to SV (Fabiano, Perkins, Berkowitz, Linkenbach, &
Stark, 2003). By targeting individual-, peer-, and community-level
risk factors for SV, bystander programs answer the numerous calls
made for a multilevel, ecological approach to strengthen preven-
tion efforts (Banyard, 2011; DeGue et al., 2014). Evaluations
indicate that bystander training can attenuate attitudinal barriers to
action (e.g., rape-myth acceptance) and increase bystanders’ desire
to intervene in risky sexual situations (e.g., bystander intentions;
for review, see Katz & Moore, 2013). Though reducing rape-
supportive attitudes is desirable, examination of attitudinal out-
comes in isolation stops short of the main outcomes of interest,
namely, fostering bystander intervention behaviors and reducing
the occurrence of SV. A focus on attitudes alone is concerning,
given a recent review of SV training programs that target attitu-
dinal or knowledge outcomes are ineffective in producing behavior
change (DeGue et al., 2014). Moreover, only a few studies have (a)
examined whether bystander training leads to increases in self-
reported prosocial bystander behavior, and (b) demonstrated pos-
itive increases in prosocial bystander behavior following training
(Coker et al., 2015; Moynihan et al., 2015).

In-person training is the most common method of enlisting
bystanders to intervene and is typically conducted through presen-
tations or small group workshops, with audiences most often
consisting of U.S. college students. Online trainings have also been
developed, which ease the burden of dissemination and have the
potential to reach more individuals, more often (Jouriles et al.,
2016; Salazar, Vivolo-Kantor, Hardin, & Berkowitz, 2014).
Though details vary, trainings share many common components,
including SV awareness education, specific techniques to identify
sexual risk markers, education about bystanders’ responsibility
when they witness risk, and discussion about or practice engaging
in strategies to intervene in risky situations (for a review, see
Storer, Casey, & Herrenkohl, 2016). Trainings often include some
consideration of the well-established finding that alcohol is a
contributing factor of SV (Abbey et al., 2002) and focus on
encouraging students to recognize risk when in alcohol-related
contexts. This focus is particularly important, given that perpetra-
tor or victim alcohol intoxication is a factor in over half of sexual
assaults (Abbey, 2002; Testa, 2002) and that bystanders report
perceiving more barriers to intervention when a potential victim is
intoxicated (Pugh, Ningard, Ven, & Butler, 2016).

Though training bystanders to attend to alcohol-related risk is
helpful, programming efforts to date have not adequately ad-
dressed how alcohol use could influence bystanders themselves.
Thus, key questions remain. Are intoxicated individuals less likely
to recognize SV risk, less able to engage in bystander behavior, or
less effective at intervening? Relatedly, what are the mechanisms
by which alcohol might influence bystander witnessing or behav-
ior? Surprisingly, no study has directly examined the effects of

alcohol use on bystander behavior in the moment, and only three
studies have examined general links between bystander alcohol
use and bystander behavior. These latter findings demonstrate that
men who drink more heavily are less willing to intervene in SV
than men who do not drink heavily (Orchowski, Berkowitz, Bog-
gis, & Oesterle, 2016); heavy alcohol use is associated with a
lower likelihood of SV intervention among men but not women
(Fleming & Wiersma-Mosley, 2015), and bystanders fail to inter-
vene in the vast majority of bystander opportunities in bar settings
(Graham et al., 2014). Though these findings suggest possible
associations between alcohol use and bystander behaviors, the
field lacks evidence to inform our understanding of the impact of
acute intoxication on bystander behavior and the putative mecha-
nisms for this effect.

An Integrative Framework for the Proximal Effect of
Alcohol on SV Intervention

The most well-established model of bystander behavior (Ben-
nett et al., 2014; Burn, 2009), the decision-making model, posits
that bystanders must make a series of decisions to intervene: They
must (a) notice the event, (b) identify the situation as intervention
appropriate, (c) take responsibility to intervene, (d) decide how to
help, and (e) take action (Latané & Darley, 1970). Progressing
through these decision-making steps is important for bystanders to
engage in prosocial behavior; however, barriers at each step may
hinder intervention. As the number of perceived barriers increases,
the likelihood that a bystander will engage in SV intervention
decreases (Burn, 2009). Moreover, bystanders’ decision-making
does not necessarily follow a linear path, wherein each step is
subsequently achieved (Banyard, 2011). Depending on the devel-
opment of the witnessed situation, bystanders may take in new
information and regress to the previous steps. Further, although
decision-making is an internal process, bystanders are influenced
by contextual variables and previous experiences with witnessing
and intervening in SV, which impact current behavior (Banyard,
2011). The present article will use the structure of the internal
decision-making process outlined by Latané and Darley (1970),
while considering how context and previous experiences impact
this process at each step. We argue that alcohol intoxication
inhibits bystander behavior because it creates barriers at multiple
steps of the decision-making model. Before reviewing data in
support of this view, it is important first to establish how acute
alcohol intoxication is theorized to influence decision-making and
behavior.

Alcohol Myopia Theory

Alcohol myopia theory (AMT; Steele & Josephs, 1990) is one of
the most well-accepted explanations of the effects of alcohol
intoxication on behavior. AMT purports that the pharmacological
properties of alcohol impair attentional capacity and processes.
Specifically, this alcohol-related impairment has a narrowing ef-
fect on attention, also known as “alcohol myopia,” which restricts
the range of internal and external cues individuals perceive and
process. By impairing attentional capacity, intoxication causes
individuals to allocate or shift their limited attentional focus to the
more salient, immediate, and easier to process cues in the envi-
ronment. As a consequence, the full meaning of less salient cues is

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640 LEONE, HAIKALIS, PARROTT, AND DILILLO

never fully processed, or possibly even perceived. Importantly, the
content of the cues that are processed is posited to influence
subsequent behavior.

To help illustrate AMT, attention may be thought of as a
spotlight. When individuals are sober, the spotlight is wide and
focuses on both salient and less salient cues. However, when an
individual is intoxicated, the spotlight is narrow and focuses only
on the most immediate and salient cues in the environment, to the
exclusion of less salient cues. For example, in SV situations,
alcohol would inhibit intervention in cases in which myopia nar-
rows attention onto peers who condone forceful sexual behavior
(e.g., salient and immediate cue) rather than onto the sexual
disinterest or discomfort of the female (e.g., less salient and less
immediate cue). In other words, alcohol’s effect on behavior is
mediated by narrowed attentional capacity. Research in support of
the AMT is well documented, most pertinently in risky sexual
behavior and aggression (for a review, see Giancola, Josephs,
Parrott, & Duke, 2010).

Bystander Decision-Making: Alcohol as a Barrier
to Intervention

At each step of the decision-making model, common barriers are
reviewed, followed by a discussion on how alcohol intoxication
may facilitate additional barriers at each step (see Table 1).

Step 1. The first step toward bystander intervention is noticing
an event. Bystanders may fail to notice SV behaviors for several
reasons, such as not looking in the direction of sexual risk behav-
iors or due to self-focus or sensory distractions (Burn, 2009;
Latané & Darley, 1970). Alcohol increases susceptibility to dis-
traction or mind-wandering, lessening one’s ability to attend to
information, particularly when it is not especially salient, and
simultaneously mitigates the ability to notice one’s mind-
wandering (Sayette, Reichle, & Schooler, 2009). In other words,
inebriated individuals are more likely to “zone out,” and not realize
it, as compared with their sober counterparts. This likelihood that

intoxicated bystanders will be distracted from noticing a risky
event is particularly concerning, given that indicators of an un-
wanted sexual advance are often subtle (e.g., averted eye contact,
paralyzed reactions, and polite resistance).

Next, inattentional blindness, a phenomenon in which individ-
uals fail to detect salient unexpected objects in the field of vision
(Mack & Rock, 1998; Simons & Chabris, 1999), helps explain
why some individuals do not notice risk cues for nearby SV. For
example, experimental research that examines this phenomenon
has demonstrated approximately half of participants failed to no-
tice a woman in a gorilla suit walking across a basketball game
they were tasked with monitoring (Simons & Chabris, 1999). SV,
particularly less severe forms, may similarly go unnoticed by
bystanders whose focus is narrowed due to alcohol intoxication.
Recent laboratory-based research suggests alcohol intoxication
increases the likelihood of inattentional blindness due to its myo-
pic effects, which makes it difficult for individuals to allocate their
attention to information outside a directed goal (Clifasefi, Ta-
karangi, & Bergman, 2006). In most drinking environments, these
goals (e.g., focusing on one’s own conversation) may not routinely
encompass risk factors for SV experienced by others. Such find-
ings suggest that alcohol-facilitated inattentional blindness de-
creases the likelihood that intoxicated bystanders notice seemingly
obvious SV behavior.

Step 2. The second step toward intervention is identifying
the situation as intervention appropriate, or high in SV risk
(Burn, 2009). Bystanders can fail to identify a situation as
intervention appropriate due to ambiguity or ignorance. Here, it
is important to recognize that SV exists on a continuum that
ranges from heinous behaviors (e.g., rape) to actions much more
commonly accepted in society (e.g., unwanted sexual com-
ments; Stout & McPhail, 1998), which can escalate into more
severe behaviors. Not surprisingly, bystanders are more likely
to intervene in “dangerous emergencies” because they are less
ambiguous and induce higher levels of arousal than lower level

Table 1
Proximal Effects of Alcohol on Bystander Decision-Making

Step Barrier Influences Effects of acute alcohol intoxication

1. Notice an event Failure to notice Self-focus Increases susceptibility to distractions or mind-wandering
(Sayette et al., 2009)Sensory distractions

Inattentional blindness Exacerbates inattentional blindness (Clifasefi et al., 2006)
2. Interpret as intervention

appropriate
Failure to identify

situation as a risk
Ambiguity
Ignorance

Cue misinterpretation (Abbey et al., 2005; Farris et al.,
2010)

Failure to identify danger cues (Testa, Livingston, &
Collins, 2000)

Delay in identifying inappropriate sexual behavior (Gross
et al., 2001; Marx et al., 1997)

3. Take responsibility Failure to take
responsibility

Diffusion of responsibility
Attributions of victims’

worthiness

Narrow bystanders’ attentional focus toward other
potential intervenors

Narrow bystanders’ attentional focus toward victim’s
“worthiness” and “responsibility”

4. Decide how to help Failure to intervene due to
uncertainty or skills
deficit

Lack of skills Impairs high-order cognitive functioning, including
working memory, problem solving, planning, set
shifting, psychomotor speed, and response inhibition
(Curtin & Fairchild, 2003; Giancola, 2000) needed to
execute skills

5. Choose to act Failure to act due to
audience inhibition

Social norms Narrow bystander’s attention on salient peer norms

641BYSTANDER ALCOHOL INTOXICATION

transgressions (Fischer et al., 2011). Situations with greater
ambiguity impede bystanders’ ability to recognize risk. This is
concerning because bystanders are more likely to witness pre-
assault SV behaviors (e.g., inappropriate sexual conversations),
which are more likely to be viewed as ambiguous and thus less
likely to be identified as intervention appropriate, than they are
to witness ongoing acts of SV (Burn, 2009).

Interpreting complex situational and interpersonal cues is not an
easy task, and alcohol intoxication further compromises this pro-
cess. Indeed, intoxication distorts men’s ability to interpret a
woman’s affective cues by increasing their likelihood of interpret-
ing her behavior as sexually suggestive (Abbey, Zawacki, & Buck,
2005; Farris, Treat, & Viken, 2010). Similarly, intoxicated men,
relative to sober men, take longer to identify a male’s inappropriate
sexual behavior toward a female (Gross, Bennett, Sloan, Marx, &
Juergens, 2001; Marx, Gross, & Juergens, 1997), because its
ambiguity does not attract the drinker’s myopic or narrowed at-
tention. In other words, alcohol can distort or delay bystanders’
understanding of SV risk. Alcohol-induced myopia can also impair
women’s abilities to recognize danger cues that may subsequently
lead to SV (Parks, Levonyan-Radloff, Dearing, Hequembourg, &
Testa, 2016; Testa, Livingston, & Collins, 2000). Though a key
goal of bystander training programs is to increase awareness that
less severe forms of SV can escalate to more severe violence, the
influence of alcohol exacerbates ambiguity in sexual risk situa-
tions, thereby impeding intervention.

Step 3. Assuming that a bystander recognizes risk and sees
the situation as meriting intervention, the third step toward
intervention is taking responsibility to intervene. This step is
often obstructed by diffusion of responsibility, or the belief that
the onus of helping is shared among all bystanders. Extant
literature unequivocally demonstrates that the presence of oth-
ers is a robust situational cue that prevents bystanders from
intervening in nondangerous emergencies (for a review, see
Fischer et al., 2011). Failure to take responsibility is also
affected by beliefs about a victim’s “worthiness” (Burn, 2009).
Some men report that women are responsible for their own
safety, and thus do not feel responsible for intervening in SV
(Koelsch, Brown, & Boisen, 2012). Further, greater victim
blame is often placed on women dressed provocatively (What-
ley, 2005; Workman & Freeburn, 1999) or who have consumed
alcohol (for a review, see Grubb & Turner, 2012).

Intoxication can exacerbate the diffusion of responsibility for
intervening by narrowing bystanders’ attentional focus toward the
presence of others who conceivably could help, thereby thwarting
intervention. Alcohol can also facilitate attention toward perceived
norms regarding sexual behavior (a salient cue), such as the
victim’s “worthiness,” rather than toward risk for SV. For exam-
ple, if a victim is drinking alcohol, intoxicated bystanders are
likely to focus on the victim’s “responsibility” for the situation,
thereby inhibiting intervention behavior. Conversely, if prointer-
vention contextual cues are more salient than others’ mere pres-
ence or negative perceptions of victim’s “worthiness,” alcohol will
facilitate prosocial bystander behaviors via this attentional mech-
anism. For example, if the victim is a friend, the relationship to the
bystander may be more salient than the presence of others. Thus,
alcohol intoxication can conceivably increase the likelihood of
prosocial intervention behavior.

Step 4. The fourth step toward intervention is deciding how to
help, which may be impaired by a bystander’s a skills deficit or
uncertainty about what strategy to use (Burn, 2009). This barrier
has been identified as one of the most prevalent in SV intervention
(Bennett et al., 2014). Although training programs aim to prepare
bystanders to intervene by building behavioral skills (e.g., using
distraction) and increasing confidence necessary to intervene (Pot-
ter, Stapleton, & Moynihan, 2008), alcohol intoxication presum-
ably undermines bystanders’ ability to execute decision-making
skills. It is well established that acute alcohol intoxication impairs
high-order cognitive functioning, including working memory,
problem solving, planning, set shifting, psychomotor speed, and
response inhibition (Curtin & Fairchild, 2003; Giancola, 2000). As
such, intoxicated bystanders who would otherwise have the skills
and confidence to intervene are less able to effectively implement
a plan of action due to cognitive impairments induced by alcohol.
For example, individuals may not be able to implement a complex
plan to help due to impairments in working memory that prevent
them from holding parts of their plan in working memory long
enough to implement them. Moreover, intoxication may make it
difficult for bystanders to shift intervention strategies in response
to changes in or escalation of a perpetrator’s tactics.

Step 5. At the final step, choosing to act, the main factor that
may stymie intervention behavior is audience inhibition, or the fear
of negative evaluation from others (Burn, 2009; Latané & Nida,
1981). This barrier is likely more common among men due to
gender norms that prevent men from intruding in another man’s
“sexual conquest” (Burn, 2009; Carlson, 2008; Fabiano et al.,
2003), or the fear of losing respect from male peers if they
intervene (Carlson, 2008). Further, men exposed to male confed-
erates who promoted misogynistic, relative to ambiguous, peer
norms were significantly less likely to intervene in SV (Leone,
Parrott, & Swartout, 2017). Though the power of peer influence is
often identified as a barrier to intervention, social context can be
harnessed to increase engagement in prosocial behavior. In cases
of interpersonal violence that require multiple interveners, individ-
uals are more likely to engage in prosocial behavior when they first
see others intervene (Christy & Voigt, 1994).

We believe that these social context effects are exacerbated by
the myopic effects of alcohol, which focus a bystander’s attention
onto highly salient norms and the presence of others rather than SV
or its consequences. Although the combined effects of alcohol and
audience inhibition have yet to be studied, research that examines
general aggression indicates intoxicated, compared with sober,
participants administered higher levels of electric shocks to an
ostensible opponent within an experimental task when they were
observed by peer-confederates who applied social pressure (Taylor
& Sears, 1988). In this study, the myopic effects of alcohol likely
facilitated participants’ attention to aggression-promoting peer
norms and, as a result, facilitated aggressive behavior.

Alternatively, in a situation in which peer norms that condemn
SV are most salient, or others engage in helping behavior first, the
narrowed attentional capacity of the inebriate will be focused more
so on those prointervention cues, leaving little working memory
space to focus on less salient, and potentially intervention-
inhibiting, cues. As a result, intoxicated bystanders should be more
likely to intervene than nonintoxicated bystanders in SV situations.
Thus, this barrier may be attenuated by prosocial peers, particu-

642 LEONE, HAIKALIS, PARROTT, AND DILILLO

larly for intoxicated persons who are likely to be myopically
focused on that norm.

Limitations and Recommendations of Current
Research and Programming Efforts

Measurement of Opportunities and Behavior

Although bystander programs are informed by basic research
about helping behavior, little is known about how often bystanders
have an opportunity to intervene. Victims of SV have reported that
someone “saw what happened to (them)” in 18% of sexual assaults
(Hamby, Weber, Grych, & Banyard, 2016). However, this rate is
likely higher after accounting for those who witness preassault
behaviors (Burn, 2009). It is also unknown whether bystanders’
likelihood of witnessing opportunities to intervene in preassault or
assault behaviors is influenced by the presence of alcohol (e.g.,
setting involving drinking and bystander intoxication). Though
much SV occurs in private settings without bystander witnesses,
heavy drinkers may be more likely to witness SV because they are
often present in the public places SV is likely to occur (e.g., bars
and parties; Thompson & Cracco, 2008). Relatedly, bystander
presence, alone, does not equate to bystander opportunity to inter-
vene. For example, some situations involve high risk for potential
backlash effects of bystander behavior (e.g., physical harm to
bystander and “ruining the party”), which would make it difficult
or dangerous for bystanders to intervene when they witness sexual
risk cues. Given that alcohol use is a contributing cause of aggres-
sion (Parrott & Eckhardt, 2017), it is likely that the potential for
backlash effects is greater when bystanders and those with whom
they are intervening are intoxicated.

It is essential that future efforts to examine the effect of alcohol
on bystander behavior move beyond attitudes and intent to exam-
ine bystander behaviors. Further, it is not known whether skills
learned in bystander training programs are effectively imple-
mented by intoxicated bystanders. As such, behavioral outcomes
should be assessed in a way that allows researchers to parse out
training effects among intoxicated versus sober bystanders as well
as within alcohol versus nonalcohol contexts.

Measurement Method

When bystander behaviors are assessed, studies have relied
largely on self-report methods to measure primary outcomes (i.e.,
efforts to intervene). Perhaps this is because no validated measure
of bystander behavior existed until recently (see Banyard, Moyni-
han, Cares, & Warner, 2014). However, responses to these ques-
tions are likely susceptible to overreporting of bystander behaviors
by participants who want to appear to have “done the right thing.”
Biased reporting may be especially common among individuals
who underwent bystander training and therefore know the “right”
answers to bystander questions. Moreover, simply participating in
bystander training can increase individuals’ awareness of the be-
haviors that they already perform, potentially inflating differences
between those who have and have not completed training. Addi-
tionally, because respondents cannot report about opportunities to
intervene that they did not notice, these measures cannot assess the
total number of opportunities an individual has to intervene in SV.
Measures are needed to elucidate whether low rates of bystander

behavior are a result of a lack of opportunity or barriers in
intervention.

Multiple methods should be used to assess the proximal effects
of alcohol on SV intervention to combat the aforementioned lim-
itations of existing research, as well as to examine the full range of
bystander decision-making. There is an urgent need for researchers
to modify self-report measures (Banyard et al., 2014; Burn, 2009)
to examine intoxicated SV intervention. Specifically, new instru-
ments or adaptations of current instruments are needed to capture
the effects of distal and proximal alcohol use on opportunity to
intervene, and effectiveness of those interventions. For example,
intensive longitudinal methods, such as daily diary and ecological
momentary assessment, would be fruitful in identifying how often
intoxicated bystanders notice SV, whether they intervene, and
what barriers may have prevented them from engaging in prosocial
behavior. Daily dairy designs are more appropriate when assessing
behavior (e.g., alcohol use and SV intervention), whereas ecolog-
ical momentary assessment, which aims to minimize recall bias
and maximize ecological validity by repeatedly sampling partici-
pants in real time (Shiffman, Stone, & Hufford, 2009), is advan-
tageous to assess intrapersonal experiences (e.g., mood states).
This approach would be especially useful in examining percep-
tions of in-the-moment barriers to intervention while bystanders
are consuming alcohol.

The limitations of self-report could be addressed via comple-
mentary laboratory-based methods that are less susceptible to
reporting biases and afford experimental control over situational
predictors of SV intervention. Bystander analogue tasks (Leone et
al., 2017; Parrott et al., 2012) and virtual reality paradigms
(Jouriles, Kleinsasser, Rosenfield, & McDonald, 2016) allow re-
searchers to observe and quantify bystander behaviors directly.
Another benefit of these techniques, as well as written vignettes for
assessing bystander behaviors (Davis et al., 2012), is the ability to
manipulate various aspects of a given sexual risk situation (e.g.,
victim characteristics) and to examine the unique and interactive
effects of intoxication and bystander training on observable be-
havior. Because each laboratory paradigm has distinct advantages
and disadvantages, the strongest conclusions will be possible when
lab-based proxies are implemented in conjunction with self-report
measures.

Analytic Approach

Given the low base rates of SV intervention (Hamby et al.,
2016), it is critical that researchers use appropriate analytic tech-
niques to model these data accurately. Experimental and survey-
based research indicate �72–75% of bystanders do not engage in
SV intervention (Leone et al., 2017; Moschella, Bennett, & Ban-
yard, 2016), resulting in zero-inflated outcome data. Techniques to
normalize skewed data (e.g., square root transformation) are often
ineffective because a large proportion of the sample does not
intervene. Count-based analytic methods based on the Poisson
family are recommended, in line with recent calls to apply these
methods to SV perpetration data (for a review, see Swartout,
Thompson, Koss, & Su, 2015).

Proposed Research Agenda

Research examining SV intervention has grown considerably in
the past 15 years despite the absence of a theoretical framework for

643BYSTANDER ALCOHOL INTOXICATION

understanding the proximal effects of alcohol on bystander behav-
ior. Our integrative framework directly addresses this need and
provides a blueprint for future research to address the identified
gaps in the extant literature. In the following text, we review the
most critical gaps to consider in this work.

Examine Alcohol as a Barrier to Intervention

Research is needed to elucidate the extent to which intoxicated
bystanders witness behaviors along the SV continuum. Studies should
focus on capturing both the distal effects of heavy drinking patterns
and the proximal effects of acute alcohol use on bystanders’ oppor-
tunity to intervene, identification of SV behavior as high risk, and
prosocial behavior. In this work, it is critical to use methods that can
overcome the limitations of self-report, which include potential inac-
curacy in bystanders’ identification and interpretation of SV.

Research is also needed to understand the social-ecological context
in which the pharmacological effects of alcohol impair bystander
behavior. A variety of factors, including peer groups, cultures and
subcultures, fraternity or athletic team norms, social status, or neigh-
borhoods, may all impact this relation, and these factors need to be
considered to better understand the complexity of bystander decision-
making. For example, research indicates alcohol outlet density is
related to assault rates in unstable, poor, minority, and rural middle-
income areas (Gruenewald, Freisthler, Remer, LaScala, & Treno,
2006). Yet, nothing is known about how alcohol outlet density, or
other social-ecological factors, influence bystander decision-making.
Similarly, environmental factors common in social drinking contexts
(e.g., dark lighting and loud music) may thwart one’s ability to notice
or intervene in SV, and studies are needed to understand how by-
stander intoxication exacerbates these effects.

It is crucial to determine if and how diffusion of responsibility is
exacerbated under alcohol intoxication. A variety of contextual fac-
tors need to be considered when determining how diffusion of re-
sponsibility may come to fruition. For example, bystanders report
more responsibility to help if the victim is a friend, rather than a
stranger (Katz, Pazienza, Olin, & Rich, 2015). Thus, intoxicated
individuals, compared with sober individuals, conceivably focus at-
tention toward their friends in distress, rather than other potential
interveners. Research is also needed to determine if alcohol narrows
intoxicated bystanders’ attention on a victim worthiness, and if this is
influenced by individual-level characteristics (e.g., hostile sexism).

Little is known about the proximal effects of alcohol on the exe-
cution of behavioral skills to prevent SV. It is particularly important
to identify whether some skills (e.g., distraction) are more susceptible
to the impairing effects of alcohol than others (e.g., enlisting a friend’s
help). Methods of intervention that require multiple or complex skills
would be difficult for intoxicated bystanders to implement. Findings
that alcohol is also associated with increased physical aggression
(Giancola et al., 2010) suggest that bystanders who are intoxicated
could become overzealous in their attempts to intervene, potentially
leading to aggressive altercations.

Empirical evidence is needed to identify how audience inhibi-
tion serves as a barrier across various situational contexts. Risky
environments (e.g., fraternity parties) and social networks (e.g.,
athletic teams), which have higher rates of alcohol-related SV
(Foubert, Newberry, & Tatum, 2007), should be examined to
determine how the myopic effects of alcohol focus bystander’s
attention onto salient SV risk cues or peer group norms minimizing

SV risk in these contexts. Relatedly, understanding the interactive
effects of individual- and situational-level factors on intoxicated
bystander’s decision-making is needed.

Work is also needed to identify the specific components of by-
stander training programs that are most responsible for change. Dis-
mantling studies would allow for investigation into the unique effects
of alcohol-specific training related to each step of Latané and Darley’s
(1970) decision-making model (e.g., noticing risk in party settings).
Further, the outcomes measured in training programs’ efficacy studies
should be specific; rather than examining increases in bystander
behavior broadly, it will be important to examine intervention in
drinking settings and while intoxicated to determine if the effects of
training are maintained under these conditions.

It is vital that researchers examine gender differences across the
decision-making model. Research suggests men are more likely to
exhibit helping behaviors than women (Eagly & Steffen, 1986);
however, this work may not apply to SV intervention (Brown,
Banyard, & Moynihan, 2014). Indeed, barriers to intervention and
mechanisms may vary by gender (Brown et al., 2014). For exam-
ple, men report more barriers than women (Burn, 2009) and fewer
bystander behaviors (Banyard & Moynihan, 2011). It is crucial to
identify how barriers and intervention behaviors differ between
men and women, and whether alcohol use explains any differ-
ences. Given these gaps in the literature, it is not surprising that
research on SV intervention among nongender-conforming indi-
viduals is nonexistent and merits investigation.

The intersection of social identities such as race/ethnicity, gen-
der, socioeconomic status, and sexuality (see Cole, 2009, for
review) of the victim, perpetrator, and bystander should be con-
sidered to examine how privilege and oppression impact interven-
tion. For example, students of color could not feel safe intervening
in SV on predominantly White campuses without peer support
(Brown et al., 2014). Alcohol could impact this effect in a variety
of ways depending on the salience of cues in the environment. For
example, alcohol could lead to either mitigated safety concerns and
increased “liquid courage,” or increased anxiety about safety or
peers’ reactions to helping behavior and decreased likelihood of
intervening. The effects of acute alcohol intoxication on anxiety
depend on the temporal relationship between alcohol consumption
and exposure to anxiogenic cues (Sayette, 1993). For example, if
an individual has safety concerns before attending a party and
consuming alcohol, these concerns are likely exacerbated and
inhibit intervention. However, if safety concerns arise following
intoxication, they may be overlooked. Research aimed at increas-
ing SV intervention should investigate if, and under what condi-
tions (e.g., minority status in a situation), alcohol intoxication
leads to increased “liquid courage” or “liquid fear” in the face of
bystander opportunity. Similarly, the combined effects of racism
and sexism may influence attributions of “victim worthiness.”
Given evidence that exposure to alcohol cues primes racial bias
(Stepanova, Bartholow, Saults, & Friedman, 2012), it is possible
that alcohol intoxication and/or contexts inhibit intervention by
eliciting biased attributions of victim worthiness.

SV intervention research has overwhelmingly focused on col-
lege undergraduates (Carlson, 2008) or students in their first se-
mester (Bennett et al., 2014). Thus, research is needed across all
years in college, as well as with high school and young adult
community samples. Indeed, the majority of youth have consumed
alcohol by grade nine and one third of high school students report

644 LEONE, HAIKALIS, PARROTT, AND DILILLO

consuming alcohol in the previous 30 days (Centers for Disease
Control and Prevention, 2016), and research indicates comparable
rates of SV (Finkelhor, Shattuck, Turner, & Hamby, 2014).

Can Proximal Alcohol Use Promote Intervention?

Although we argue that alcohol predominately inhibits SV inter-
vention, as noted earlier, AMT makes the counterintuitive prediction
that alcohol can also increase prosocial behavior in situations in which
prointervention cues (e.g., support of peers) are more salient than
barrier-related cues. In this manner, it is possible to harness alcohol’s
myopic effects to promote prosocial bystander behaviors. Thus, in-
terventions aimed at enhancing the salience and immediacy of proin-
tervention cues could prompt intoxicated persons to intervene. Re-
search indicates intoxicated individuals were faster, but not more
likely, to come to the aid of an experimenter who dropped items (van
Bommel, van Prooijen, Elffers, & Van Lange, 2016), likely because
individuals have less attentional capacity to focus on both the benefits
and costs of helping than sober individuals. Research is needed to
determine how alcohol can help attenuate the bystander effect, and
what cues (e.g., consequences of not intervening) are most effective to
increase SV intervention.

Recommendations for Bystander
Training Programming

As reviewed, few findings address the role of alcohol consump-
tion in SV intervention, and thus, our goal is to provide recom-
mendations that should be considered in developing theory-
informed prevention strategies before evidence exists. Until an
evidence base exists, which can support this framework, any
modifications to current efforts should be implemented with cau-
tion and ongoing evaluation.

First, bystander training programs should attend to how alcohol-
intoxication impacts bystanders themselves, rather than just vic-
tims and perpetrators of SV. Specifically, efforts are needed to (a)
reduce heavy drinking, (b) educate bystanders on the potential
impairing effects of alcohol on intervention, and (c) train bystand-
ers how to be effective interveners when drinking. Training pro-
grams should promote awareness of the influence of alcohol and
encourage problem-solving strategies to compensate for potential
alcohol-specific barriers and maximize the likelihood that proxi-
mal alcohol use can actually promote SV intervention.

Reflecting the notion that bystander training should target outer
levels of the social ecology (Banyard, 2011), social marketing
campaigns have also emerged as a means of disseminating the
bystander message more widely (Potter & Stapleton, 2012; Bor-
sky, McDonnell, Turner, & Rimal, 2016). Exposure to these cam-
paigns is associated with more positive attitudes toward bystander
behavior and self-reported increases in SV intervention (Potter &
Stapleton, 2012). These campaigns allow for easy incorporation of
information about alcohol’s potential impact on bystander behav-
ior. For example, a campaign depicting a split-screen sexual risk
scenario with an intoxicated and a sober bystander on each side of
the screen could raise awareness about the potential for alcohol to
inhibit one’s ability to effectively intervene to help a friend.

Next, laws and policies at the community level should be closely
examined and altered to reduce heavy drinking and encourage
bystander behavior. If, in fact, sober individuals encounter fewer

barriers to intervention than intoxicated individuals, evidence-
based efforts to reduce heavy alcohol use—including college bans
or limits on alcohol or restricting alcohol outlet density (for a
review, see Toomey, Lenk, & Wagenaar, 2007)—may in turn
increase SV intervention. Similarly, laws that encourage and pro-
mote SV intervention should be considered, including those that
require witnesses to inform law enforcement of crimes (see Swan,
2015) and those that protect reporters of crimes from punishment
for underage alcohol use.

The next wave of prevention programming should move beyond
college campuses and consider other “hotspots” for SV where
bystanders are often present (e.g., alcohol-serving establishments,
house parties, and military bases). For example, bars and clubs
play an important role in bystander decision-making by creating a
safe environment for patrons to engage in intervention behavior.
Environmental antecedents of SV such as misogynistic music or
sexual décor (Graham, 2009) may set SV norms that become
salient among intoxicated patrons and thwart intervention. Amend-
ing such contextual cues will help to transform local SV norms
and, if replaced with prosocial or feminist messages, will help to
ultimately promote SV intervention. Moreover, because bars and
parties are not the only places SV is likely to be witnessed,
interventions could also target peer groups that are a greater risk
for witnessing SV (e.g., fraternities, student-athletes, and attendees
at music festivals). These groups could be targeted in various
ways, including through social media via targeted messages that
aim to change norms and behaviors. Ultimately, addressing the
role of alcohol use on SV intervention at multiple levels of the
social ecology will have the greatest likelihood of increasing
bystander behavior and helping to reduce rates of SV.

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Received February 6, 2017
Revision received July 6, 2017

Accepted August 9, 2017 �

647BYSTANDER ALCOHOL INTOXICATION

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Bystander Intervention to Prevent Sexual Violence: The Overlooked Role of Bystander Alcohol Into …

Review of Bystander Training Programming
An Integrative Framework for the Proximal Effect of Alcohol on SV Intervention
Alcohol Myopia Theory
Bystander Decision-Making: Alcohol as a Barrier to Intervention
Step 1
Step 2
Step 3
Step 4
Step 5

Limitations and Recommendations of Current Research and Programming Efforts
Measurement of Opportunities and Behavior
Measurement Method
Analytic Approach
Proposed Research Agenda
Examine Alcohol as a Barrier to Intervention
Can Proximal Alcohol Use Promote Intervention?
Recommendations for Bystander Training Programming
References

SOCIAL
WORK
PRACTICE &
SKILL

Author
Laura Gale, LCSW

Cinahl Information Systems, Glendale, CA

Reviewer
Jessica Therivel, LMSW-IPR

Cinahl Information Systems, Glendale, CA

June 14, 2019

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2019, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Biopsychosocial-Spiritual Assessment: an Overview

What is Biopsychosocial-spiritual Assessment?
› The social work profession is unique among healthcare disciplines in its emphasis on

assessing and treating the client from a person-in-environmentperspective, meaning that
social workers conceptualize the client and his or her physical and mental health needs
as existing within a social context. The social worker not only looks at psychological or
physical needs but also assesses how the client is affected by his or her environment and
how the client’s spirituality influences his or her overall sense of well-being.Spirituality
can be defined as one’s religious beliefs and practices as well as one’s sense of purpose
and meaning in life. The professional social worker understands the client as being not
only a psychological, spiritual, and physical entity, but also a person who is socially
engaged in relationships and who interacts with his or her environment. As the term
indicates, a biopsychosocial-spiritual assessment evaluates the client in four domains:
biological, psychological, social, and spiritual. This assessment is both the process of
gathering information about these domains and their interactions and a written document
that is used to determine treatment goals and objectives for the client
• What:Biopsychosocial-spiritual assessment is a holistic approach to understanding

the client’s experiences, including his or her physical and mental health. The
biopsychosocial-spiritual assessment is the primary means used by the social worker
to evaluate a client’s treatment needs. It consists of a variety of activities and processes
used to gather information about a client’s current circumstances, needs, risk and
protective factors, and the environmental context within which these elements exist.
These elements are organized into a written document, which is used to determine
treatment goals and objectives. In mental health settings, the biopsychosocial-spiritual
assessment is also used to help determine the mental health diagnosis for the client.
While the specifics of each assessment will vary based on the client’s age and
challenges, a biopsychosocial-spiritualassessment will always include information from
all four domains

• How: A biopsychosocial-spiritual assessment is completed through observation and
clinical interviews, standardized screening tools, and review of existing records. The
sources of information vary according to the client’s age, circumstances, and problems.
Informants may include the client, his or her family members, other individuals
determined to be significant by the client, and other professionals who have worked
with the client in the past or are currently working with him or her. Because the
client’s perspective on his or her needs and resources can differ substantially from
the professional’s perspective, the client is included in the biopsychosocial-spiritual
assessment and is the key provider of information. Consistent with the value placed
by the social work profession on client self-determination, a biopsychosocial-spiritual
assessment is a collaborative process between the social worker and the client.
Biopsychosocial-spiritualassessments are initially completed at the time of intake (or
over the first several sessions with the client). However, the content of the assessment is
continually reevaluated as the client’s physical, psychological, social, and spiritual needs
and resources change and as new information arises throughout the course of treatment

• Where: A biopsychosocial-spiritual assessment can take place in any setting,
including inpatient or outpatient clinics, healthcare facilities, the client’s home,
or other community settings. A social worker will often choose to conduct a

biopsychosocial-spiritual assessment in multiple settings in order to observe the client’s
interactions, relationships, and behaviors in a variety of contexts

• Who: Biopsychosocial-spiritual assessments are used by social workers as a primary means of assessment. However, other
clinicians, including physicians and nurses, also incorporate aspects of the biopsychosocial-spiritual assessment into their
practice. Biopsychosocial-spiritual assessments are used to assess all clients, including children, adolescents, adults, older
adults, and families

What is the Desired Outcome of a Biopsychosocial-spiritual Assessment?
› The desired outcome of a biopsychosocial-spiritual assessment is a complete understanding of the complex interactions

that take place between the biological, psychological, social, and spiritual domains of a client’s life. A thorough and
accurate biopsychosocial-spiritual assessment will determine the best course of treatment and identify specific treatment
goals and interventions that are most appropriate for the client. This will result in a higher likelihood of resolution of the
client’s concerns. Through the social worker’s development of a complete understanding of the client in the collaborative
biopsychosocial-spiritual assessment process, the client will feel fully understood by the social worker, which will result in
the development of trust and a therapeutic working relationship between the client and the social worker and an increased
utilization of services by the client

Why Are Biopsychosocial-spiritual Assessments Important?
› Social workers are usually employed by social institutions such as hospitals, correctional facilities, and child welfare

departments. Even social workers who work in private practice settings come into contact with social institutions as they
help their clients navigate their social environments. Therefore it is critically important to understand how these institutions
impact the client and how the client interacts with them. The emphasis of the biopsychosocial-spiritual assessment on the
interaction of the client and his or her environment helps the social worker understand this dynamic and any barriers to
services provided by these institutions that clients might experience

Facts and Figures
› Studies illustrate the complexities of the interactions between the physical (i.e., biological), psychological, social, and

spiritual aspects of the client’s lived experience and the need to assess and intervene in all four domains
• Quality of life is higher for persons with paraplegia when they a have strong sense of spiritual well-being (Finocchiaro et

al., 2014)
• Persons with schizophrenia have more chronic health conditions than persons without schizophrenia, including congestive

heart failure, chronic obstructive pulmonary disease, and hypothyroidism. They also have higher rates of dementia than
those without schizophrenia (Hendrie et al., 2014)

• Risk for obesity and type 2 diabetes mellitus is higher for older women living in disadvantaged neighborhoods. Researchers
found that as neighborhood characteristics improve, body mass decreases (Corriere et al., 2014). Neighborhood
characteristics also influence depressive symptoms. Investigators for a separate study found that study participants with
type 2 diabetes who lived in neighborhoods that were more affluent, had more residential stability, and whose residents
had higher levels of education and professional occupations had fewer depressive symptoms than participants with type 2
diabetes who lived in less advantaged neighborhoods (O’Donnell et al., 2015)

• Researchers have found that social support islinked with spiritual well-being and better health outcomes in institutionalized
older adults (Chen et al., 2017)

• Researchers studying the impact of social relationships on health found that social integration (particularly social
connections in adolescence and social support in older adulthood) was associated with lower risk ofphysical dysregulation
(Yang et al., 2016)

What You Need to Know Before Proceeding with a Biopsychosocial-spiritual
Assessment
› In order to understand the complexities of the interactions between the four domains, information for

a biopsychosocial-spiritual assessment should come from a variety of sources. Before completing a
biopsychosocial-spiritualassessment, the social worker should be aware of the types of sources available and what
information can be obtained from each. These sources include
• A review of client case records

– Review of the client’s medical and/or mental health records can assist the social worker in understanding current and past
medical or mental health concerns, medications, and compliance with treatments. It will also provide information on past

treatments that have been successful and give the social worker an idea of what risk factors to assess for (e.g., suicidal
ideation, self-harming behavior, psychosis, aggression). It can also help the social worker develop a historical timeline
of the overall course of the client’s medical or mental health needs. For a child, adolescent, or student client, a review of
academic records such as grades and behavior reports is needed. This provides information about the student’s academic
strengths and challenges. For children and adolescents in special education, a review of the student’s individualized
education plan (IEP) is needed. An IEP is an individualized learning plan that outlines the student’s learning disabilities
and sets academic goals and objectives for the student for the coming academic year. An IEP can provide information
about how the student’s learning disabilities affect his or her academic success and outlines interventions that the school
has used to support his or her learning needs. For students with receptive or expressive language difficulties, a review
of the IEP can assist the social worker in understanding how to best communicate with the child in treatment and how
he or she experiences and interacts with others. The drawback of using record review as a source of information is that
records tend to be deficits-based instead of strengths-based. Rather than focusing on client strengths and resiliencies, they
focus on the client’s needs. Care should be taken to give as much weight to other sources of information such as client
interviews and observations of the client in his or her environment in order to prevent social worker bias and failure to
recognize the client’s strengths and competencies

• Verbal report from the client
– All biopsychosocial-spiritual assessments should include an interview with the client. The value placed in social work

on client self-determination dictates that clients should be involved in all aspects of their treatment to the extent of their
ability. In fact, the primary source of information for the biopsychosocial-spiritual assessment should be the client him-
or herself. The client’s own perspective on his or her needs and strengths may be very different from those held by social
workers or other professionals. Understanding the client’s perspective is critically important in order to develop goals
that are consistent with the client’s concerns. Client interviews can provide the social worker with factual information
such as identifying information, problems, historical information, cultural information, and spirituality. However, a skilled
interviewer will also be able to elicit more personal information from the client, such as his or her perception of his or her
relationships with others, interactions with the systems that are present within his or her life, his or her sense of safety and
belonging in the community, and how he or she finds a sense of purpose and meaning in life

– Adolescents should participate in their own biopsychosocial-spiritual assessment. Adolescence is a key stage of growth
and development, in which the individual begins to form his or her own identity and develop personal and environmental
resources that will help him or her navigate the transition to adulthood (Sales & Irwin, 2013). Understanding the
adolescent’s own perception of his or her mastery of these transitions and his or her needs and strengths is important to
developing an understanding of the client within his or her environment. Interviews with adolescents can be facilitated
by encouraging the client to share media content (e.g., music lyrics, movies) that he or she feels relates to his or her own
experiences and by encouraging the client to share his or her interests and discuss peer and family relationships

– Even very young clients can participate in direct client interview. For young children, gathering of verbal information
may be assisted by the use of play-therapytechniques. Play is the primary way in which children learn about the world and
make sense of their experiences. The social worker can use objects and toys that facilitate storytelling, such as puppets
and dollhouses, and art therapy techniques to help the child communicate his or her feelings, challenges, and experiences.
Young children who have developed verbal skills will be able to provide information on their basic emotional state
(e.g., happy, sad, mad) and basic information about their fears and interests. Because young children experience and
understand their environment very differently from adults, this direct client information is critical to understanding the
biopsychosocial-spiritual needs of the young client. The young child’s perception of why he or she is being seen by the
social worker is a critical starting point for building a therapeutic relationship with the child and should be determined
during the assessment process

– Direct interview of older adults can give the social worker a sense of the senior’s cognitive abilities. Older adults can
often provide rich historical information about their lives and often have a strong sense of spirituality or purpose, which
can be identified as a source of spiritual and psychological strength for the client

– When working with families, individual interviews with each family member as well as a group interview with all
members are necessary. In addition, the social worker may wish to interview dyads, such as the parents or caregivers
together, or specific sibling sets. In this way the social worker can gather information about the strengths and needs of
each family member, as well as the family as a whole. Conducting multiple types of interviews with client families will
also give the social worker an understanding of the ways in which family members relate to one another, alliances and
conflicts that might exist, and how each family member perceives the others

• Direct observation
– A major source of information for the biopsychosocial-spiritual assessment is the social worker’s direct observation of

the client in a variety of environments. Observation of clients can take place during the direct client interview, as well

as through observations of the client in his or her environment. During environmental observations, the social worker
may choose not to interact with the client, but rather to observe the client’s natural way of interacting with his or her
environment (e.g., observing how a child interacts with his or her peers at school). Nonverbal information about the client
can be observed in his or her manner of dress and in the body language and facial expressions he or she uses with the
social worker and others, including family members, friends, and other professionals. Observations can be made about the
client’s executive functions, such as flexibility, problem-solving skills, and frustration tolerance

– Observations of adolescents can take place at school and in peer groups as well as during joint interviews with the
adolescent and the adolescent’s caregivers. Observations of the client in the classroom can provide the social worker
with information on the client’s interactions with authority figures, as well as his or her ability to handle frustrations or
redirection from authority figures. Observing peer interactions provides information about the client’s social development
and the quality and type of peers with whom he or she associates. Family dynamics and style of resolving conflicts can be
observed during joint interviews with the adolescent’s caregivers

– Observing children at home and at school, both in the classroom and on the playground, can provide the social worker
with a wealth of knowledge about the child’s relationships with peers and teachers, the child’s level of impulse control,
and his or her emotional, verbal, and cognitive development in relation to that of peers. Observing interactions between
the child and the caregiver can give the social worker a sense of the family dynamics, the child’s attachment to the
caregiver, and how the child responds to the caregiver’s parenting style

– Observing older adult clients in the home environment can help the social worker gather information on the client’s level
of isolation and whether basic needs are being met. Any physical or mobility restrictions can be noted, as well as the older
adult’s ability to adapt to any limitations that are present

– When working with families, it is important to observe interactions between each family member and within specific
dyads, as well as the interactions of the family as a whole. Through observation the social worker can gather information
about the structure and boundaries of the family, the family’s style of addressing and resolving conflicts, and the ways
in which family members engage positively with one another. Observing interactions between the identified client in the
family (i.e., the family member whom the family identifies as having the problem) and other family members can also
provide information about how the family as a whole might be contributing to the family dynamics

• Information from collateral sources
– Collateral sources include caregivers, family members, teachers, employers, and friends. Other professionals can be

valuable sources of information as well. Family members will perceive the client’s challenges and strengths differently
from the client him- or herself and can provide firsthand information about the client’s behaviors and their impact on
the family system. Adolescents and their caregivers often have very different perceptions of the adolescent’s needs
and resources. For children, family members or guardians may be the primary source of historical information such
as developmental history, school attendance, and medical background. If an older adult client is dependent on others
for physical or financial support, the adult children or caregivers of the older adult should be interviewed in order to
understand the level of support or distress that these relationships may present for the older adult and to alert the social
worker to any signs of neglect or abuse. Social workers should understand that family members may present information
based on their own biases. Care should be taken to evaluate all sources of information and not rely too much on negative
views of the client presented by others. Other professionals such as employers and teachers can also be good sources of
information. Persons outside of the family system may evaluate the client’s interactions and behaviors based on the norms
and values of the systems within which the client interacts (i.e., school or work). This perspective can give the social
worker an idea of how the client is functioning in systems outside of the family

• Standardized screening instruments
– Although all of the sources of information mentioned thus far provide subjective information about the client,

standardized screening instruments can be used to gain objective information on the client’s functioning. Social workers
can choose from a variety of screening tools based on the issues and concerns of the client. Some of these tools are
completed by the client and others need to be completed by the social worker or other trained professionals. Although
screening tools should not be used in exclusion to diagnose or determine client needs, they can alert the social worker
to symptoms or needs that might not otherwise be identified. Numerous screening tools are available that screen for
specific symptoms or disorders. Below is a sampling of tools that are exceptionally useful for biopsychosocial-spiritual
assessment because they screen generally for needs in one domain, screen for concerns in multiple domains, or examine
the relationship between two or more domains
– The WHO Quality of Life spiritual,religious, and personal beliefs scale, brief format (WHOQOL-SRPB_BRIEF), is a

34-item screening tool designed to evaluate personal, spiritual, and religious beliefs and religious practices (Skevington
et al., 2013)

– The Spiritual Well-Being Scale evaluates both existential and religious ideas about spirituality. It is a 20-item scale,
with 10 items that measure religious well-being and 10that measure existential well-being. The tool is not based on any
specific religion or spiritual ideology

– Psychological Adjustment to Illness Scale–Self Report (PAIS-SR) is a 46-item tool that measures the quality of
psychosocial adjustment to illness in seven categories: healthcare orientation, vocational environment, domestic
environment, sexual relationships, extended family relationships, social environment, and psychological distress

– The Achenbach System of Empirically Based Assessment (ASEBA) is a series of assessment tools that can be used to
assess clients between the ages of 1.5 and 90. The ASEBA evaluates the client’s competencies, strengths, and adaptive
functioning, as well as behavioral, emotional, and social concerns. Scales vary based on the client’s age. For all ages,
scales are available that are to be completed by the client through self-report, as well as scales that are to be completed
by others who know the client such as parent, teachers, or significant others (ASEBA, n.d.; Rescorla, 2009)

– The Strengths and Difficulties Questionnaire (SDQ) is a 25-item standardized screening tool for use with adolescents.
The SDQ incorporates five subscales: hyperactivity/inattention; emotional, conduct, and peer relationship problems;
and prosocial behaviors. The SDQ is available in 40 languages and has been found to be reliable across socioeconomic
groups (He etal., 2013)

– The Child and Adolescent Functional Assessment Scale (CAFAS) is a tool used to measure the extent to which the
functioning of a child or adolescent (ages 7–17) is impacted by a mental health or substance use disorder. A professional
trained in the administration of the CAFAS must complete the scale. The CAFAS measures functioning in eight areas:
school/work, home, community, behavior towards others, mood and emotions, self-harm, substance abuse, and thinking
(Holosko et al., 2013)

– The Problem-Oriented Screening Instrument for Teenagers (POSIT) is self-administered and assesses 10 areas of
functioning: substance use, physical health, mental health, family relationships, peer relationships, educational status,
vocational status, social skills, leisure and recreational activity, and aggressive behavior and delinquency (Holosko et al.,
2013)

– HEADS-ED (Home, Education, Activities/Peers, Drugs/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources)
is a brief, standardized assessment tool that has been found to be effective in identifying a wide range of adolescent
concerns. Benefits of using HEADS-ED include the use of an easy mnemonic device to guide the interview process and
no additional training needed to interpret (Cappelli etal., 2012)

– Ages and Stages Questionnaire (ASQ) is a parent-completed screening tool used to identify social, emotional, and
developmental delays in children between 1 and 66 months old. The ASQ, which identifies both developmental
strengths and concerns, assesses children’s social and emotional concerns in the areas of self-regulation,compliance,
adaptive functioning, autonomy, affect, interaction with others, and social communication. Nine screening tools are
available for children of different ages (San Antonio et al., 2014)

– Ecomaps, culturagrams, and genograms are assessment tools that use diagrams to assess the environmental context of the
client. All are visual representations of the client’s environment and can be completed using simple tools such as paper
and pencil/pen
– In an ecomap, the client or family is drawn in a circle in the center of the page and the individuals, systems, activities,

and resources of the client are drawn in circles surrounding the client or family
– A culturagram is an assessment tool used to examine the role that culture plays in a client’s life. It is particularly useful

for clients or families who have recently immigrated or for second- or third-generation immigrants
– A genogram is used to assess the history, relationships, and dynamics of multiple generations within a family. A

genogram is a graph that has levels to capture information on each generation of the family

Social Work Responsibilities in Regard to Completing a Biopsychosocial-spiritual
Assessment
A biopsychosocial-spiritual assessment will contain different elements depending upon the age and concerns of the client.
Throughout the process it is important to remember that the client is considered the expert on his or her problems and that each
client has resources that can be identified and utilized to help resolve his or her concerns. Clients should be allowed to maintain
control of the process and identify their own priorities for treatment. Social workers should be assessing all of the following
areas, although the emphasis placed on each will vary by client
› Identifying demographic information

• The social worker should note the client’s name, age, marital status, contact information, referral source, and living
arrangement. Emergency contact information, and, if relevant, billing information should be included

• Presenting concerns: Presenting concerns are the issues for which the client has come into contact with the social worker.
Presenting concerns may arise in any domain. Physical concerns may include pain management or palliative care needs;
psychological concerns may include depression, anxiety, substance use, or other mental health issues. The client may
need help with social factors such as difficult family relationships, feelings of isolation, financial concerns, or a lack of
social supports. Other social concerns may involve larger social systems such as difficulty accessing medical benefits, a
need for housing or welfare benefits, or assistance navigating the complexities of the child welfare or education systems.
Clients may have spiritual concerns, including existential questions about the meaning of life, or may need assistance
with integrating their spiritual beliefs with other belief systems. When working with families as clients, the social worker
may need to help the family identify the presenting concern of the whole family unit by bringing together the individual
viewpoints of each member. It should be noted that the concerns of the client can be significantly different from the
concerns of professionals or the referral source. Information on presenting concerns should be obtained from the referral
source as well as from the client. The social worker should establish a timeline that indicates when the concern first arose
and whether it has continued, abated, or increased over time. The client’s ideas about the causes of the concern and how he
or she has attempted to address it should be noted

› Assessment of risk factors
• All biopsychosocial-spiritual assessments should include an assessment of risk factors, which should take place

early in the assessment process. Risk factors will need to be addressed immediately, before completion of the
biopsychosocial-spiritualassessment. Critical risk factors to assess include
– Current or past suicidal ideation or self-harm

– Clients should be asked directly about any current or past suicidal ideation or attempts. For those clients with current
ideation or past attempts, further assessment should be conducted to determine current level of risk, whether the client
has a plan for suicide, and if so if he or she has the means to carry out the plan. For clients with active suicidal ideation,
the biopsychosocial-spiritual assessment process should be delayed until safety of the client has been established
through psychiatric hospitalization or other appropriate means. For those clients who report no active suicidal ideation
but admit to suicidal ideation in the past, the social worker should explore triggers and risk factors. These may include
biological factors (e.g., extreme, unmanaged pain), psychological factors (e.g., increases in depression), social factors
(e.g., strained relationship with a loved one, high levels of work or home stress), spiritual factors (e.g., lack of a sense of
meaning for life), or a combination of factors

– Clients should also be asked directly if they have any history of self-harming behavior (e.g., cutting or burning
themselves). Although not all self-harming behavior is related to suicidal ideation, it can still present a significant
physical risk for the client and indicates that there is severe psychological distress taking place. The social worker may
ask to see any scars or other physical evidence of self-harming behavior in order to assess its severity and how recently
it took place. For clients with active self-harmingbehavior, safety should be established first through a non-harm
contract or other means. Once safety has been established, as with suicidal ideation triggers and risk factors should be
assessed

– Danger to others
– All clients should be assessed for current ideation or plans for hurting others. In the United States, if the client is

threatening to harm another person social workers in most states are obligated by law to break confidentiality and
take reasonable steps to protect the potential victim or victims either through warning the victim directly or through
contacting law enforcement (National Conference of State Legislatures, 2015). Social workers should follow state, local,
and facility protocol when responding to client violence or potential violence

– Grave disability
– Some clients may be a danger to themselves not through suicidal ideation but because they are unable to take care of

their own basic needs for food, shelter, and clothing as a result of a severe mental health disorder or cognitive decline.
Social workers should follow applicable state, local, and facility protocol when responding to grave disability. Possible
signs of grave disability include
– Physical: Disheveled or dirty clothing, public nudity, if the client has poor hygiene, malnutrition or dehydration, or an

inability of the client to consume food or water due to mental health symptoms or cognitive decline
– Psychological: severe paranoia, hallucinations, or catatonia that prevents the client from taking care of his or her basic

needs
– Social: an inability to establish or maintain consistent shelter due to mental health symptoms or cognitive decline

– Child maltreatment
– All children and adolescents should be assessed for current or past maltreatment. Child maltreatment includes

psychological, physical, or sexual abuse and neglect. Children and adolescents can be asked directly about their

experiences of maltreatment, but may not be forthcoming with information because of fear of the consequences of
reporting (e.g., further abuse or punishment from the abuser, fear that they may be removed from their home), because
of mistrust of adults, or because of feelings of shame. The social worker may need to rely on direct observation,
collateral reports, or historical records to accurately assess. If child maltreatment is suspected, the social worker should
follow local reporting laws and agency/facility protocol. Although none of these symptoms should be used to identify
child maltreatment on its own, possible signs of child maltreatment include
– Physical: unexplained injuries, bruising, cuts, current or past sexually transmitted diseases, pregnancy, dirty clothing or

signs of poor hygiene, failure to meet developmental milestones
– Psychological: impulsivity or inattention, changes in behavior (e.g., increased anger, hostility, or depression),

suicide attempts, exaggerated startle response, delayed emotional development; parent inability to recognize signs of
emotional distress in his or her child

– Social: withdrawal from friends or family members or isolation from support systems by parents, lack of support for
or supervision of child at home, poor school attendance and/or performance, parents who blame the child for their
problems or expect academic and behavioral performance beyond the child’s developmental level

– Spiritual: belief that God has abandoned him or her, existential crisis
– Elder abuse

– Elder abuse can include physical, sexual, or emotional abuse, neglect, abandonment, or financial exploitation of an older
adult. Information used in assessing for elder abuse can be obtained through client interview, interview with collateral
informants, or through observation. As with child abuse, if elder abuse is suspected local and facility/agency protocols
for responding and reporting should be followed. Possible signs of elder abuse include
– Physical: unexplained injury, disheveled appearance, evidence of having been restrained, weight loss, poor hygiene,

bedsores, sexually transmitted disease
– Psychological: depression, loneliness, suicidal ideation, anxiety, fear
– Social: relationship conflicts between the older adult and his or her adult children, other family members, or caregiver;

social isolation or lack of contact with others outside the home
– Spiritual: existential crisis, belief that God has abandoned him or her

› Advance care directives
• An advance care directive allows a client to make determinations about his or her healthcare in advance of incapacitation.

Whether an advanced care directive exists is particularly important to determine for clients who are receiving medical
care or hospice care, are elderly or disabled, or are living in long-term care facilities. If there is an advanced care directive
in place, a copy should be obtained and reviewed. If one is not in place, completion of an advanced care directive can be
noted as a possible treatment goal

› Past history of treatment/interventions
• Record review, collateral report, and client self-report can all be used to gather information about the client’s past history

of treatments for his or her presenting concerns. The social worker should determine what treatments have been tried and
when treatments took place, as well as the effectiveness of treatments. The social worker should assess not only treatments
and interventions that have been prescribed by a professional, but also assess any efforts that the client has made on his or
her own to resolve the concern and any social supports that have been utilized to resolve the issue. Most clients will utilize
their own informal social supports (i.e., friends and family members) to resolve concerns before turning to professional
interventions. Those clients with strong spiritual practices may utilize the support of a clergyperson or other spiritual guide
before seeking the help of a mental health professional. Some clients may also utilize cultural practices or folk medicine.
All of these treatments should be assessed and viewed as valid and potentially effective treatments

› Medications
• An assessment of any past or present medications the client has taken or has been prescribed should be obtained.

Information should be gathered on any medications the client has taken to address the presenting concern, as well as any
other medications taken or prescribed for other concerns. Both professionally prescribed and self-prescribed (i.e., OTC
or herbal remedies) should be included. Dosage, frequency, duration, and effectiveness should be determined as well as
information on side effects, drug interactions, and the effectiveness of any drug combinations

› Medical information
• A complete medical history for the client should be obtained through client and collateral report and through record review.

Information should include current and past illnesses, injuries, hospitalizations, and surgeries, as well chronic illnesses
and disabilities. The social worker should gather information on treatments that were or are being provided, as well as
information on pain management for any current medical concerns. If injuries are reported, the cause of injury should be
noted. For clients seeking assistance for mental health concerns, medical causes of mental health issues should be evaluated

› Substance use
• By including past and present substance use in the biopsychosocial-spiritual assessment, the social worker is able to

identify how the use of substances might be impacting the client’s physical, psychological, social, and spiritual functioning.
Direct client interviews, collateral interviews, and record review may all be useful tools for assessing substance use. The
following areas should be included
– Historical use: The age at which the client began using substances should be included as well as what types of substances

were initially used and if the type of substance changed over time. If there are any times during which the client did not
use substances, this should be explored to identify reasons for stopping use and determining length of sobriety

– Current use: Any current substances used by the client should be established, including the type of substance, if the use is
chronic or episodic, the amount used during each episode, and the duration of use (i.e., how long each episode lasts)

– Reasons for use: The client might be able to identify when and why substances are used. For example, some clients might
use substances while in social situations or when they wish to relax, while others might use in isolation or to increase
mood or decrease anxiety. Collaterals close to the client might have additional perspectives as to the client’s patterns of
use or triggers for use

– Impact of use: Some clients may use substances extensively yet their use seems to have little or no impact on their
biopsychosocial-spiritual functioning. Others may use very little but experience more severe impacts. The social
worker should assess the client’s perceptions of the impact of substance use, as well as gather information to assess the
actual impact. Although clients may be unable to identify these impacts themselves, establishing a timeline of use and
biopsychosocial factors present in the client’s life can help establish connections between use and present circumstances.
The level of denial the client experiences regarding the impact of substances provides the social worker with important
information about the client’s readiness for change

– Past or present treatment: The social worker should assess if the client has been treated for substance use in the past or is
currently in treatment. The type of treatment should be determined (e.g., inpatient, outpatient, AA) as well as its outcome
(i.e., whether sobriety or a reduction in consumption was achieved and for how long)

› Family history
• Family history can have physical, psychological, social, and spiritual impacts on the client and should be included in all

biopsychosocial-spiritual assessments. Some medical and psychiatric disorders can run in families. Substance use is often
“passed down” from one generation to another as a result of a complex combination of biological, psychological, and social
factors. Family dynamics often repeat themselves throughout multiple generations. Assessing at least three generations of
family history can allow for the emergence of patterns of experiences or behaviors. In addition, the social worker should
be alert to nonverbal information from the client and family members regarding their feelings about their family and
whether they sense the family as a whole as being a source of strength or stress for them. Completing a genogram can be
particularly helpful for assessing family history. The following areas should be assessed
– Medical: family history of diseases including cancers, heart disease, genetic disorders, disabilities, and dementia or other

cognitive disorders
– Psychiatric: history of mental illness, suicide (both completed and attempted)
– Substance use: family members’ use of alcohol and other substances, including known or suspected addictions, or family

members who do not use substances at all. If there is a history of addiction in the family, the social worker should note
any attempted or successful treatments as well as length of sustained sobriety

– Family relationships/dynamics: any marriages, divorces, or separations should be determined, as well as the ages of
all impacted family members (e.g., husband, wife, children) when these events took place. The social worker should
determine the number of children both conceived and delivered for each dyad in the family and whether the pregnancies
were planned or unplanned. Dates of and reasons for the deaths of family members, and any traumatic events the family
has experienced, should be noted. Both clients and family members can provide information on the relationships between
family members, including individuals who are estranged from one another or have severed relationships and those who
maintain strong bonds

– Criminal: Any family history of contact with law enforcement, including probation, incarceration, and parole, should be
determined. Reasons for law enforcement contact should be established as well as length of incarceration if present. For
adolescents, a family history of gang involvement or association with gangs in the community should be assessed

› Developmental history
• Establishing a client’s developmental history is critically important when assessing children and adolescents, but is

also a useful component of adult biopsychosocial-spiritual assessments. Children and adolescents often develop at
different rates in different domains. In one area of development the child or adolescent may be below the age-appropriate
norm, whereas in another he or she might be advanced. Development is highly influenced by both biological and

environmental factors. Determining if clients have reached developmental milestones can help the social worker begin
to make connections between the child or adolescent’s environment, genetic or other biological factors, and his or her
strengths and deficits. A thorough understanding of normative child development is crucial for the social worker working
with children and adolescents. For social workers working with adults, an understanding of the client’s attainment of
developmental milestones can provide explanation for the way in which the client’s early environment affects his or her
current functioning. The child or adult client’s attainment of developmental milestones should be assessed in the following
areas
– Physical development: birth weight, length of gestation, gross and fine motor skills, speech/language acquisition, vision

and hearing
– Cognitive development: learning, problem solving, memory, executive functions
– Social and emotional development: bonding, interactions with others, cooperation, ability to respond to the feelings of

others, impulse control, age-appropriate moral development
› Spirituality

• A client’s spiritual beliefs will deeply impact his or her perception of his or her concerns, health, place and purpose
in the world, and interactions with the environment. Spirituality and religious beliefs are often a part of one’s cultural
identity. Thus, including spirituality in biopsychosocial-spiritual assessment is imperative (Hunt, 2014). When assessing
a client’s spirituality, it is important to look at a variety of factors that might influence the client’s beliefs. This includes
an assessment of the religious or spiritual beliefs of the client’s family of origin and the importance that spirituality
or religious beliefs were assigned in the home, influences on the client’s development of current belief systems, and
significant life events that have shaped current beliefs. The client’s current spiritual beliefs should be assessed, including
rituals or services in which he or she participates, the importance of these practices in his or her life, and any spiritual
struggles being experienced or sources of strength that are derived from these beliefs or practices (Hunt, 2014). Although
the positive benefits of spirituality have been documented in research (Finocchiaro et al., 2014), not all clients will derive a
sense of support from spiritual beliefs. For some clients, the way in which religion was practiced by their family of origin
(e.g., participation in belief systems that were overly controlling, or harsh consequences for nonconformity) can create
barriers to establishing their own belief system. For others, their current struggles have created a religious or spiritual
crisis of belief, in which they feel separate from God or are questioning their beliefs. Social workers should take care to
use non-specific terminology (e.g., “Do you participate in any spiritual rituals?” versus “Do you attend church?”) when
assessing spiritual beliefs in order to establish a sense of trust and safety with the client (Hunt, 2014)

› Cultural/racial identity
• When assessing clients and families it is important to understand them within a cultural context. This includes not only race

or ethnicity, but also cultural factors specific to the client or family’s region of origin, language, and time of immigration
if relevant. The client’s experiences of racism and discrimination are also hugely important to understanding the client’s
perceptions of his or her cultural and racial identity and how he or she relates to and interacts with social systems and the
larger society
– Current cultural/racial identity: the race or ethnicity the client identifies as;whether he or she wishes to marry or form

relationships within his or her own race or culture
– Immigration: why the client or his or her family/ancestors immigrated, when immigration took place, whether the family

immigrated together or at different times, whether the client/family maintains relationships or connection to the country of
origin, legal status, primary or preferred language of client and family members, challenges faced during immigration or
adjustment to the new community

– Beliefs about health and social services:what the client understands to be the causes or reasons for illness, disability,
or social problems, how he or she interprets symptoms, what he or she understands about treatment and his or her
perceptions of treatment providers, stigma attached to illness or seeking help

– Cultural practices: how the client celebrates holidays, religious events, or other special occasions, participation in cultural
institutions

– Oppression and discrimination: client’s experiences of discrimination or oppression in his or her country of origin, current
experiences of oppression and discrimination

– Values and beliefs: beliefs about childbearing; child-rearingpractices; values concerning work and education
– Family: gender role expectations, the importance placed on family, the boundaries between family members, role

expectations for children, parents, and older generations
› Personal history

• Education: For adults, the level of educational attainment should be determined. For children, a history should be
determined of all schools attended and academic and social strengths and challenges. If the child is in special education,

a copy of the child’s IEP or other documentation should be obtained. Both adult and child clients can provide subjective
information on their experiences in the education system, both positive and negative

• Employment: Assessment information should be gathered on the type, location, and duration of each job, along with
reasons for leaving the position. Any gaps in employment should be explored. Information on wages and benefits can
assist the social worker in identifying socioeconomic status and access to services. Subjective information from the client
on his or her employment experiences, including relationships with coworkers and supervisors, overall job satisfaction,
and employment goals, can assist the social worker in understanding the positive and negative aspects of the client’s
employment experiences

• Legal history: If the client has been involved with law enforcement, the social worker should learn the reason for arrest,
time spent in jail or prison, and if the client is on parole or probation. For adolescents, gang involvement or association
with community gang activity should be determined and how safe the adolescent is in his or her community should be
established

• Marital/relationship status: the client’s current and past relationship status should be explored, including number and dates
of marriages and divorces, reasons for divorce, and the status of the relationship with the former husband or wife. Sexual
functioning and satisfaction within past or current relationships should be determined. If the client is a parent, the names,
ages, and the client’s current relationship with the children should be established. The client’s satisfaction with his or her
current relationship status should be explored

› Strengths, support, and resiliencies
• By assessing a client’s strengths, support, and resiliencies the social worker and client are able to identify possible

resources that can be used in the treatment process, and the client begins to develop a sense of empowerment and mastery
over his or her own environment. Personal strengths to be assessed include the client’s interests, skills, talents, and
positive attributes. Resiliencies are protective factors that allow the client to positively adapt to challenges. Exploration of
resiliencies such as the client’s or family’s ability to persevere and overcome obstacles; tenacity; and survival skills can
help clients identify the strengths they utilized during incidents or situations that were challenging. Social strengths include
the client’s ability to identify and utilize social support systems such as immediate and extended family and friends, as well
as his or her ability to develop and maintain new relationships. Community strengths may include positive aspects of the
client’s neighborhood or religious or cultural institutions

› Results of structured screening tools
• Any screening tools that have been administered should be scored and the outcomes recorded. A copy of the completed

assessment tool should be included with the biopsychosocial-spiritual assessment
› Mental status exam

• The mental status exam evaluates the client’s current mental state. Mental status examination information is gathered from
both client report and observations of the client during the initial assessment interview. Areas of assessment include (Royal
Children’s Hospital Melbourne, n.d.)
– Appearance: grooming, hygiene, appropriateness of clothing for the environment
– Behavior: appropriateness of facial expressions for social situation; posture; level of arousal (e.g., calm, agitated);

psychomotor activity; tremors, tics, or involuntary movements
– Affect: whether affect is blunt, restricted, or overly expansive, appropriateness of affect to the social situation, whether

mood or affect is stable or labile
– Speech: is speech pressured or halted, is volume appropriate, ease with which client converses, tone
– Cognition: is the client oriented to person, place, and time; ability to process information; level of consciousness (e.g.,

sleepy, awake, intoxicated); general knowledge; ability to interpret abstract concepts; basic memory functions
– Thoughts: is the client experiencing delusions, visual or auditory hallucinations,obsessions, preoccupations, or phobias;

loose associations (i.e., making irrelevant comments); flight of ideas (i.e., frequently changing subjects)
– Insights and judgments: acknowledgement of concerns for presenting problems, understanding of treatment options,

problem-solving abilities
› Summary impression

• A brief overview of the client, integrating all aspects of the biopsychosocial-spiritual assessment, will allow the social
worker to bring together the various aspects of the assessment into one cohesive narrative. The summary impression should
include the social worker’s impressions of how the various domains influence one another and the presenting concern(s) of
the client

› Diagnostic information
• If working in a mental health setting, a biopsychosocial-spiritualassessment will include the identification of aDSM-5

diagnosis, as well as supporting information on how the client meets the diagnostic criteria

› Service plan
• The focus of treatment efforts should be established and written into the client’s service plan. The service plan is a written

document describing the goals and objectives that will be addressed in treatment, as well as who will be involved in the
treatment plan. Roles and tasks for the social worker, the client, the family, and other significant collaterals who will be
involved in the treatment process can be included. Goals are long-term outcomes that the client wishes to achieve related
to the presenting concern. Objectives are the steps that will be taken to achieve the goals. Goals should be measurable and
objectives achievable in order to clearly define when they have been met in order to facilitate a sense of mastery for the
client. Working from a strengths perspective, clients should be actively involved in the identification and development of
the service plan. Clients should be directing this process by identifying what they consider to be priorities for treatment and
what interventions they believe will best work for them

› Social workers should practice with awareness of and adherence to the social work principles of respect for human rights
and human dignity, social justice, and professional conduct as described in the International Federation of Social Workers
(IFSW) Statement of Ethical Principles, as well as the national code of ethics that applies in the country in which they
practice

› Social workers should develop an awareness of their own cultural values, beliefs, and biases and develop knowledge about
the histories, traditions, and values of their clients. They should adopt treatment methodologies that reflect the cultural needs
of the client

Other Interventions that may be Necessary Before, During, or After Completing a
Biopsychosocial-spiritual Assessment
› All risk factors should be addressed and resolved or stabilized before biopsychosocial-spiritual assessment takes place
› Some clients may be reluctant to allow the social worker to access all the collateral information needed to complete the

biopsychosocial-spiritualassessment. Mistrust of the social worker and the assessment process, or conflicts with collaterals,
may hinder the collection of information. The social worker may need to focus on building a therapeutic alliance and rapport
with the client before a thorough assessment can be completed

› A biopsychosocial-spiritual assessment is an ongoing process that continues to develop and change as the interactions
between the client and his or her environment change and new challenges present themselves. Client service plan goals and
interventions should change accordingly

› The biopsychosocial-spiritual assessment may reveal a need for immediate referral of the client to services or resources that
the social worker is unable to provide. The social worker should provide case management to connect the client to necessary
services

› Although the biopsychosocial-spiritual assessment is a client-driven process, the social worker may need to educate the
client and the family about the causes and possible solutions for the client’s presenting issue in order to develop achievable
goals and objectives for the client

What Social Work Models are used with Completing Biopsychosocial-spiritual
Assessments?
Biopsychosocial-spiritual assessment is compatible with any established and generally accepted social work model, as it
provides a way of understanding the client within the context of his or her environment and is not a system of interventions.
The following theories and perspectives provide a conceptual framework for understanding the client and his or her
interactions with his or her environment.
› Systems theory: Human behavior takes place within a social environment. Individuals interact with a number of different

systems, each of which interacts with one another and either negatively impacts or promotes the well-being of the client.
These systems can be classified as micro (i.e., the individuals with whom a client comes in contact), mezzo (i.e., family
members, support networks, and small groups with whom the client interacts), and macro (i.e., society as a whole,
neighborhoods, communities, and institutions). All systems have distinct boundaries, yet have reciprocal relationships with
one another. Biopsychosocial-spiritualassessment will include information on the intersection of these different entities and
how they impact the client (Rogers, 2016)

› Conflict theory: Conflict theory can be used to understand oppression and discrimination that might affect the client.
According to this theory, there is an unequal distribution of power in society. Groups and individuals with power control
resources and try to advance their own best interests by using their power to control and manipulate less powerful groups
and individuals. Powerful groups determine social norms and will punish or stigmatize those who act outside of these norms
(Murray, 2014)

› Ecological theory: Ecological theory states that both the organism (in this context the human) and the environment will
adapt to one another to find a goodness of fit between the two (Mattaini & Huffman-Gottschling, 2012)

› Family systems theory: This theory views the family as a system in which each member is strongly emotionally connected
to and reactive toward the others. When there is a change in one person’s functioning, the other family members will also
change in order to maintain equilibrium in the family system. Some family members will do more accommodating than
others, and these individuals may begin to give up their own autonomy and neglect their own needs in order to stabilize the
family. This can result in a variety of dysfunctional behaviors and negative emotions (Dore, 2012)

› Person in environment (PIE) perspective: This perspective emphasizes the interactions between the person and the context
within which he or she exists. The PIE approach to assessment includes information on the client, his or her problem or
concern, and his or her social environment (Holosko et al., 2013)

› Psychosocial theory: Psychosocial theory explains human development as a lifetime interaction between a person’s
personality and the environment. The eight different stages of life proposed by this theory each presents new social
demands that must be resolved in order for development to continue. When these social demands cannot be met, the person
experiences identity confusion and alienation from society (Greene, 2012)

› Strengths perspective: The strengths perspective emphasizes the strengths and resiliencies of the client over his or her
challenges, problems, or weaknesses. Clients will do better if they are helped to identify their strengths and the resources
they have in the community (Gray etal., 2012). It also draws from the idea that all clients are using their resources and
strengths to resolve their problems; if a client is struggling to resolve a problem it is because of a deficit in available
resources (e.g., the social environment), not in the client him- or herself (Holosko et al., 2013)

› Critical race theory: This theory is useful for an understanding of the role that race and gender play in a client’s experience
in the United States of the systems with which he or she interacts. Identity is not one-dimensional but multidimensional (e.g.,
is composed of race, gender, ethnicity, and socioeconomic aspects)

Red Flags
› Today’s focus on short-term treatment has limited the amount of time that can be spent on biopsychosocial-spiritual

assessment
› The medical model that is the basis for reimbursement for services in many agencies is a deficits-based model, which can

make integration of a strengths-based biopsychosocial-spiritual assessment challenging in these settings
› A complete biopsychosocial-spiritual assessment requires interactions with numerous collaterals and professionals, as

well as gaining access to client records. Care should be taken to ensure that appropriate releases of information have been
obtained and that the client is fully informed of the type of information that will be gathered from these sources and what
information, if any, will be released

› Biopsychosocial research in medicine is needed to elucidate relationships between biological,psychosocial, and spiritual
dimensions ofillness and disease outcomes, particularly those of chronic diseases (Kusnanto et al., 2018)

› Spiritualityis a relatively recent addition to the biopsychosocial model; however, there is increasing recognition that the
spiritual dimension plays an important role in health and coping (Saad et al., 2017)

› In a United States study of licensed clinical social workers, researchers found that only 9.1% reported that they received
education on how to integrate religion and spirituality into practice (Oxhandler & Giardina, 2017)

What Do I Need to Teach the Client/Client’s Family about Biopsychosocial-spiritual
Assessment?
› The client should be included throughout the biopsychosocial-spiritualassessment process. Because in-depth information on

every area of an individual’s life is gathered in biopsychosocial-spiritual assessments, they can feel extremely invasive for
some clients. Explaining to the client the purpose of the assessment, as well as what the results will be used for, can increase
the client’s comfort level with the process and help establish rapport between the client and the social worker

› When appropriate, the client’s family members should be included in the biopsychosocial-spiritual assessment process.
Family members should understand that although they are an important source of information, it is not their perception of the
client’s needs that is primary, but rather the client’s perceptions of his or her own needs

DSM 5 Codes
› There are no applicable DSM-5 codes

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Review Manuscrip

Who, When, How, and Why Bystanders
Intervene in Physical and Psychological
Teen Dating Violenc

Katrina J. Debnam
1

and Victoria Mauer
2

Abstract
Teen dating violence victimization is associated with a host of adverse mental and physical health problems. A number of
bystander-focused interventions have been developed to mitigate the occurrence of abuse but with varying effectiveness. There
remains a need to understand more about bystander behaviors used by adolescents to ensure that existing intervention com-
ponents match with bystanders’ attitudes and behaviors about intervening. The current study is a scoping review of existing
literature on adolescents’ use of bystander behaviors to determine who, when, how, and why adolescents intervene. Seventee

articles met inclusion criteria, the majority of which used qualitative or observational survey designs. Adolescents who either feel
a sense of responsibility and confidence to intervene or are directly involved with or know the individuals involved in the dating
violence are more likely to intervene. Adolescents intervene when they are able to define an act as dating violence and tend to
intervene when the victim is female and when they have a supportive relationship with at least one teacher in their school. The
various ways how bystander intervention is engaged in ranges from verbally or physically confronting the abuser, distracting the
abuser, seeking support from an adult, to passively accepting the abuse. Reasons why adolescents intervene include believing the
abuse is wrong and that intervening will diffuse the situation and help the victim. A number of barriers to bystander intervention
emerged from analysis including individual attitudes and school climate factors. Implications for strengthening bystander inter-
vention programs are discussed

Keywords
dating violence, adolescents, relationship abuse, bystanders

In recent years, researchers and service providers have increas-

ingly focused on how to increase bystander intervention in teen

dating violence (TDV). A number of bystander-focused inter-

ventions have been developed to mitigate the occurrence of

abuse and assault but with varying effectiveness (Storer, Casey,

& Herenkohl, 2016). There remains a need to understand more

about actual adolescent bystander behaviors in order to ensure

that interventions are targeting the correct persons and direct-

ing intervention components in a manner that matches with

attitudes and behaviors about intervening. The current study

examines existing literature on bystander behaviors to uncover

who, when, how, and why adolescent bystanders intervene in

dating violence.

TDV

TDV or teen dating violence is defined as the physical, sexual,

or psychological/emotional violence within a romantic or dat-

ing relationship, including stalking. Physical TDV is defined as

the intentional or purposeful pushing, hitting, shoving, or kick-

ing by a dating partner. Data from the national Youth Risk

Behavior Survey reveal that 9.6% of high schools students who

dated or went out with someone during the 12 months before

the survey (11.7% of female students and 7.2% of male stu-
dents) report being physically hurt on purpose by that person

(Kann, 2016). Sexual violence has similar national prevalence

rates. 10.6% of students (15.6% of female students and 5.4% of
male students) had been forced to do sexual things (i.e., kissed,

touched, or physically forced to have sexual intercourse) they

did not want to do by someone they were dating or going out

with one or more times (Kann, 2016). Emotional abuse is char-

acterized as threatening a partner or harming his or her self-

worth. This type of abuse can come in the form of name calling,

making a partner feel guilty, purposeful embarrassment, or

controlling behaviors such as keeping him or her away from

friends and family. Although national prevalence of

1
School of Nursing, University of Virginia, Charlottesville, VA, USA

2 Department of Psychology, University of Virginia, Charlottesville, VA, USA

Corresponding Author:

Katrina J. Debnam, School of Nursing, University of Virginia, P. O. Box 800782,

Charlottesville, VA 22908, USA.

Email: kjd2m@virginia.edu

TRAUMA, VIOLENCE, & ABUSE
2021, Vol. 22(1) 54-67
ª The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1524838018806505
journals.sagepub.com/home/tva

mailto:kjd2m@virginia.edu

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psychological or emotional abuse are not currently collected,

studies estimate that emotional TDV prevalence ranges from

24% (Haynie et al., 2013) to 96% (Jouriles, Garrido, Rosen-
field, & McDonald, 2009).

TDV victimization has been shown to be associated with a

host of adverse mental and physical health problems including

depression, substance use, suicidal ideation, risky sexual beha-

vior, and drug use (Exner-Cortens, Eckenrode, & Rothman,

2013; Nahapetyan, Orpinas, Song, & Holland, 2014; Parker,

Debnam, Pas, & Bradshaw, 2016; Shorey et al., 2015). These

risky behaviors are not limited to adolescence; 5 years after

experiencing TDV, young adults reported increased heavy epi-

sodic drinking, depressive symptomatology, antisocial beha-

viors, suicidal ideation, smoking, marijuana use, and adult

intimate partner victimization (Exner-Cortens et al., 2013).

Moreover, a recent report commissioned by the Centers for

Disease Control found that approximately 7% of adult women
and 4% of adult men who ever experienced rape, physical
violence, or stalking by an intimate partner first experienced

some form of partner violence by a partner before 18 years of

age (Black et al., 2011).

Help-Seeking Behaviors

Given the potential and long-lasting effects of TDV, seeking

assistance from others has many benefits to victims (Carlson,

McNutt, Choi, & Rose, 2002; Goodman, Dutton, Vankos, &

Weinfurt, 2005; Waldrop & Resick, 2004). Help seeking can

provide emotional support in the form of concern and encour-

agement to leave the relationship (Carson et al., 2002; Weisz &

Black, 2009). Information or advice from others can assist in

problem-solving, conflict negotiation, and additional knowl-

edge about healthy relationships (Weisz & Black, 2009).

Finally, help seeking can result in additional resources, protec-

tion from the abuser, and potentially reduce the severity or

frequency of the abuse (Weisz & Black, 2009).

However, the majority of adolescents experiencing dating

violence do not seek help (Ashley & Foshee, 2005). Victims

are often afraid the severity or frequency of abuse will be

increased by their abusers, as a result of speaking out (Martin,

Houston, Mmari, & Decker, 2012). Of those victims of TDV

who do seek help, the majority seek informal or nonprofes-

sional help, such as family or friends (Ahrens & Campbell,

2000; Ashley & Foshee, 2005; Banyard, Moynihan, Walsh,

Cohn, & Ward, 2010; Martin et al., 2012). Ashley and Foshee

(2005) reported that after experiencing dating violence, only

40% of adolescent victims sought help: 89% from a friend,
40% from a sibling or extended family, and 13–30% from a
parent. Black and Weisz (2003) found that, within a sample of

African American middle schoolers, more than 50% of youth
reported that they would be willing to seek help from their

parents, grandparents, and other adults in issues related to vio-

lence in their dating relationships.

Research also suggests that educating peer groups on how to

respond to friends asking for help when experiencing TDV

could be helpful (Ashley & Foshee, 2005). Indeed, Banyard,

Moynihan, Walsh, Cohn, and Ward (2010) found that friends of

sexual violence survivors felt they were able to be a good

source of help and support for the friend. Furthermore, a recent

study (Van Camp, Hébert, Guidi, Lavoie, & Blais, 2014) also

found that many adolescents feel confident in their ability to

deal with dating violence, reporting greater self-efficacy in

helping someone else. Yet there remains little research regard-

ing the role of friends and the disclosure process in physical and

psychological TDV.

Bystander Theoretical Underpinnings

Latané and Darley’s (1969) situational model of bystander

behavior (SMBB) is typically used to understand bystander

behaviors as related to adult intimate partner violence. The

SMBB posits that the decision to intervene in an emergency

is based on sequential choices by the individual (Hoefnagels &

Zwikker, 2001): (1) notice that something is happening, (2

)

interpret the event as an emergency, (3) decide that it is his

or her personal responsibility to intervene, (4) decide how he or

she wants to intervene, and (5) implement the planned inter-

vention. This decision process may be especially relevant to

understanding adolescent bystander behaviors. Key aspects of

adolescents’ psychosocial development at this developmental

stage include increasing autonomy and peer affiliation. The

SMBB is consistent with adolescents desire to make indepen-

dent choices and consider peer affiliation when deciding how

they want to intervene. Indeed, Nickerson, Aloe, Livingston,

and Feeley (2014), in a study of U.S. youth, found each deci-

sion point in the SMBB significantly predicted willingness to

intervene in the context of bullying and sexual harassment.

Recently, Casey, Lindhorst, and Storer (2017) proposed a new

theoretical model that seeks to further elucidate adolescent use

of bystander behaviors as related to TDV and bullying. This

model incorporates the theory of planned behavior (TPB;

Ajzen, 1991) with the SMBB to explain the broad range of

adolescent attitudes and beliefs (i.e., cognitive factors) that

may play a role in this decision process. While research sug-

gests that SMBB is helpful for understanding the decision-

making process, TPB could help differentiate interveners from

noninterveners. The TPB, a social cognitive theory, posits that

adolescents’ behaviors can be predicted by their intention to

perform the behavior. However, adolescents’ intentions are

influenced by their attitude toward the specific behavior, social

norms regarding what important referrents (i.e., peers, family)

would want them to do, and perceived behavioral control or

self-efficacy to intervene. For example, adolescents, with their

increasing levels of peer affiliation, may be more likely to be

influenced by the perceived social norms regarding violence

among their peers. If adolescents perceive that their peers

would look positively upon intervening in a violence situation,

they may be more likely to make that decision. Casey, Lind-

horst, et al. (2017) found that adolescents’ qualitative descrip-

tion of their bystander decision-making process supports the

integration of SMBB and TPB to form a “situational-cognitive

model of bystander behavior.” While quantitative tests are

Debnam and Mauer 55

needed to further validate this emerging model, it is clear that

adolescent bystander behavior is complex and more research is

needed to advance intervention programming.

Bystander Interventions for Preventing TDV

Bystander-based prevention programs have been introduced as

an innovative strategy to prevent partner violence. These pro-

grams generally focus on arming adolescents or young adults

with the necessary skills and self-efficacy to safely intervene

when they witness dating violence and sexual violence. The

programs do not assume that the bystanders know or are famil-

iar with the abuser or victim but are built on the assumption that

“when community members ignore or fail to respond to beha-

viors across this spectrum, they tacitly reinforce the behavior”

(Storer, Casey, & Herrenkohl, 2016, p. 257). The goals of these

programs are to increase the likelihood that specific instances

of violence or abuse are disrupted and to foster a peer and

community environment that discourages aggressive or violent

behavior. This is particularly relevant to adolescents as there is

evidence that approximately half of all dating violence happens

in the presence of others (Molidor & Tolman, 1998). In fact,

existing bystander-focused programs, such as Bringing in the

Bystander, Coaching Boys Into Men and Green Dot, have

shown that changing social norms can result in a reduction in

sexual assault (Banyard, Moynihan, & Plante, 2007; Coker

et al., 2015, 2016; Miller et al., 2013).

However, research also suggests that bystander decisions to

intervene are contextual, contingent on individual characteris-

tics and form of violence (Weitzman, Cowan, & Walsh, 2017).

For example, Weitzman, Cowan, and Walsh (2017) found that,

within an adult sample, bystanders were more likely to inter-

vene in partner violence when compared to sexual assault. This

study also found that the method of intervention bystanders

chose was different for sexual assault and partner violence

(Weitzman et al., 2017). Furthermore, a study among college

students showed that men had the highest probability of

directly intervening in sexual assault, whereas women had the

highest probability of indirectly intervening in partner violence

(Palmer, Nicksa, & McMahon, 2018). Results also showed that

students who knew neither the victim nor the perpetrator

tended to choose to delegate the intervention to someone else

(Palmer et al., 2018). While emerging research suggests that

bystander intervention is an effective strategy for preventing

interpersonal violence (Banyard, Plante, & Moynihan, 2004;

Coker et al., 2017; Palm Reed, Hines, Armstrong, & Cameron,

2015), more research is needed to evaluate the contextual fac-

tors (i.e., individual characteristics, form of violence, and type

of intervention method) influencing the use of this strategy for

adolescents (Casey & Ohler, 2012; Storer et al., 2016; Taylor,

Stein, Mumford, & Woods, 2013).

Overview of Current Study

The number of bystander-based programs has grown substan-

tially in the last decade, with a recent systematic review

documenting 15 programs since 2007 (Storer et al., 2016).

However, it is important to note only 2 of those 15 programs

have been tested with an adolescent population. Storer and

colleagues’ review showed that bystander programs show

promise in increasing bystanders’ willingness to positively

intervene in situations that could become violent, but note that

results are mixed and there are limitations in our understanding

actual bystander behaviors. In addition, the bystander studies

evaluated in the review focused almost exclusively on sexual

violence (i.e., 12 of 15 studies). Comparatively, little is known

regarding the use of bystander interventions and bystander

behavior specifically related to physical or psychological dat-

ing violence. Therefore, the current review focused on unco-

vering empirical research exploring adolescent bystander

behaviors in response to physical and psychological dating

violence. The following question guided this review of litera-

ture: Who, when, how, and why do adolescent bystanders inter-

vene in physical and psychological teen dating violence?

Method

This scoping review was conducted in three stages: (a) devel-

opment of criteria for inclusion and literature search, (b) extrac-

tion and coding of study characteristics and findings, and (c)

data analysis and aggregation of findings.

Inclusion Criteria and Literature Search

To be included in the review articles needed to describe bystan-

der behaviors of TDV, specifically related to physical and psy-

chological (emotional) abuse. Empirical studies were selected

for inclusion in the review if they fulfilled the following cri-

teria: (a) published in English, (b) included in a peer-reviewed

journal, and (c) included outcome data on adolescent bystander

behavior related to TDV. Articles were excluded if they only

included data related to persons college-aged or older (18 and

above) or only examined sexual violence, sexual assault, and/or

rape without mention of physical and/or emotional/psycholo-

gical dating violence. Studies that examined physical and/or

emotional/psychological dating violence along with forms of

sexual violence were retained in

the review.

The authors worked with a professional research librarian to

create a list of search teams for the search. The search was

conducted in the following databases: PsycINFO, PubMed,

SocIndex (with Full text), and ERIC (ProQuest). The search

terms as they were searched were (“bystander behavior” OR

“bystander behavior” OR bystander) AND (“physical abuse”

OR “dating violence” OR “sexual violence” OR “psychological

abuse” OR “emotional abuse” OR “psychological aggression”

OR “physical aggression” OR “physical violence” OR

“psychological violence” OR “adolescent relationship abuse”)

AND (adolescent OR adolescence OR teenager OR teen). There

was no limit on the date of publication and the search was

conducted on July 1, 2017. See Figure 1 for a depiction of the

steps included in the scoping review. A total of 17 articles met

the selection criteria and are included in this review.

56 TRAUMA, VIOLENCE, & ABUSE 22(1)

Data Extraction and Analysis

As the focus of this review was to better understand the beha-

viors of adolescent bystanders as related to physical and psy-

chological TDV, data analysis and extraction concentrated on

these data in the articles. Specifically, the second author

extracted data from the articles on who intervenes, when do

they intervene or decide to intervene, how do the bystanders

intervene (i.e., what does the intervention behavior look like),

and why bystanders do or do not intervene. In addition, data

regarding the study design, participants, and measures used

was extracted to better understand the range of included

studies. Table 1 includes a summary of the data extracted for

the review.

Results

A total of 17 articles are included in this review (see Table 1).

The majority of the articles (n ¼ 10) were descriptive and
collected qualitative data (n ¼ 8) to explore dating violence.
Other study designs included were randomized control trials

(n ¼ 4) and quasi-experimental design (n ¼ 3). Of the articles
that contained postintervention data (n ¼ 6), three examined
the Coaching Boys Into Men (CBIM) intervention or an adapta-

tion of CBIM. The majority of the studies included in the review

were at least partially obtained from school-based samples (n ¼
15). Participants surveyed were all middle or high school aged,

with the oldest age reported being 19 years old.

Who Intervenes

In examining results from the included empirical articles, we

gathered information on who engages in bystander interven-

tion. In general, adolescents who directly know the individuals

involved in the dating violence are most likely to intervene

(Casey, Lindhorst, & Storer, 2017). In particular, those youth

who are friends with the involved individuals, especially the

victim, are more likely to intervene (Edwards, Rodenhizer-

Stämpfli, & Eckstein, 2015).

A number of attitudes and beliefs were associated with

engaging in bystander intervention strategies. These include

feeling a moral sense of responsibility to intervene (Casey,

Lindhorst, et al., 2017), having a sense of self-efficacy and

confidence around their ability to effectively intervene (Casey,

Lindhorst, et al., 2017; Herbert et al., 2014; Jouriles, Rosen-

field, Yule, Sargent, & McDonald, 2016), believing that inter-

vening would help make the situation better and help the abuser

reflect on their actions (Casey, Lindhorst, et al., 2017), and

believing intervening would foster self-respect (Casey, Lind-

horst, et al., 2017). Conversely, Hébert, Van Camp, Lavoie,

Blais, and Guerrier (2014) showed that adolescents experien-

cing sexual abuse and dating violence in the past 12 months

reported lower self-efficacy to help others when witnessing

dating violence. Finally, feeling that situations of dating vio-

lence are not their business or that they should not be the ones

to intervene makes adolescents less inclined to utilize bystander

intervention (Casey, Lindhorst, et al., 2017).

Sc
re
en

n
g

In
cl
ud

ed
El
ig
i

b
ili

Id
en

�fi
ca
�o

Records iden�fied through
database searching

(n = 620)

Records screened for
exclusion criteria

(n = 556)

Full-text ar�cles assessed
for eligibility

(n = 76)

Studies included in
systema�c review

(n = 17)

480 ar�cles were excluded a�er a review of ar�cle
abstracts determined they met exclusion criteria

Full-text ar�cles were reviewed. 56 were excluded.
• 4 Systema�c Reviews
• 1 Descrip�ve Study
• 51 did not assess adolescent roman�c

rela�onships or adolescents’ bystander behaviors

63 duplicates were removed

Figure 1. Flow chart of studies selected for scoping review adolescent bystander behaviors.

Debnam and Mauer 57

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Some studies found differences in bystander intervention

based on youth demographic characteristics. Three studies

showed that female youth are more likely to intervene and more

optimistic about their intervention abilities (Edwards et al.,

2015; Fry et al., 2014; Hébert, Van Camp, Lavoie, Blais, &

Guerrier 2014; Van Camp et al., 2014). Moreover, Fry and

colleagues (2013) and Sargent and colleagues (2017) found

that Hispanic adolescents were more likely to use bystander

intervention than non-Hispanic adolescents. They also found

that adolescents born in the United States were more likely to

talk to their friends about dating violence and give their friends

advice related to dating violence than foreign-born adolescents

(Fry et al., 2014).

Studies found that participation in bystander training pro-

gramming impacted engagement in bystander behaviors. For

instance, students exposed to the TakeCARE bystander pro-

gram reported engagement in more “helpful” bystander beha-

viors at a 3-month follow-up (Sargent, Jouriles, Rosenfield, &

McDonald, 2017). While athletes participating in Coaching

Boys Into Men (CBIM) intervention reported initial increases

in bystander intervention (Jaime et al., 2015; Miller et al., 2012,

2013), the 12-month follow-up study of CBIM found that the

effects of the intervention on athletes’ utilization of and will-

ingness to use bystander behavior were no longer significant

(Miller et al., 2013). In addition,“Parivartan” an adaptation of

CBIM for adolescent male athletes in India found that athletes

who participated in the program reported significantly fewer

“negative” bystander behaviors (e.g., laughing at or going

along with peers’ abusive behaviors) at the 12-month follow-

up (Miller et al., 2014). However, this study did not find sig-

nificant differences between intervention and nonintervention

athletes in terms of positive bystander behaviors or abuse per-

petration (Miller et al., 2014).

When Do Adolescents Intervene

Our examination of results from the included empirical articles

also included an exploration of time and spaces in which ado-

lescents utilize or feel comfortable engaging in bystander inter-

vention. The studies revealed that adolescents’ ability to

determine whether an act constitutes abuse impacts when they

intervene. Casey, Lindhorst, et al. (2017) found that adoles-

cents use a number of factors to determine whether an act

constitutes abuse, including the victim’s reaction to the beha-

vior. Two studies showed that adolescents are more likely to

intervene when the victim of the abuse is female and in situa-

tions of physical abuse, especially if it causes injury or signif-

icant distress to the victim (Casey, Lindhorst, et al., 2017;

Edwards, Haynes, & Rodenhizer-Stämpfli, 2016). Another

study found that adolescents are more likely to intervene in

situations that do not include the presence of a perpetrator

(Sargent et al., 2017). Adolescents are also more likely to inter-

vene when they observe controlling behaviors in their peers’

romantic relationships (Edwards et al., 2015). For example, if

they overhear a friend insulting their partner, or saying things

like, “she deserved to be raped” (Edwards et al., 2015, p.223).

Yet Sargent and colleagues (2017) found that adolescents most

often intervene after situations of abuse have occurred, as

opposed to interrupting abuse that is occurring in the moment

or before it occurs.

A few studies discussed contextual issues that facilitate

when adolescents’ intervene. For instance, Edwards, Rodenhi-

zer-Stämpfli, and Eckstein (2015) found that adolescents are

less likely to intervene when they observe abusive behaviors

over social media as opposed to observing abuse in person.

Additionally, Storer, Casey, and Herrenkohl (2017) showed

that adolescents who report having social support in school

(i.e., at least one supportive relationship with a teacher in

school) were more likely to intervene.

How Do Adolescents Intervene/What Does It Look Like

We also examined the articles, for examples, of how adoles-

cents engage in bystander intervention. From this analysis, we

found five trends in the description of bystander behavior used

by adolescents: (1) direct verbal confrontation, (2) direct phys-

ical confrontation, (3) distraction, (4) indirect intervention, and

(5) passive or active acceptance.

Direct verbal confrontation was discussed in 11 of the

reviewed studies. Direct verbal confrontation describes beha-

viors in which adolescents directly address the abuse with the

perpetrator and/or victim using a verbal response. It can look

like adolescents verbally interrupting the abuse as it is occur-

ring and saying things such as “Stop” or “Knock it off” (Casey,

Lindhorst, et al., 2017; Casey, Storer, & Herrenkohl, 2017;

Edwards et al., 2015) or correcting problematic language and

reacting negatively to sexist jokes (Jaime et al., 2015; Kervin &

Obinna, 2010). Direct verbal confrontation also includes ado-

lescents having conversations with a member of the couple,

especially the victim (Edwards et al., 2015; Fry et al., 2014;

Miller et al., 2012). In such conversations, adolescents

described providing emotional support (Baker, 2017; Casey,

Storer, et al., 2017; Plourde et al., 2016) and advice to the

victim (Baker, 2017; Casey, Storer, et al., 2017; Fry et al.,

2014; Plourde et al., 2016; Van Camp et al., 2014). Advice

included such things as encouraging the victim to disclose the

abuse to a trusted adult (Fry et al., 2014; Van Camp et al., 2014)

or hotline (Fry et al., 2014) and encouraging the victim to leave

their abusive partner (Casey, Storer, et al., 2017; Fry et al.,

2014; Plourde et al., 2016). In two of the reviewed studies,

adolescents also discussed having conversations with the per-

petrator (Casey, Storer, et al., 2017; Fry et al., 2014). In the

Casey, Storer, and Herrenkohl study (2017), adolescents dis-

cussed having a private conversation with the perpetrator to

express disapproval for the abusive behavior and attempt to

educate the abuser.

Direct physical confrontation was discussed in three of the

reviewed studies (Casey, Storer, et al., 2017; Edwards et al.,

2015; Weisz & Black, 2009). We use the description of phys-

ical confrontation to describe the physical nature of adolescent

bystanders, most often male adolescents’, attempts to interrupt

abuse, which is distinct from verbal confrontation. Such

60 TRAUMA, VIOLENCE, & ABUSE 22(1)

physical confrontations include stepping in between the couple

(Casey, Storer, et al., 2017), using physical aggression

(Edwards et al., 2015), and fighting the perpetrator (Casey,

Storer, et al., 2017; Weisz & Black, 2009).

Distraction, as an intervening method, was also often phys-

ical in nature but describes adolescents’ attempts to interrupt

the behavior and have parties focus on something else. Distrac-

tion was discussed by three of the reviewed articles (Casey,

Lindhorst, et al., 2017; Casey, Storer, et al., 2017; Edwards

et al., 2015). Distraction included efforts to interrupt abusive

behavior as it occurred by creating a distraction, ignoring the

perpetrator, and removing the victim from the moment (Casey,

Lindhorst, et al., 2017; Casey, Storer, et al., 2017). More spe-

cifically, in one study, male adolescents described their efforts

to use distraction by asking the victim to dance or starting a

conversation with the victim (

Edwards et al., 2015).

Indirect methods of intervention, which were discussed in

six of the reviewed articles, included adolescents’ attempts to

enlist support for addressing the abuse. All of the articles that

discussed indirect methods described ways adolescents enlisted

the support of an adult (i.e., parents, school staff; Casey, Lind-

horst, et al., 2017; Casey, Storer, et al., 2017; Edwards et al.,

2015; Fry et al., 2014; Miller et al., 2013; Plourde et al., 2016).

Indirect methods also included accompanying a friend to speak

with an adult or get support services (Casey, Storer, et al., 2017;

Fry et al., 2014) and calling a support or crisis hotline (Fry

et al., 2014; Plourde et al., 2016).

Finally, passive or active acceptance of the abuse describes

bystander behaviors that do not seek to support the victim or stop

the abuse. The nature of these actions has the potential to com-

municate acceptance of the abusive behavior. Passive or active

acceptance of the abuse was discussed in two of the reviewed

articles. Casey, Storer, et al. (2017) found that these include not

doing anything when observing abuse, withdrawing from the

victim, and attempting to diagnose the victim in order to figure

out what would make them accepting of such abusive treatment.

Furthermore, Edwards and colleagues (2015) found that adoles-

cents sometimes ignore the abuse as a way to avoid “drama.”

Why Do Adolescents Intervene

Few studies provided reasons why adolescents do or do not

intervene in dating violence (Baker & Carreno, 2016; Casey,

Lindhorst, et al., 2017; Casey, Storer, et al., 2017; Edwards

et al., 2015). Casey, Lindhorst, et al. (2017) found that adoles-

cents intervene because they see the abuse as serious. In this

study (Casey, Lindhorst, et al., 2017), the seriousness of the

abuse was determined by adolescents’ examination of the vic-

tim’s distress, whether or not the abuse is part of a repeated

pattern (i.e., more likely to intervene), and whether it is mutual

(i.e., less likely to intervene). Consistent with a sense of per-

sonal responsibility described in “who” intervenes, interven-

tion occurs because adolescents feel that relationship abuse is

wrong and should be stopped. Simply stated; adolescents must

believe that intervening is the right thing to do (Casey, Lind-

horst, et al., 2017). Furthermore, there is a need to believe that

intervening as a bystander can help diffuse the situation and

will help improve things for the victim. In contrast, some ado-

lescents may decide to intervene for negative reasons. Two

studies showed that some adolescents may intervene because

they desire to fuel the “drama” within the relationship, which

often occurs through social media (Baker & Carreno, 2016;

Edwards et al., 2015).

Barriers to Bystander Intervention

In reviewing the studies included in this review, a number of

barriers that inhibit adolescents’ use of bystander intervention

emerged. First, as adolescents become more uncertain about

whether a couple’s acts constitute abuse they are less able to

determine how to safely intervene (Casey, Lindhorst, et al.,

2017). Three studies described attitudes that impede interven-

ing including: (1) sensing that intervention would somehow

make the situation more risky for the victim, (2) feeling inter-

vening would risk their own physical safety, (3) believing inter-

vention will not permanently make a difference, and (4)

considering abuse to be a private matter and that if they inter-

vene they will be considered intrusive (Casey, Lindhorst, et al.,

2017; Edwards et al., 2015; Storer, Casey, & Herrenkohl,

2017). Adolescents who are of a lower social status (e.g.,

younger, less popular) than the abuser or abused often feel that

intervention will not be successful (Casey, Lindhorst, et al.,

2017) and fear social repercussions for their actions (Edwards

et al., 2015). Moreover, adolescents are less likely to intervene

in situations more likely to be characterized as harassment

(e.g., sexist jokes, catcalls; Edwards et al., 2015).

Just as factors in schools can facilitate adolescents’ use of

bystander intervention, school climate factors can also inhibit

intervention. Such factors include (1) feeling teachers and

administrators are more equipped to intervene, and (2) perceiv-

ing that schools do not take adolescent dating abuse seriously

and lack awareness of the issue (Storer et al., 2017). Addition-

ally, school cultures that reinforce “slut-shaming” and other

sexist attitudes can diminish the likelihood that students will

intervene (Storer et al., 2017). Finally, students are often hesi-

tant to report abuse to teachers and other school officials for a

number of reasons including (1) concerns that they will be

considered a “snitch,” (2) lack of comfort discussing sensitive

topics with teachers they are not close to, and (3) perceptions

that teachers are not concerned about dating and sexual aggres-

sion among students (Edwards et al., 2015).

Discussion

To date, little research has explored how adolescents intervene

in situations of physical and psychological dating violence.

This scoping review sought to describe who, when, how, and

why adolescents intervene in the context of TDV. The review

provides evidence that adolescents can and do use bystander

behaviors when faced with situations of TDV. This review also

shows that contextual factors influence whether or not adoles-

cents feel capable of using such behaviors, and researchers

Debnam and Mauer 61

have described a number of barriers that prevent adolescents

from feeling they can effectively intervene.

Adolescents intervene when it is a close friend who is

involved in the violent relationship and when they feel confi-

dent about their ability to contribute to a positive outcome both

for the victim and for themselves. This finding is consistent

with social cognitive model of adolescent bystander behavior

in that adolescents’ self-efficacy or confidence to intervene

plays a role in their decision-making process. Results suggest

more research is needed to identify how often and what factors

might positively impact adolescents’ confidence in intervening

with peers who they do not share a close relationship with. It is

clear that an adolescent’s sense of the utility of bystander inter-

vention when observing dating violence must override any

sense that the violence is none of their business (Casey, Lind-

horst, et al., 2017). Some sexual assault prevention program-

ming has been successful at encouraging bystander

intervention through social norm campaigns (Gidycz, Orch-

owski, & Berkowitz, 2011).

In line with the SMBB which suggests that defining the

situation as an emergency is important to the decision-

making process, the current study found that adolescents

must be able to define an act as abusive if they are to

actually intervene. Adolescents define acts as abusive by

observing such factors as the gender of the victim and the

types of abusive behaviors. In fact, adolescents’ uncertainty

about whether acts can be considered abusive impacts their

likelihood of intervening (Casey, Lindhorst, et al., 2017).

Continuing to educate adolescents about the different forms

of dating violence and how they may manifest themselves in

their friends’ relationships may increase their likelihood of

intervening. It is important to provide modern examples of

dating violence that speak to the real lives of adolescents to

translate the definitions of abuse (Sears, Byers, Whelan, &

Saint-Pierre, 2006).

This review explored how bystander intervention is car-

ried out when adolescents observe physical and psychologi-

cal dating violence. Direct verbal confrontation was most

often used to intervene. While adolescents utilize such con-

frontation in a number of ways, more research is need to

determine whether it is the most effective intervention strat-

egy for physical and psychological TDV. Some studies

found that when adolescents confronted their friends in abu-

sive relationships, telling them they should break up with

their abusive partner because they deserved to be treated

better, their friends pulled away from the friendship (Baker,

2017). It is possible that there is a strategically effective

manner in which adolescents can utilize verbal confronta-

tion; however, adolescents may need additional training and

support for how to engage in these conversations with their

friends (Kim, Weinstein, & Selman, 2017). Furthermore,

adolescents’ ability to discern the proper time to utilize such

interventions is potentially limited. Encouraging friends to

leave an abusive relationship may be best completed using

specific motivational language over the course of several

conversations (Cunningham et al., 2013). TDV prevention

programming should seek to provide adolescents with the

skills necessary to effectively and sensitively respond to

observed abuse.

The reviewed articles discussed a number of barriers to

adolescent bystander intervention. A number of these barriers

described the ways school culture and climate can be a major

barrier to disclosures about abuse. This review highlights the

important role teachers, school support staff, and school admin-

istrators can play in creating and fostering school climates that

deem TDV a serious matter that is not tolerated and that stu-

dents are expected to aid in the prevention of such abuse. This

finding further lends credibility to the social cognitive model of

adolescent bystander behavior which theorizes that social

norms about intervening could be vital to increasing positive

bystander behaviors. Such school and social climates would

also encourage adolescent disclosure of abuse by fostering pos-

itive connections between students and teachers and adminis-

trators. Indeed, Storer et al. (2017) found that adolescents were

more willing to intervene in dating violence when they per-

ceived the school personnel had expertise to respond effec-

tively, the school environment was intolerant of abuse, and

when students had trusted the relationships with teachers.

Existing school-based interventions will be more effective if

they are able to cultivate a whole school response to abuse and

violence (Storer et al., 2017; Taylor et al., 2013). For example,

efforts to strengthen student connectedness to the school, staff,

and other students may increase their likelihood of reporting

dating abuse (Debnam, Johnson, & Bradshaw, 2014).

Consistent with the recent review of bystander intervention

programs (Storer et al., 2016) and the social cognitive model of

adolescent bystander behavior, study findings show there is a

need for bystander-based interventions to consider the context

in which adolescents operate in. Engaging in bystander beha-

viors is contingent on a myriad of situational and cognitive

factors, which then may be affected by the social norms of that

environment. For example, even if adolescents endorse a sense

of personal responsibility to intervene in witnessed dating vio-

lence, they still may be less likely to engage in an indirect

intervention if they don’t perceive support from trusted adults

in their community. Thus, attention to setting-level policies and

norms is important component of bystander programming.

In addition, the current study extends the review of bystan-

der programs by considering specific traits of bystanders.

Examining these traits across studies, in aggregate, makes it

easier to see the gaps in our current knowledge and contributes

to our understanding of the necessary components of bystander

interventions. Specifically, few studies provided information of

when and why adolescents intervene. Future research that con-

siders these factors may see a greater impact on bystander

behavior. For instance, coaches in the CBIM intervention dis-

cussed the fact that many youth need time to grapple with the

idea of intervening against their peers. CBIM found that ath-

letes are often hesitant to intervene with their teammates and

feared retaliation (Jaime et al., 2015). The push toward bystan-

der intervention programming like CBIM as a means to prevent

dating violence by promoting awareness of and intervention in

62 TRAUMA, VIOLENCE, & ABUSE 22(1)

situations of TDV continues to increase (Banyard, Edwards, &

Seibold, 2016; Kaukinen et al., 2018). However, such program-

ming requires an understanding of how and when adolescents

utilize bystander behaviors. This review can be used to inform

efforts to enhance researchers’ and service providers’ under-

standing of adolescent bystander intervention. For instance,

adolescents noted concern for their own physical safety as a

barrier to bystander intervention. Service providers may con-

sider alternative ways (e.g., anonymous or confidential help

lines) for adolescents to report their concerns about dating

abuse that protects the reporter.

Limitations of our review should be noted. Given that

the search uncovered only 17 studies meeting the review

criteria, many findings are based on a small number (i.e.,

2–3) of peer-reviewed articles. In addition, the review

includes only those articles written in English and pub-

lished studies. However, the review did benefit from using

a professional research librarian consultation in the search

of online databases. Data for this review were extracted

from data available in the published article. Thus, addi-

tional data that might be available through other sources

were not obtained, and no input was sought from the indi-

vidual authors. This review focuses on results from studies

that explicitly included physical and psychological dating

violence. As a result, the findings do not readily generalize

to programs targeting only sexual harassment, assault, or

abuse. Moreover, this review did not include articles that

described intervening behaviors by adults or parents. There

is an emerging literature base regarding the role of parents

in response to dating abuse that is also important for future

bystander intervention development (Black & Preble,

2016). This review intentionally included studies that pro-

vided both qualitative and quantitative data as well as data

collected pre- and postintervention. Thus, the heterogeneity

of outcomes and assessment methods precluded performing

a formal meta-analysis and bystander data may have been

influenced by the study intervention. It is also important

note that there was adequate diversity across study partici-

pants. While the majority of data were collected from

school-based samples, participants were diverse in race and

ethnicity (i.e., five samples were majority Black, five sam-

ples were majority White, and two samples were majority

Hispanic or Latino). In addition, three of the studies (Her-

bert et al., 2014; Miller et al., 2014; Van Camp et al.,

2014) were conducted with adolescents outside of the

United States.

As demonstrated in our findings who engages in bystander

intervention and how they engage in these behaviors varies

widely. Through this review, we demonstrated that there are

many factors to consider in increasing adolescents willingness

and ability to intervene on a peer’s behalf. Findings from the

study can be used to strengthen our bystander programming

and prevention efforts particularly as related to physical and

psychological abuse. Future research must also examine the

effectiveness of this approach in reducing the overall occur-

rence of dating violence.

Critical Findings

� Consistent with bystander intervention literature, the
findings of this review reveal that adolescents do utilize

bystander behaviors in response to TDV, especially

when they feel confident that their intervention will be

effective and positively contribute to a friend’s well-

being. Additionally, adolescents’ ability to intervene is

impacted by their capacity to define an act as abusive.

Adolescents’ efficacy in defining acts as abuse remains

unclear, but many adolescents use factors like gender

and the type of abusive behavior to determine whether

they should intervene.

� When observing TDV, adolescents use bystander inter-
vention in a number of ways including: direct verbal

confrontation, direct physical confrontation, distraction,

and indirect intervention (e.g., soliciting the help of an

adult). However, not all adolescents effectively inter-

vene when faced with TDV and some studies show that

adolescents exhibit passive or active acceptance when

observing TDV.

� This review revealed a number of barriers adolescents
face against using bystander intervention. Adolescents’

own attitudes toward bystander intervention can get in

the way. Feeling that the intervention would be too

risky, both socially and physically, and that abuse is a

private matter between the couple stops adolescents

from utilizing bystander behaviors. Further, the culture

and climate of an adolescent’s school can inhibit bystan-

der intervention, especially in schools that do not com-

municate that TDV is a serious matter that will be

effectively dealt with by school officials.

� While little is known about why adolescents intervene as
bystanders, the findings of this review show that adoles-

cents intervene when they perceive abusive behaviors to

be serious, which may be based on victim’s level of

distress and the pattern of abuse. Adolescents who inter-

vene to stop violence do so because they believe that

dating violence is not okay and that intervening will

diffuse the situation and help the victim.

Recommendations and Implications for Practice,
Policy, and Research

� This scoping review highlights the need for relevant
examples to teach adolescents ways to identify different

forms of dating violence with consideration of how the

forms manifest in adolescent relationships.

� This study revealed the strong influence context plays in
supporting or inhibiting bystander behaviors. Because

adolescents spend much of their time in school, school

officials may need to create and foster school climates

that communicate that TDV is not okay, students are

encouraged to disclose abuse when they observe it, and

Debnam and Mauer 63

further cultivate school-wide response to abuse. Adoles-

cents are sensitive to adult responses to abuse and

schools must exhibit that they can effectively respond

to TDV.

� Bystander intervention programming may benefit from
more information about how and when adolescents actu-

ally use bystander behaviors. Such programs can strive

to provide adolescents with intervention strategies that

both effectively and sensitively respond to TDV. Fur-

ther, when training adolescents to respond, program

operators may dedicate time to allowing adolescents to

consider and discuss any barriers they perceive in inter-

vening with their peers.

� This scoping review highlights the need for additional
research to understand what factors impact adolescents’

confidence and understanding of when it is appropriate

and useful to use bystander behaviors. Moreover,

research should strive to understand what bystander

intervention strategies are most effective for physical

and psychological TDV and when is the proper time to

utilize such interventions. Finally, continued research is

needed to determine how effective bystander interven-

tion programming is in reducing the occurrence of TDV.

Acknowledgments

The authors would like to thank Chloe Grinage for her early help in

conducting this review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for

the research, authorship, and/or publication of this article: The

research reported here was supported by the Institute of Education

Sciences, U.S. Department of Education, through Grant

#R305B140026 to the Rectors and Visitors of the University of

Virginia.

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Author Biographies

Katrina J. Debnam is an assistant professor in the Schools of Nursing

and Education at the University of Virginia. She holds an MPH in

health behavior and health education and a doctorate in behavioral and

community health. For over 10 years, Dr. Debnam led numerous

school-based randomized-controlled trials at Johns Hopkins Bloom-

berg School of Public Health strengthening her expertise in mixed-

methods research, including hierarchical linear modeling and the

conduct and analysis of data from focus groups and interviews. Her

research focuses on the intersection of health and education with a

strong concentration on conditions that disproportionately affect com-

munities of color. Specifically, her research interests include adoles-

cent violence prevention and dating abuse, school climate, health

disparities, and faith-based programs for positive youth development.

She is currently the Co-I/Co-PI on multiple-funded studies, including

one to evaluate the effectiveness of an intervention designed to

66 TRAUMA, VIOLENCE, & ABUSE 22(1)

address the overrepresentation of students of color in discipline and

exclusionary practices.

Victoria Mauer is a doctoral student in community psychology at the

University of Virginia and an Institute for Education Sciences (IES)

predoctoral fellow in the Virginia Education Science Training pro-

gram. She received a bachelor of arts in psychology from New York

University in 2011 and a master of arts in counseling psychology from

Northwestern University in 2014. Victoria conducts community-based

research on prevention of gender-based violence, disproportionate

minority contact in the juvenile justice system, and school-based pro-

gramming to increase prosocial connections among adolescents. Her

work is dedicated to researching community and school-based pro-

gramming targeting problematic racial and gender norms that

marginalize youth.

Debnam and Mauer 67

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2020-11-13T13:46:16+0530
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