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Content uploaded by Anne Stephens
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All content in this area was uploaded by Anne Stephens on Feb 13, 2018
Content may be subject to copyright.
The Cooktown Ten: A Problem Structuring Model for
Violence Prevention
Addressing Violence Through Primary Care
William Liley & Anne Stephens
The Cooktown Ten: A Problem Structuring
Model for Violence Prevention
Addressing Violence Through Primary Care
William Liley & Anne Stephens
Suggested Citation
Liley, W. and A. Stephens, The Cooktown ten: A problem structuring model for violence prevention.
Addressing violence through primary care. 2018. The Cairns Institute, James Cook University: Cairns.
DOI: 10.13140/RG.2.2.36627.58405
This report is licenced under a Creative Commons Attribution 4.0 Australia licence. You are free to
copy, communicate and adapt this work, so long as you attribute James Cook University [The Cairns
Institute] and the authors.
Cover image acknowledgement:
Cooktown orchid | MaX Fulcher | https://flic.kr/p/8Z63Vu
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Contents
Figures ...................................................................................................................................................... i
Abstract ................................................................................................................................................... 1
Firstly, a few words about the first word … ............................................................................................ 2
The problem ........................................................................................................................................ 3
What some others have said about what causes violence ................................................................. 7
Is this a good idea for doctors who are already busy? We think yes ................................................. 9
The Cooktown Ten - a pathogenesis, problem structuring model (C-10)......................................... 10
The 6 factors necessary for violence..................................................................................................... 13
Isolation – lack of connection ........................................................................................................... 13
Frustration – lack of options ............................................................................................................. 14
Desperation – no hope ..................................................................................................................... 14
Prejudice – reinforced by media, pornography, self-opinion, racism & sexism ............................... 15
Place – of relative stability ................................................................................................................ 16
Triggers – context specific................................................................................................................. 16
Confluence of the 6 factors ............................................................................................................... 17
Clinical use of the C-10 .......................................................................................................................... 21
Finally, a word about the flower … ................................................................................................... 23
About the authors ................................................................................................................................. 25
References ............................................................................................................................................ 26
Figures
Figure 1. The Cooktown Ten model ...................................................................................................... 11
Figure 2. Duluth wheel of equality ........................................................................................................ 19
Figure 3: Duluth wheel of power and control ....................................................................................... 20
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Abstract
This piece of writing is to provide background and description of our thinking behind The Cooktown-
Ten (C-10). The C-10 is a model for use in primary care to encourage the prevention of violence.
Understood as a pathogenesis, it can be used by health professionals in primary care settings. The
violence that has the potential to be prevented in primary care settings is violence that occurs on a
personal scale. This includes a range of significant harms to individuals and groups including self-harm,
workplace, domestic, intimate partner, family and community violence, and suicide. The subject of
significant attention in Australia, the elimination of violence against women and their children, such
as gender-based sexual assault, harassment and domestic violence, is a national priority. In our
opinion a significant gap in the suite of prevention efforts is the capacity to work with all people at risk
of using violence prior to any event. Yet most practitioners work with those affected after the act. The
pathogenesis of violence presented in this paper is based on many years of clinical practice and brings
together literature from divergent fields. The C-10 is a problem structuring tool for counselling
opportunities to understand, explain and ameliorate all types of violence including physical,
psychological, social, and self-directed harms, and to identify and make an effective plan to support
people to make positive choices for non-violent action. It has been developed and used in time and
resource poor settings with and for General Practitioners (GPs), nurses, allied and other health sector
workers. Any such model should be useful to practitioners and be just complex and robust enough to
enable an exploration of the variety of nuances within a persons’ situation. Our model can be used to
explain repetitive cycles and effects of interpersonal violence and self-directed harm. The C-10 can be
used with individuals, groups, families and communities. It is intended as a free resource for clinical
use. Currently clinical applications are based on Level 5 evidence. It is hoped that ongoing research
will build on this evidence base. At a minimum, this model provides a conversation template and a
take-home framework to allow individuals to reflect, anticipate and modify their responses to
problems—to make deliberate choices to avoid violence in their actions.
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Firstly, a few words about the first word …
Cooktown is a unique place in Far North Queensland, Australia, with a rich cultural heritage. It includes
a clearing on the bank of the river which according to local history, has for several hundred generations
over several thousand years, been a place kept separate and sacred where neighbouring cultural
groups of First Australians maintained a lore that no violence was permitted. One day in 1770, in
relatively recent history, this place was where Captain James Cook beached his stricken vessel, The
Endeavour. This might now be seen as an unrecognised act of territorial violation. The boat and its
occupants, however, were tolerated by the people already living in the area who adhered to their
long-held mores and local law. At this time of writing, Cooktown is a small community which includes
people from a wide range of cultural and linguistic backgrounds. It seems fitting that a model
developed in this region that encourages violence prevention and ongoing deliberate efforts to avoid
violence, acknowledges this rich tradition.
“One of the real difficulties when talking about violence is that people think they know
what you are talking about. Everyone thinks they have an idea of what violence is and
means and how it occurs.”
Anonymous, 2017
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The problem
Almost everyone has an understanding of violence based on their experience and their learning.
Defining violence is notoriously difficult [2]. Almost all people have had an intimate experience of
violence in their own lives. Variously labelled, family, domestic and sexual violence are major health
and welfare issues in Australia and globally.
The Queensland Coroners Court [3] reported on two five-year periods (2006 to 2015) finding that the
rate of domestic and family homicides in Queensland has remained stable at approximately two per
month. Of those, where the offender’s gender is known, nearly 84% were male and 16% were female.
Females are more likely to be victims of intimate partner homicides by a ratio of 4 to 1. Within the
broader category of family violence related homicide there is no significant gender difference among
victims. Within this group, more than half of the victims of family homicide were children under 18.
Another significant group are bystanders, killed by an offender in the context of family violence, but
not an intimate partner or family member. In this group, the victims are male and between 2006 and
2016 in Queensland, 17 men are killed in this way [3].
This is repeated Australia-wide with four women dying each month, and 20,100 people hospitalised
due to assault [4]. Police are called to a domestic and family violence event at a rate of one every two
minutes [5]. One in six women in Australia have been subjected to physical or sexual violence from an
intimate partner and one in 19 men [6]. Suicide and intentional self-harm are also significant public
health problems in Australia. Since 2000, at least 2,000 Australians have died by suicide each year and
20,000 have been admitted to hospitals as a result of deliberately inflicted self-harm events [7].
No group appears to be free from the problem of violence. Medical service providers and primary
health care teams are situated within the expression of these problems and fundamental to the social
and community-wide responses. There have been calls for health care professions and primary care
specialists to be actively engaged in population based efforts to prevent and decrease violence [8]. A
lesser known but disturbing realm of violence exists within the medical profession itself. There is a
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culture of unspoken tolerance toward violence shown recently as Stone, Douglas, Mitchell, and
Raphael [9] bravely lift the covers of silence around the gendered violence within the medical
professions in Australia, reflecting and confirming similar experiences world-wide [10, 11].
Primary prevention is an effort to prevent the emergence of a particular disease or disturbance or
harm before it occurs [12]. Within the wider community, we can see a growing awareness of the need
for individuals and communities to take action to prevent violence before it occurs [13]. Yet to be
developed, however, are widely available, specific, practical, clinical tools that are efficient and
effective in generalist practice settings. These tools are vital because when it comes to harm and
violence, we often miss primary preventative opportunities.
There are multiple efforts to attempt to address violence at the secondary and tertiary prevention
levels. These include targeted interventions aimed at minimising recurrent or escalating acts of harm,
preventing death, severe disturbances or harms. Every state of Australia has concerted and often
government funded campaigns as part of the national response to the alarming levels of violence in
Australia. The Our WATCh
1
campaign is an example of a national campaign to tackle the problem of
gender-based violence. It situates women’s social and economic inequality as theoretically prime and
correlated to domestic violence. It has multi-layered, multi-pronged, well-resourced programs and
encourages everyone to be active in violence prevention in their own local contexts. This work is to
be encouraged and is creating change.
The Queensland Domestic and Family Violence Death Review and Advisory Board [14] have called for
innovative approaches that are flexible, responsive and focus on strengths if we are to achieve better
outcomes responding to family violence, especially in services provided to Aboriginal and Torres Strait
Islander people. The Special Taskforce on Domestic and Family Violence [15] in Queensland points to
1
https://www.ourwatch.org.au/
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the problem of acute need prioritisation, the predominant focus of many current service agencies’
responses and recommended breaking away from an incident focussed response system (p. 46).
Addressing the needs of those who have experienced harm in their homes and communities, most
likely women and their children continues to be a vital task. Responding after a violent action or only
after a complaint has been made is not sufficient. We need to find new processes and bring attention
to opportunities for early intervention, action and education, that ‘emphasise prevention in the first
place’ [16].
The C-10 model is for use in clinical practice to complement the variety of initiatives developed to
tackle violence in our communities. The model has been developed in reflective clinical practice and
is the result of generative and systemic activity. It has been informed by literature from various
disciplinary fields including the micro-sociology of violence of Randal Collins [17], behavioural
psychology [18, 19], intersectional theory [20] and other critical theories (feminism, critical race
theory etc).
AUSTRALIAN CAMPAIGNS TO END GENDER-BASED VIOLENCE
Australian Government Our WATChWatch - End Violence Against Women and Their Children
www.ourwatch.org.au
NSW www.domesticviolence.nsw.gov.au
NT nt.gov.au/law/crime/domestic-and-family-violence
QLD www.communities.qld.gov.au/gateway/end-domestic-family-violence/about/special-
taskforce
SA www.agd.sa.gov.au/projects-and-consultations/projects-archive/domestic-violence
TAS www.legalaid.tas.gov.au/factsheets/family-violence
VIC dvvic.org.au/
WA www.wa.gov.au/information-about/community-safety/domestic-violence
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The work to date that has been done captures ‘Level 5’ evidence: single case anecdotes from clinicians
using the C-10, accompanied by their expert opinion and the personal observations from colleagues,
patients and, on occasions, their families or partners. We believe that health professionals have a
powerful role in making decisions and interpretations about the meaning of experiences, signs and
symptoms of others who come for care. While the practitioners are important, they are perhaps not
the most important ‘expert’ when it comes to the effective use of the C-10. For practitioners, the C-
10 encourages the expression of cultural humility, recognising that the people who come to them for
help are experts in their own culture and lived experience. This practice of cultural humility requires a
deep respect [21]. The authors expressly endorse an ethical use of clinicians’ interpretation and
explanation capacity, also known technically as hermeneutical power. The ethical use of
hermeneutical power is summarised by Vattimo [22] as a philosophical position that embodies the
deliberate softening of strong and aggressive identity, the rejection of violence and the recognition of
other. Extending that recognition to the point where power will be used to benefit the other. This
process has the intention of enabling and engendering ‘inhabitability’ [23]. Inhabitability, contrary to
the multiple types of uninhabitable, requires more of a state of balance to meet the needs of all living
people and things within a particular environment. The ongoing problem of intimate partner,
domestic and community violence, including pets and other animals, renders homes and workplaces
hostile environments, which become uninhabitable and requires deliberate, thoughtful and respectful
processes and efforts to change.
Pathology is the study of suffering and as discussed above, violence is a ubiquitous pathway to
suffering. The word violence comes from the Latin viola – to violate or breach. It is appropriate to
continue to use this word as it implies and conveys the unwelcome and ‘breaking-into’ aspect of harm.
A functional pathogenesis describes the necessary conditions and processes that lead to problem
states [24]. To understand how violence emerges, erupts or occurs, it is important to have a
pathogenesis of violence itself. Developing a useful pathogenesis is an important stage in intervention
design. From understanding the process of emergence, opportunities to change the situation become
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clearer. When those deliberate change actions are effective, they may become treatments. Once we
have an effective treatment for a problem, only then can the process of screening for the early stages
of that problem be of any use [25]. What we currently lack in violence prevention is a clear, generic
pathogenesis for violence and interpersonal level harm. Models like ours proposed here, need to
reflect the scholarship devoted to explaining the social constructs, risk factors and social
determinants, as well as build on more individual level emotional and psychological learning, models
hypothesis and work [13, 26].
What some others have said about what causes violence
The Prevention Institute [27] in the United States assert that violence is a learned behaviour that can
be unlearned or not learned in the first place. This organisation recommends an integrated framework
of programs, practices and policies at local, regional state and national levels. The Spectrum of
Prevention tool [28] is recommended and at the first level is strengthening individual knowledge and
skill, to enhance an individual’s capacity to prevent injury and promote safety. The prevention
spectrum model builds on the Haddon Matrix from 1964 [29], which recommends an ecological
approach to prevention understanding time, setting, resources and opportunity influence outcome
and harm.
More recent work adds value to these foundations. Randal Collins [17] recent work describes a
microsociology of violence. Through his detailed reconstructions and analysis of actual violent events,
he demonstrates some of the immediate factors necessary for violent acts. From the available
information obtained via CCTV, social media, contemporary video, photographs, witness recall and
police reports, he presents a comprehensive understanding of violent acts from multiple standpoints.
His work is not dependent on just mediated versions of events from the news media. Deliberately
focussing on a microanalysis of many different types and instances of violence, Collins does two very
significant things. Firstly, he demonstrates that contrary to many widely held myths in popular culture,
violence is not easy. Collins highlights that the precursors to actions, in what becomes a violent
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situation, is confrontational tension, fear and heightened emotion. He shows that this tension and
fear actually block practiced, planned or imagined responses.
“I have argued that people are not good at violence; the big barrier that any violence must
find it’s a way around is confrontational tension/fear. This is what they are chiefly afraid of –
not the fear of being hurt, fear of sanctions from the larger society, fear of being punished.”
[17 pp. 148‐149]
Secondly, Collins explores various situational process of transforming the confrontational tension/fear
into acts of violence. For example, he describes ‘forward panic’ and ‘ritual repetitive emotional
control’ and other strategies used to penetrate the regular barriers that usually counter‐act and block
violence from happening. We are, therefore, of the view after reading Collins [17], that the low
hanging fruit in violence prevention may be an understanding of just how difficult violence is to
initiate. This emotional barrier to violence is the feature to concentrate primary prevention effort
toward. As we will go on to explain, if just one of the factors of violence is kept below its threshold,
violence may be averted. The importance of Collins’ work is to show that emotional tension must be
overcome for violence to emerge, and that this emotional tension can be reinforced and enhanced
where possible to avoid, delay and prevent emergent violence. Efforts to increase the awareness of
risk, i.e., to make it harder for violence to emerge, are likely to be effective at relatively low cost. For
example, the relative low cost of primary violence prevention efforts have been shown in a
randomised control trial of an emergency department intervention where the authors conclude that
the cost to prevent an episode of youth violence or its consequences is less than the cost of placing
an intravenous line [30].
The positive behaviour approach has been in continuous use for over 30 years and was developed by
the Institute for Applied Behaviour Analysis (IABA) [31, 32]. The positive behaviour approach responds
to problem situations in complex social circumstances characterised by significant levels of
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disturbance and harms. Their approach informs our
primary prevention pathogenesis and is distinct from
categorical models that posit people who perpetrate
violence as inherently damaged or evil.
From developmental psychology, a significant
contribution to understanding violent action in this
field is through the Tompkins Institute and the work of
Daniel Nathanson. Nathanson, a clinical professor of
psychiatry and human behaviour at Jefferson Medical
College, built on Tompkins’ theory of affect as part of
the George Bush Senior’s National Campaign Against
Youth Violence 2003 [19, 33]. This body of work
explores an individual’s reactions when their situation
disrupts their connections with others and aligns with
the significant body of work around the pathology of
social exclusion, for example see DeWall et al and
Wesselmann, Wirth and Bernstein [34‐36].
Is this a good idea for doctors who are already
busy? We think yes
The C‐10 model enables clinicians to address these
challenges with people who are able to reflect on their
situation. It is not intended to be an alternative to post-
event crisis intervention but to inform primary care
prevention. Working through the C‐10 model people
are able to more clearly understand their situation and
The Period of PURPLE Crying®
program
This is an effective example in a
particular area of specific violence
prevention that is used widely
across the world, including here in
Australia. This positive and
strengths focussed primary
prevention program designed to
educate all parents and families
with a newborn. It is a resource to
assist parent learning about their
baby’s early development and
their pattern of increased crying in
the first few months of life. The
resource identifies the situations
and consequences of responding
to this crying with frustration and
teaches baby soothing and carer
self-control strategies to help
individuals and families better
understand and care for
themselves and their new infants.
The program demonstrates the
viability and value of a positive
intervention aimed at education,
developing resilience and
identifying key factors that lead to
the tragic occurrence of an inflicted
infant head trauma event. [1]
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its potential for violence and then take pre‐emptive action to prevent or interrupt its emergence. This
enriched understanding enables reflective adjustment within situations, changing attitudes and
identifying opportunities to make violence less likely.
General practitioners and other health care providers working in primary care settings are in a unique
position for the primary prevention of violence. They have the potential capacity to implement both
broad based, and targeted, positive prevention strategies and initiatives in Australia. Addressing the
potential for violence, in a caring and sensitive manner is difficult, and depends on effective
partnerships between clinicians and the people seeking help [37]. Our work aims to foster and
strengthen those relationships particularly enabling an effective problem structuring conversation
about any situation that may lead to violence. This seems to us to be completely within the remit of a
professional group that provides whole‐of‐person, whole‐of‐life care [12, 38]. Some responsibility for
this work appropriately belongs to generalist doctors and other health professionals who work to
minimise suffering in all of their different community and workplace contexts, rather than what might
be seen as the exclusive domain of psychologists, social workers and violence response professionals.
In particular, in more resource poor settings, the remote primary health care clinic may be the only
available setting for this work.
The Cooktown Ten - a pathogenesis, problem structuring model (C-10)
There are ten concepts drawn together within this model. The C‐10 takes an educational opportunity
to describe and recognise four generic processes of a rich and diverse life that will proceed with or
without violence, within the situation at hand. Paraphrasing an ancient African legend [39] life’s rich
diversity revolves around four ongoing processes that are simplified for our model, use, convenience
and counselling:
inputs (nutrition and resources input) ‐ partaking
outputs (waste and produce management) ‐ pooping
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social action (moving, meeting and mixing with others and in groups) ‐ procreating
palliation (managing heritage, legacy and tradition) ‐ passing on
Accepting this ancient wisdom, these processes always require future action. In real life, problems
emerge within the daily activity of these processes, and there is always a range of learned cultural
responses to these problems. Potentially, it is within these responses that the factors necessary for
violence to begin are identified. A rich picture is a systemic tool used to explore, acknowledge, and
define a situation and create a mental model of what is going on [40]. As a visual prompt and to map
the process, the clinician creates a C‐10 rich picture (see Figure 1 below). The rich picture will explicitly
show in the final product, the vectors, influence opportunities, capacities and experiences that might
move someone and their immediate group toward or away from an expression of violence.
Figure 1. The Cooktown Ten model
In green, the four basic life processes. On the left of the diagram are the 6 factors necessary for
violence. Making explicit the connections and processes to shift from one state to another is the ‘how’
of the Cooktown Ten as a diagnostic tool for clinicians.
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The four basic life processes are labelled on the right, and six factors necessary for violence, depicted
to look a bit like the petals of a flower, are also drawn and discussed. These six factors are: isolation,
frustration, desperation, prejudice, place and triggers. Each will be elaborated in the section below.
The overall purpose of the diagram is to prevent, avoid and minimise the chances of violent
expression, represented in the rich picture as a ‘V’ at the foot of the flower’s stem. It points away from
the whole situation and emphasises that an act of violence is a violation. Once perpetrated every act
of violence cannot be undone. The ‘V’ which is an imagined future violent act and represents the
crucial event to be prevented.
The four process and six factors make the ten elements of the C‐10. Explicitly, these are analysed with
the situation and person in focus to enable effective problem structuring. This allows the situation to
be understood and to design future actions and plans that don’t include violence. Connecting flows or
influence vectors demonstrate to the patient or client how to shift from the left to the right side of
the picture, without resorting to interpersonal power abuse or violating others or self. This model is
used to show how opportunities might be developed to return to the life process side of the rich
picture. Emphasis is drawn to express that the life processes always continue. Potential changes can
effect each person’s experience of their connectedness and enjoyment within their situation and
among their community or family group.
When you look back at the rich picture with the person in the session, you can emphasise the positive
elements and highlight areas that require deliberate effort for change. Within the take home rich
picture there are seven elements of positive action and reflection without violence that can be
highlighted as a visual prompt or to do list—maintaining and building hope, creating and increasing
connections, recognising and developing options, and engaging in activities of daily living for
partaking, pooping, procreating, and passing on. The other three—prejudice, place and triggers—
require deliberate violence avoidance efforts. A review of the particular expression of these concepts
and the connections between them, in a real life situation, provide clinicians with an opportunity to
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improve the understanding of that situation as a system with their patients, clients and their families.
The next section of this discussion paper describes in turn each factor for violence.
The 6 factors necessary for violence
There are six factors above a necessary threshold for an act of emergent, entrained, and likely
incompetent, violence to be initiated. It is our contention that if all six are necessary for an initiating
an act of violence, then if any one of these factors is kept below threshold, violence can then be
prevented primarily. To re‐emphasise, we believe primary care is an important context to teach people
about these opportunities.
Isolation – lack of connection
One of these necessary factors for the initiation of a violent act is a level of perceived isolation. In this
context isolation is a private and internal sense that develops when and wherever somebody feels cut
off from the pathway, processes and opportunities that they were expecting to be a part of [17]. There
is a mismatch between their expectations and their life experience. In colloquial terms, the person
feels that: there is no one who will help me with this.
This idea resonates with Nathanson [33] and the Tomkins Institute [19] construct of shame and with
the notion of being cut off from the herd [41]. Clinicians might also bear in mind that memories
created by exclusion and social pain have been shown to be more disruptive, more intense and more
easily recalled than memories invoked by physical pain [42, 43]. There is an increasing imperative to
act to change your situation as this deep sense of separation becomes intolerable. We see this
reflected in violence demographics and statistics with increasing geographical, social and economic
isolation [44]. This sense of isolation feeds on itself and interacts with the other factors. If deliberate
effort to improve social connection and contact with others to relieve any sense of pathological
isolation, violence might be avoided.
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Frustration – lack of options
Frustration is a feeling of being upset or annoyed as a result of being unable to change or achieve
something [45]. It is a common emotional response to the failure of another to meet one’s
expectations and arises when somebody perceives resistance to the fulfilment of an individual’s will
or goals—it is likely to increase when a will or goal is blocked [46‐48].
Frustration, and the belief that one has exhausted all other options, is another factor that must reach
above a threshold to enable violent action [17]. It is the result of an ongoing perception of the absence
of viable options. Frustration embodies a sense of disappointment at previously ineffective actions for
change. The anticipation of ongoing frustration is another debilitating internal position [17].
An expectation of ongoing frustration into the future and the perception that the situation or another
person will continue to do what they are they doing, is relevant to this factor. The person involved
believes that the others in the situation will continue acting in a predictable and unwanted manner
[49]. The development of patience is multidimensional and complex. Patience depends on rich
resources of frustration tolerance. Frustration tolerance is a strength but when spent, is a clear factor
in the emergence of violence [50].
Desperation – no hope
Desperation results from an ongoing experience of feeling deprived of hope [17, 51]. It is the
perception that the situation you are in is so bad, that it is impossible to deal with. A sense that there
is no hope that anything will change. Our model posits that as a trio, isolation, frustration and
desperation, reinforce one another: an absence of meaningful connections to others; an anticipation
that there will be no change in the future, and that previous efforts to make a difference have not
resulted in altering the outcome. Collins [17] shows repeatedly that without the three elements of
isolation, frustration and desperation co‐existing, violent actions do not proceed.
15 | P a g e
An awful effect of ongoing violence in the home is illustrated by McGee [52]. People who experience
ongoing violence themselves become isolated, frustrated and desperate. Their strength within this
situation, ironically, is often a barrier for accessing help [52, 53] Women and children who are
perceived to be strong and coping with their situation are not prioritised for intervention either by
themselves or service providers [52].
Prejudice – reinforced by media, pornography, self-opinion, racism & sexism
Prejudice is what you actually believe to be true. It is an important concept in the C‐10. Prejudicial
thinking is another key factor that must be present above a necessary threshold for violence to occur.
A significant factor needed for an act of violence in this model is the intuition or knowledge that a
person brings into a situation. Prejudice is a firmly held belief which is often unacknowledged; that
your own ideas are worth more than others in your environment.
Prejudice is a judgement made prior to an event or a situation that helps people make sense of a
situation. It is forming a decision or opinion based on knowledge brought to the situation by the
individuals involved and is reinforced by people’s experiences, capacities and preferences to reflect
on their experiences. Modifying prejudice challenges one’s opinions and those of their perceived
authority figures. Prejudice is not always malevolent, however, the prejudicial thinking that informs
malevolence or harm to others is what we are particularly interested in exploring and analysing [54‐
58].
Significant reinforcers of social and situational prejudice include the media, and in particular for
domestic and sexual violence, and pornography is a major influence [59, 60], as are the broad
intersectional flows [20] (i.e. sexism, racism, ableism, ageism). Another significant part of prejudice,
in our context, includes a person’s beliefs about themselves, their own capacity and their
opportunities, expectations and experiences. We recognise that it is difficult for everyone to challenge
their own prejudices. The Our WATCh project in Australia is hoping to encourage everyone to
16 | P a g e
challenge their own beliefs about gender equality. The aim of that project is to decrease the level of
violence experienced by women and children in Australia [61].
Place – of relative stability
The IABA approach underpins the two remaining factors [32]. In this framework for primary
prevention a key factor is the setting, which includes time, place and circumstances [62]. A shared
setting is a physical space or place where a person feels comfortable enough to act. A protagonists’
sense of, and confidence in, their physical and emotional stability within a place is key to reaching the
threshold of this factor. Even a momentary and transient stability may be enough for a violent act to
occur. Places of familiarity, routine and relative security are predictable social environments. They are
more likely to match the places where violence first occurs and are ubiquitously familiar places such
as the home, car, work place, Centrelink office, areas of public entertainment (i.e. bars, nightclub
precincts), school and, for those who live in them, prisons.
The importance of stability can also be seen from a strictly bio‐mechanical perspective [63]. No one is
able to move except from a position of stability, even if this is momentary and transient. Because it is
hard to be violent and one needs to overcome the barriers of confrontational tension, fear and
heightened emotion [17], it is more likely that violence will occur in environments where a person
feels more secure, stable and able to summon the focus necessary to initiate the act. This explains
why so much violence occurs in the home. In some situations going to another place may be the
easiest option available to the person who might otherwise act in a violent manner.
Triggers – context specific
Drawing on the work of IABA, actions and behaviours can be triggered by a particular moment, event,
situation or stimulus. These events focus a person’s thinking on their prejudice, frustration,
desperation and isolation, and creates a sense of stability from which a person acts. Triggers are
situation and person specific. The trigger can be complex or quite simple. Many triggers are well
17 | P a g e
recognised, and may range from a crying infant, to a harshly spoken word or challenging eye contact,
while others maybe more individual.
Sensitivity to triggers is related closely to cognitive arousal and inhibition [18, 19, 32]. Impulse control
is an important concept here. Substances and situations that decrease your inhibition also change
impulse control. For example, alcohol and hypnotic drugs decrease your resistance to your reflective
inhibitions where other substances, like stimulants, heighten impulsivity. Substance use does not
cause violence in and of itself but decreased inhibition and/or increased impulsivity. Our model
enables recognition of the influence of substances and situations that increase a persons’ sensitivity
to their likely triggers needed for a violent act [64]. Other clinical situations (e.g. from within
psychiatric settings, or for some people living with an acquired brain injury), where impulse control
and the capacity for reflection prior to action are limited, are often characterised by violent acts.
Confluence of the 6 factors
An important notion for people to recognise is that the six factors may co‐exist, that each factor will
have a threshold which, when exceeded, an act of violence is more likely to be initiated, yet the
threshold of each will be context specific. When the six factors reach threshold, strong emotions of
contempt and condemnation arise just prior to a violent act [65]. This point is crucial and is
represented by the dark space at the centre of the ‘flower’ in the rich picture. This represents when
and where the factors conflate and converge. At this point, the only person who can prevent the
violence is the one who would perform it. A deliberate rejection of violence is an option that depends
on the recognition of the vulnerability of all the participants and their relative power and capacity to
change the situation. If this moment is not recognised and this opportunity is not taken, an act of
violence may occur. In our rich picture, this is drawn as a ‘V’ below the confluence of the six factors at
the edge of the diagram (see Figure 1 above). It serves as a reminder that the act of violation cannot
be undone and that there is no return to a situation where any involved person or relationship does
not include at least a memory of an act of violence. This experience of violence cannot be taken out
18 | P a g e
of the memories of those in a relationship after it has occurred; there is never any going back. Crucial
trust and innocence can never be completely restored [66]. If at the penultimate moment one of the
pathways away from a violent act is chosen, becoming a perpetrator has been avoided.
In practice, the conversation is introduced and started by taking a sheet of paper, holding it in
landscape orientation and drawing a ‘V’ marked ‘violence’ near the bottom left corner of the page.
The topic is introduced by saying something like:
Many people in this situation end up being violent. In fact, lots of people become violent – even
though it is really hard to do. What I’d like to do is go through the process of how violence
occurs, and what we can do to make sure this doesn’t happen with you.
Choice opportunities become apparent and are illustrated within the rich picture as the conversation
evolves and the picture is drawn.
There are two significant vectors left for us to describe. One is the vector which demonstrates acts of
deliberate self‐control, kindness, consent or self‐education which shifts the situation from one of
impending violence to a healthy expression of the four processes of life. This links the stem below the
petals, away from the potential act of violence, to enable positive re‐engagement in the processes of
a rich and diverse life. These future actions are illustrated and discussed within the ‘equality’
nonviolence Duluth Wheel [67].
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Figure 2. Duluth wheel of equality
Source: Domestic Abuse Intervention Program https://www.theduluthmodel.org/
For a person who can easily recognise their situation as potentially sitting within the dark confluence
of all of these factors, but who asks: well what can I do now?, they may be helped by one particular
strategy that we have used and taught elsewhere. It is a mindful, self‐calming technique called the
‘Gentle Hands’ strategy [68, 69]. The hand off the stem symbolises an open, relaxed and calm
disposition. The Gentle Hands strategy involves a person deliberately relaxing their hands, softening
their gaze and deliberately breathing deeply and slowly. This technique is an example of deliberately
mindful self‐control.
The other important vector is drawn from the left side of the rich picture linking the ‘V’ to the
confluence of the factors. This vector shows that if violence is not avoided, there is great potential for
styles and types of violence to become recurring or reiterating. Assuming there has been a violent act,
20 | P a g e
and we have missed the opportunity for primary prevention, the C‐10 model also illustrates just how
easily violent acts reinforce the prejudice factor, and that recurring cycles of violence can be
understood, imagined and explained. These cycles are all too clearly experienced by many, and very
well represented by the power and control Duluth wheel [67].
Figure 3: Duluth wheel of power and control
Source: Domestic Abuse Intervention Program https://www.theduluthmodel.org/
The purpose of our primary prevention work is to avoid any more people living and dying within cycles
of violence.
On conclusion of this education intervention, the rich picture is taken by the person in focus. We are
told by several people that the picture is taken home to post on the fridge, keep next to the bed, or
kept in a pocket, as a reminder of the conversation. This then enables individuals to make
modifications to any factors to move their situation away from the escalating potential for harm and
21 | P a g e
violence. A factor modification might include deliberately seeking connections and decreasing a sense
of isolation. Another example might be to pursue options to minimise a sense of frustration. Another
important modification might be to understand the influence of alcohol and drug use on lowering the
thresholds of each factor.
The contention is that if a factor is kept below the required threshold, the act of violence is delayed,
then avoided, and does not occur. Violence has then, in fact, been prevented.
Clinical use of the C-10
The C‐10 is being used in clinical application by professionals in Far North Queensland, including the
lead‐author, and has been utilised to enable problem structuring and program design around
nonlethal self‐directed harm, interpersonal family community violence prevention and alcohol and
prescription drug misuse, with patients from mainstream Australian, Aboriginal and Torres Strait
Islander, and culturally and linguistically diverse communities. The challenge for all of us interested in
minimising or avoiding the harm of violence is helping people recognise the finality of their misuse of
power. Much of the prevention literature and problem structuring in our contemporary understanding
of violence, especially against women and their children, focusses on these cycles of recurring and
developing interactions (i.e. coercive control and power misuse).
The C‐10 violence prevention model rests on the belief that for each individual and their various
relationship with others, there is a time before any act of violence has occurred. It is imagined that
this model will inform education efforts. These efforts should be targeted and developmentally
appropriate where necessary for high‐risk groups. It is a counselling tool to prevent subsequent acts
of violence if the opportunity is recognised and the chance is taken to improve the situation.
22 | P a g e
The C‐10 is generating interest in the non‐government and social justice sectors including youth
services and prisoner repatriation programmes. An earlier version of the C‐10 is included in the Rural
Doctors Family and Domestic Violence Education Package for members of the Australian College of
Rural and Remote Medicine (www.acrrm.org.au) and is the subject of ongoing trial and development
in partnership with the Rural Doctors Association of Queensland Foundation (RDAQF).
An example of the accumulating level 5 evidence for this model
A situation arose where a gentleman was brought to the clinic by his sister who was
very concerned that he would act upon his frequently expressed suicidal intent. And
that as a part of this threat he would also harm a significant person in his life whose
actions had greatly upset him. After determining that his actual suicide risk was
chronically low and situationally moderate, especially in the context of alcohol use,
the lead author then used the process outlined in this paper to frame a conversation
and construct a C-10 rich picture particularising each element within his situation.
We talked about all of the aspects. Place, triggers and other factors were important
but especially helpful was identifying the factors of frustration and isolation. This
gentleman and his sister were able to leave the clinic, sharing a new perspective to
address the different difficulties in his situation. They both appreciated the life’s
processes aspect of the model and could easily see areas of strength and capacity
not directly impacting on his anguish and difficulties. This process took about 25
minutes. He left with a concrete safety plan to address future suicidal thoughts and
intent. Subsequently, this gentleman did not act on his impulses. He did form a much
deeper therapeutic relationship with the clinician, whom he had not previously
known, has now modified his drinking behaviours including accepting a referral to a
residential rehabilitation service. He plans to seek alternative employment after his
rehabilitation, is no longer expressing threats to others and when last encountered
did not consider suicide an option.
23 | P a g e
Another area where the C‐10 model has proved useful in clinical practice by the primary author is the
retrospective analysis of a surprisingly violent event. For example, following an unpredicted suicide of
a family member several different family members have presented with various responses of anguish,
disquiet and upset. The lead author has used the C‐10 to structure a conversation around the events
and influences that might have been modified and may have led to a different outcome.
At a macro level, there is an emerging interest among professional bodies involved in the
selfregulation of the medical profession whose response will need to strengthen the capacity to
recognise and respond with effective primary prevention action to stop violence within the medical
workplace setting. We believe the C‐10 may inform some of these responses.
Violence prevention in Australia requires robust and ongoing effort to make any difference. At this
stage of this violence prevention project, we have very little level 1, 2 or 3 evidence. At this stage we
have only level 5 evidence, however, the problems are so significant and pressing with appropriately
philosophically sound and responsible use, clinical endeavour is justified.
We suggest that GPs can use the model as a tool for developing a dialogue of analysis and reflection
for a holistic approach. It looks into the opportunities, constraints, and relationships of the people,
structures and events that make up the situation in focus. This is a systemic empowerment approach
intended to capture the importance of problem structuring and situation mapping by individuals and
collectives, to foster a range of outcomes that are desired.
Finally, a word about the flower …
We are often asked about the flower that features strongly in the rich picture of the C-10. We believe
this serves two purposes. Firstly, it is a strategy to create cognitive dissonance and encourage thought
because people are not expecting you to draw a flower when talking about the potential to do
violence. Secondly, when the person leaves the clinic they have not performed imagined acts of
violence, and they leave with a symbol of great hope. The flower is a symbol of the belief of the clinic
24 | P a g e
staff in the value and worth of the person who has come for care, that despite the difficulties and
complexities of the situation, they can participate in life’s rich diversity without resorting to acts of
violence.
25 | P a g e
About the authors
Dr William Liley
MBBS DipStEd (UQ), DRANZCOG FACRRM FRACGP; Adjunct Professor of Research, The Cairns Institute
Rural Generalist Specialist General Practitioner, Cooktown Medical Centre, Queensland, AUSTRALIA
Dr William Liley has a keen interest in rural and remote primary care, family medicine, and harm
prevention. He has a background in physical therapy, education and counselling.
Dr Anne Stephens
PhD, BEd(GE), BA
College of Arts, Society and Education, James Cook University, Adjunct Professor Research, The Cairns
Institute, James Cook University, Cairns, Queensland, AUSTRALIA
Dr Anne Stephens is an education sociologist specialising in systems thinking for applied and
theoretical social systems and evaluation research.
26 | P a g e
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