Domestic Violence : Clinical issues

Outline The Problem of Detection Clinical Indicators of Abuse Asking the Question? Responding to the Patient Stages of Change Principles of Management Common Pitfalls

Links Domestic Violence: An Introduction Domestic Violence: Referral Services Northern Domestic Violence Service

THE PROBLEM OF DETECTION

In the Australian community domestic violence may remain hidden for years. It is often not until the abuse escalates into severe physical violence with the risk of significant injury and death that the community is made aware. The attendance of a patient to a doctor provides an important opportunity for the identification of the abuse and the provision of information to patients experiencing domestic violence.

Victims of abuse utilise health services significantly more frequently than the rest of the community and often attend doctors for help in respect to the morbidity resulting from domestic violence. Studies have reported, for example, that 30% of women attending the Emergency Department and General practice have experienced domestic violence in their current or previous relationship and that one in eight of all women attending the Emergency Department present as a direct result of the domestic violence. In the majority of these cases, however, the domestic violence is not detected by medical and nursing staff. The principle reason for this poor rate of detection is the failure of staff to consider the possibility and to ask the patient about domestic violence.

Often not recognised by medical and nursing staff is that patients may present with not just physical injuries but with a wide range of psychosomatic complaints, chronic pain, anxiety and depressive disorders, attempted suicide, alcohol / sedative / analgesic abuse and other symptoms related to the severe emotional stress experienced in an abusive relationship. For many patients the relationship between the abuse and their symptoms may also not be recognised. Unless specifically asked by the doctor the majority of patients will not spontaneously disclose the abuse.

CLINICAL INDICATORS OF ABUSE

Although it is best clinical practice to consider the possibility of domestic violence in every patient you attend and ask about it, there are a number of circumstances that should increase your suspicion significantly. These include the following :

• The partner attends with the patient, seems overly attentive or attempts to answer all the questions
• The poor historian or anxious/tense patient. (The woman may be frightened, nervous, guarded, hesitant, evasive or embarrassed)
• Minor or trivial presenting symptoms including the seemingly trivial injury
• Psychosomatic symptoms (including the generally unwell, tired or patient with somatic pain syndromes)
• Anxiety or Depression
• Frequent use of sedatives / analgesic agents
• Self poisoning, suicidal presentations
• Pregnancy complications (pain, PV bleeding)
• Domestic violence should always be considered with all trauma related presentations, particularly if there is a delay in seeking medical attention, inconsistency between the injury pattern and explanation, repeated presentations or a characteristic patterns of injuries :
  • Central : head, neck, breasts, abdomen and genitalia
  • Defensive / Restraining injuries
  • Injuries concealed by clothing
  • Specific injuries : fractured teeth, orbital blowout fracture, strangulation marks, bites / burns

DOMESTIC VIOLENCE : ASKING THE QUESTION ?

Asking about the possibility of domestic violence usually will need only 2 or 3 questions and should only take a few minutes in the majority of cases. You will not upset, offend or anger the patient provided you use a sensitive and supportive approach. It is important, however to first ensure that the patient is alone and in a quiet secure location. The presence of the partner in the room or in a position to overhear the conversation is an absolute contraindication to asking about domestic violence as it may place the woman at greater risk and is unlikely to provide useful clinical information.

After first establishing rapport with your initial assessment of their presenting complaint ask ‘tentative’ questions in a supportive and interested manner. For example :

• How are things at home (between you and your partner) ?
• When you argue, does it ever get physical?
• Are you afraid that he may harm you or the children when you argue ?
• In the Emergency department we commonly see women who experience conflicts or arguments at home that upset them greatly. They often find it difficult to talk about these openly because they are afraid or ashamed or think they will not be believed. I wonder if you may be experiencing anything like this.

Listen carefully to their answer. It is often useful to wait a few moments before continuing so if the patient is a little hesitant she may continue if she wishes.

In some cases where the clinical evidence supports a strong suspicion of domestic violence it may be important to be a little more direct. For example :

"In some relationships one of the partners use threats or even acts of physical violence to control the other partners actions. They may even make it difficult or impossible to see friends or family or make the other feel they are always to blame for the bad things that happen in the relationship. This sort of behaviour is what we recognise as domestic violence. From what you have been telling me, I wonder if you have experienced anything like this in your relationship?"

RESPONDING TO A PATIENT WITH DOMESTIC VIOLENCE

For many medical and nursing staff the issue of domestic violence is a source of concern :

What should I say? What can I do in such a limited time? Is there any point in trying ?

It is easy to be overwhelmed by the complexity of the issue, or be acutely aware of a sense of powerlessness to bring about change or limited by our consciousness of how short a time we can spend with the patient. It is crucial, however, at this point we take a broad view of domestic violence and see change as a process occurring over months to years, which in the majority of cases we will not witness. Our role is to assist patients in this gradual process of change, by discussing the violence and offering appropriate referral and information on domestic abuse. This need not involve excessive time with the patient and 5-10 minutes is usually sufficient in most cases.

The benefits of this strategy are enormous and will assist the woman to recognise the violence, validate her experience and assist her to make changes. However, in nearly all cases this will happen after she has left the department and may be months to years later. The crucial point is that through your brief intervention this process is set in motion - the seeds are planted, and the results may be only evident at a much later stage.

STAGES OF CHANGE : A MODEL OF HOPE

A useful model to assist in understanding this process is known as the ‘Stages of Change’. This model concerns behavioural change (and originally was used in relation to cessation of smoking). It describes 5 stages that a person will pass through before behavioural change is maintained. These are listed below and described in relation to a developing awareness of the experience of domestic violence by the patient, their likely presentation and the intervention that is most appropriate from the medical practitioner.

This model can be used to help understand where the woman is in her perception of her position in the violent situation, and what intervention is likely to be useful at this stage. The aim is to gently assist the woman to move along from pre-contemplation to contemplation to decision, action and finally to maintenance. This is usually possible through discussion, ongoing support for the woman, provision of information and use of appropriate referral.

Pre-contemplation

This describes the initial stage in which a person does not recognise that what they are experiencing is domestic violence. Simply asking about domestic abuse and ‘naming’ it for the patient is often all that is needed in this circumstance.

• The person is unaware of the problem or the possibility of change and may present with repeated somatic complaints, chronic pain syndromes, depression
• Response : explore the possibility of domestic violence and suggest the possibility between what is happening at home and her symptoms
• To suggest at this point the possibility of a woman leaving is futile and may even be detrimental

Contemplation

This is the stage that follows and although the domestic violence is recognised by the woman she is ambivalent about whether she wants or is able to make changes. Often just explaining other possibilities with her is useful, should she decide to initiate change.

• The woman has identified the problem but remains ambivalent about whether or not she wants, and is able to make any changes. "Yes but" is the classic phrase at this stage
• Response : it is useful to encourage the woman to look at the possibilities for change should she decide to do something.

Just pointing out that she does have options, that violence in any form is wrong and that she does not have to up with it, will help to build her self esteem and identify you as a supportive agent

Decision

This stage is often characterised by an event (eg the partner has threatened the children) and results in a decision (‘something must change, this can’t go on’) and development of a plan for change.

• Something has happened to tip the scales in favour of change. eg "I’ve had enough". "Something has got to change".
• Response : The doctor needs to be aware of community resources and to explore the resources the woman may have within her own social network and family : What is it the woman wants to change, How does she intend going about it , What role does she want you to play

Action

This describes the stage in which the plan devised in the decision stage is carried out. A well thought out and supported plan has more chance of succeeding than something acted out on impulse.

• Examples include : Changing locks on the house, Taking out a summary protection (Restraining) order, Talking to family or friends, Seeing a counsellor, Joining a support group, Leaving the relationship

Relapse / Action

A cycle of Relapse / Action often follows and should not be seen as failure (there are many complex factors that make it difficult for a woman to leave a relationship permanently) but as a step toward change. Numerous attempts are usually required before the change can be maintained.

• Maintaining change is often extremely difficult. Many factors make it difficult for a woman to leave the relationship permanently and often several attempts are required before success is achieved in the long term. ie. Relapse is not failure.
• Response : nonjudgemental support is essential at this stage

Maintenance

The stage in which the response to the violence is maintained.

PRINCIPLES OF MANAGEMENT

The principles of management are not complicated and can be summarised into six points. It is important that if domestic violence is disclosed that you :

1. Acknowledge and Name the abuse as domestic violence.

‘From what you have been saying I would recognise this as domestic violence.’

2. Ensure the woman is safe to return home:

‘Is it safe for you to go home?’

3. Provide information about the nature of domestic violence

Define what you understand ‘domestic violence’ is, that it is common and not the

partners etc.

4. Provide options (usually one or two only) for referral

‘I can see that this is a problem that you could benefit with some help with. I will

give you the name and contact number of someone who can help you.’

5. Discuss a crisis plan should the woman need help urgently

‘Where will you go if your safety is threatened ?’

6. Document the violence in the case notes

Acknowledge and Name the abuse as domestic violence

In counselling a woman experiencing domestic violence it is very important to be supportive and always believe her as she is more likely to minimise the violence than exaggerate it. Listen and discuss openly the fears and concerns expressed by the woman. Summarising and reflecting back these issues helps to not only clarify the situation in the doctors mind, but reassures the woman that she is being listened to and believed. Define the problem as violence where possible and use your knowledge about domestic violence to provide information that can help the woman to express herself and not blame herself for the violence. Feel comfortable to make statements that express your values (eg "I believe that there is never a justification for the use of physical violence in a relationship" ) but be careful to not impose your values on the woman.

In some situations it may be the first time the woman has disclosed the abuse and simply having raised the issue is the only therapeutic intervention required. Where the woman acknowledges the violence find out what she wants to do (which may include nothing for the present). Try to work out what the woman sees as her apparent goals and understand her limited choices. Offer support but don’t rush. Where possible provide information, present options and choices.

Ensure the woman is safe to return home

The safety of the woman must be assessed in every circumstance. This is particularly important in the patients presenting for medical help as the result of acute crisis situations. Failure to address this issue may expose the woman (and her children) to the risk of serious physical injury including permanent disability and death. Options for acute intervention when the woman’s safety is at risk include admission to hospital, women’s shelters or accommodation with a supportive friend/relative of the woman providing this is considered a safe option. Intervention by the police and the obtaining of a Summary Protection (Restraining) Order are options that should be explained to the woman.

The very nature of the abusive relationship disempowers the woman. The perpetrator by dominating the relationship prevents the woman from making decisions or having control over her life. Feelings of helplessness and dependency by the victim are common under these circumstances and it is essential to avoid making decisions or offering well meaning advice for these patients if the risk of being aligned with the perpetrator is to be prevented. The doctor must seek, rather, to empower the woman by supporting her in any decisions she makes, independent of whether the doctor considers them appropriate or not.

This is possibly one of the most difficult things for a doctor to do as it cuts across the very essence of the medical model. The doctor instead of being the active prescriber of treatment must change roles and become the supporter of the treatment prescribed by the patient instead. The doctor still has a very important role in reflecting back the issues to clarify the situation and outlining the options available to the patient but must stand back when it comes to making the choice. Encouraging the woman to take responsibility for her own actions and for making choices in her own life are important steps to breaking the cycle of domination and control exerted by the perpetrator in abusive relationships.

Provide information on domestic violence & options available for assistance

The provision of accurate and detailed information about the options available to her is an important part of this process. This aspect of management is consistently listed as one of the major criticisms of doctors by victims of domestic violence. It is essential that doctors obtain an accurate knowledge of local support services and referral networks to cover the broad spectrum of needs that these patients may require. These include not only acute medical and crisis care but assistance with housing, financial, legal and childcare needs. The doctors role is about offering choices to victims of domestic violence and then supporting them in whatever course of action they choose.

In some cases the woman’s decision may conflict with what the doctor would want for the patient but this should not be allowed to frustrate the doctor or threaten the support offered to the woman. The fact remains that many women do choose to return to abusive relationships time and time again. The reasons for this are complex. The doctor rather than acting in a judgemental fashion with the risk of alienating the patient should instead continue to remain supportive. It frequently takes considerable time for a woman to build up the necessary psychological strength to seek change and leave the relationship permanently. Several attempts to leave may occur before the final separation is achieved. During this phase it is essential that the doctor continue to support and empower the woman by respecting her decisions in every circumstance.

Discuss a crisis plan should the woman need help urgently

One of the most important roles for the Emergency Department staff in the management of domestic violence lies in the formulation of a ‘crisis plan’. By providing information about services and options available a plan is worked out that can be enacted should an acute crisis develop in the woman’s home situation. It is essential that with the woman know who she can turn to for immediate help and where she can go to be safe. She must be clear about her rights under these circumstances (including rights to protection and emergency accommodation) and be given the information she needs to access the available community services for help (financial, housing, counselling, legal and medical).

The crisis plan will need to be individualised in each case dependent upon the woman’s circumstances and perceived needs. Therefore, whenever a history of current abuse is detected and the woman chooses to return home, a crisis plan should be is formulated so that in the event of a future abusive episode, perceived by the woman as a serious threat to her and/or the children, she knows where she can obtain immediate help and be safe from her partner.

Document the violence in the case notes

Accurate medical records are a central part in management but in many cases documentation by doctors is poor. It is important to keep accurate records of all visits and quote directly as much as possible. It is not uncommon for the woman to later require this documentation for legal purposes (eg restraining orders). There is no legal problem in accurately quoting the woman or recording a diagnosis of domestic violence based on the woman’s history or your clinical suspicions. If you make the diagnosis or strongly suspect domestic violence, record this in the notes.

COMMON PITFALLS IN MANAGEMENT

Never

• Deny the violence committed
• Minimise the violence (eg "I’ve seen women much worse off than you")
• Blame the victim (eg "You should try harder")
• Prescribe Tranquillisers unnecessarily
• Refer the woman to a psychiatrist inappropriately
• Refer the woman to marriage guidance when the husband is not interested or disbelieving in admitting to domestic violence. It is not a relationship problem!
• Set explicit criteria that must be met before any other assistance will be given eg "I can’t help you while you stay with him")

REFERRAL SERVICES

On the following page is a list of referral services. It is not comprehensive but will provide you with enough options to manage most situations. Be careful not to give too many numbers to the patient and confuse them. If the patient is safe to be discharged I generally advise patients to contact either

Domestic Violence Outreach Service (DVOS)

Available between 9 to 5 pm weekdays to discuss the issue by phone and arrange referral to services appropriate to the persons need . They will also provide advice to clinicians on options for referral.

The Community Health Service

A counsellor is available between 1 pm to 3 pm most working days and they are able to arrange either an appointment for individual counselling (according to the priority of the situation) or involve the patient in one of groups currently run at the community health centre for women experiencing domestic violence.

They are also able to advise on groups for male perpetrators of domestic violence.

Prepared by Dr. Peter Stuart
13/6/2001