Intimate Partner Violence NOTES 2009

How many of you have worked in a domestic violence shelter or on a hot line for intimate partner violence (IPV) as a volunteer or paid employee either during or before medical school?

What one thing have you learned about IPV in the course of your work that you would you like to tell your classmates as they prepare to talk with people who may have experienced IPV in their lives?

Learning Objectives:

After participating in the large and small group sessions on this topic, medical students will be able to:

  1. Demonstrate a transition within the medial interview to the subject of intimate partner violence.
  2. Ask appropriate screening questions during a routine patient visit whether or not IPV is suspected.
  3. Directly ask a patient about IPV when IPV is suspected on the basis of history of physical exam findings.
  4. Respond to the disclosure of actual or possible IPV with

a)Empathy

b)Validating messages

c)Assistance with making a safety plan.

Case #1:

A 34-year old woman had been seen by several different physicians for jaw pain. Finally a primary care physician diagnosed temporomandibular joint (TMJ) syndrome and referred her to a specialist. This specialist, knowledgeable about domestic violence, determined that the TMJ syndrome had been caused by repeated episodes of battering during which the woman’s husband had grabbed her by the jaw and forcefully yanked it from side to side.

What reaction do you have to this story?

How could any of the physicians that saw this patient have determined what was going on?

Background (in this presentation I will generally refer to the victim as “she” although IPV does affect men, though in much lower numbers)

Prevalence

Primary Health Care Problem

How do victims of IPV present?

  1. No particular symptom, complaint or demographic.
  2. With an injury directly resulting from IPV.
  3. With illnesses or health problems resulting from the effects of the abuser’s behavior (muscle spasm, headache, STI, etc.)
  4. With seemingly unrelated health problems that are due to or aggravated by the abuser’s controlling behavior (difficulty managing a chronic illness [asthma, DM, ^BP] due to abuser withholding meds, preventing travel to appts, interfering with treatment, etc.)

What is IPV?

IPV IS a pattern [“cycle”] of assaultive or coercive behaviors (physical, sexual, psychological/verbal/nonverbal, economic coercion) that an adult uses against [in order to control] an adult or adolescent intimate partner.

What are the causes of IPV?

What are the guiding principles for physicians and other healthcare workers in responding to the societal problem of domestic violence?

How should physicians and other healthcare workers respond to IPV?

Routine screening

Assessment of victims

Intervention with victims

Documentation

Why do healthcare workers need to act? Why do physicians need to ask questions and otherwise find these victims? Why doesn’t every abused woman just go to the police or the local battered women’s shelter or ask her friends or family or neighbors for help? WHY DON’T VICTIMS JUST LEAVE?

Barriers to Leaving

Routine Screening

Goal = identify [otherwise hidden] victims in order to be able to respond to them more effectively.

What do I need to do in order to do a good job screening?

Screening Tips (one by one)

  1. Privacy (if companion refuses to leave, call security).
  2. Only after establishing a connection with the patient.
  3. and 4. Confidentiality (may have limits - discuss; interpreter issues)
  1. Present screening as routine (ubiquity statements: “Because this is so common, I ask allof my patients about whether they feel safe in their relationships.”
  2. Calm, matter-of-fact, non-judgmental (NOT THE SAME as accepting of the abuse!)
  3. Gather behavioral not motivational data; specific actions of abuser and her response.
  4. Start with open-ended questions and move to clarifying questions.
  5. Be respectful
  6. Listen

Sample transitional or opening statements:

  • We now know domestic violence is a very common problem. About 20% of women in this country are abused by their partners. Has that ever happened to you?
  • Because violence is common in women’s lives, I now ask every woman in my practice about domestic violence.
  • I don’t know if this is a problem for you, but many of the women I see as patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I’ve started asking about it routinely.
  • Some women think they deserve abuse because they have not lived up to their partners’ expectations, but no matter what someone has or hasn’t done, no one deserves to be beaten. Have you ever been hit or threatened because of something you did or didn’t do?
  • Because so many women I see in my practice are involved with someone who hits them, threatens them, continually puts them down, or tries to control them, I now ask all my patients about abuse.
  • Lots of the lesbians and gay men we see here are hurt by their partners. Does your partner ever try to hurt you?

How to respond?

If the patient denies any abuse, accept her answer. You can offer yourself and your organization for support “if you ever need it or know someone who does”.

But what if you still suspect IPV?

Case #2:

A 22 year old woman came to an urgent care clinic for evaluation of a head injury. She said that she sustained the injury when she fell off of a step ladder. Careful examination failed to reveal any evidence of trauma except for a tender hematoma in the scalp on the superior aspect of her head. The nurse practitioner, recognizing that the injury was not compatible with the patient’s explanation, asked her directly if someone had hit her on the top of her head.

This case illustrates exactly what you should do if IPV is a likely cause of the patient’s presenting problem or of something else elicited in the history or on the physical exam.

“Did someone do this to you?”

“What happened?”

If the patient acknowledges that she is being abused and/or has been injured, PERFORM AN ASSESSMENT.

  1. Immediate safety

“Will you be safe if you go home?”

“Where is the perpetrator now? Where will he/she be whenyou are finished with this medical care appointment?”

“Is there someplace else you can go to be safe?”

“Do you want or need security to be notified immediately?”

  1. Pattern and history of abuse

“What generally happens when the abuser harms you?”

“How long has the violence been going on?”

“Has your partner forced or harmed you sexually?”

“Have others been harmed by your partner?”

“Does your partner control your activities, money, or the children?”

  1. Assess connection between IPV and patient’s health issues

“Have there been other incidents resulting in injuries or medical problems?”

“How is the abusive behavior affecting your current health?”

  1. Assess victim’s access to advocacy and support resources

“Who is available to you now as a support resource?”

“Have you tried to use community support resources in the past? If so, what happened?”

  1. Assess lethality

“Does your partner have access to a gun? Has he used a gun in the past? Has the frequency or severity of the abuse increased recently? Has he taken anyone hostage or stalked anyone? Has he ever committed homicide? Does he threaten suicide? Does he abuse alcohol or drugs? Are the children safe?

Intervening with Victims of IPV


Goals: 1. Increase victim’s safety.

2. Support victims in protecting themselves and their children (or other dependents) by:

a. validating their experiences

“You don’t deserve this. There is no excuse for domestic violence. You deserve better.”

“I am concerned. This is harmful to you and can be harmful to your children.”

“This is complicated. Sometimes it takes time to figure things out.”

“You are not alone in trying to figure this out. There may be some options. I will support your choices.”

“I care. I’m glad you told me. I was to know about domestic violence so that we can work together to keep you safe and healthy.”

b. providing emotional support

c. providing information about resources and options.

Note: the goal is NOT to get the victim to leave the abuser, nor to fix the situation or relationship.

Encourage the patient to develop a safety plan when

  • The batterer is present in the medical setting
  • The victim expresses fear of leaving
  • The victim is returning to the batterer

Safety Plan

1. Have important phone numbers memorized.

2. Keep this information about domestic violence in a safe place.

3. Keep change for pay phones with you at all times.

4. If you can, open your own bank account.

5. Stay in touch with friends. Get to know your neighbors.

6. Rehearse your escape plan until you know it by heart.

7. Leave a set of car keys, extra money, a change of clothes and copiesof the following documents, with a trusted friend or relative: your and your children’s birth certificates, your children’s school and medical records, bank books, welfare identification, passport or green cards, immigration papers, your social security card, lease agreements or

mortgage payment books, insurance papers, important addresses and telephone numbers, any other important documents.

Note: In UVa Hospital Primary Care Clinics and the Emergency Department, there will always be a nurse or social worker who is acquainted with safety planning and local resources. Call her (or him) in. If you have time, stayt and listen to what she/he does with and for the patient.

Providing Information

  1. IPV is a health issue for the patient and any children. It can escalate, in which case the damage also escalates.
  2. Stopping IPV is the responsibility of the perpetrator, NOT the victim.
  3. Victims, with assistance and support from others, can increase their own safety and that of their children.
  4. Provide a list of local support services: health care system, shelter, legal

Follow-up

  1. Schedule future appointments, especially for primary care.
  2. Review medical history to assess for other potential abuse-related episodes of care– this is to communicate concern for the patient and a willingness to address this health issue openly.
  3. Realize that domestic violence, like other chronic conditions, often requires multiples interventions over time before it is resolved.

Documentation

  1. Body maps or drawings to demonstrate injuries
  2. Describe specifics: what was done, by whom, where; whether alcohol or drugs were used by perpetrator or victim; whether use of weapons occurred or was threatened.
  3. Use the patient’s own words whenever possible.
  4. Record what options were discussed, referrals made, resources provided, follow-up arrangements made.
  5. If mandatory reporting is indicated, document how it was or will be done.

Summary

Health care providers’ goals are to 1) increase the victims’ safety, and 2) support victims in protecting themselves and their children by validating the experience, providing emotional support and providing information.

The goal is NOT to get the victim to leave the abuser or to “fix” the situation of relationship.

Communicate: There is no excuse for IPV, the patient is not alone, you care.

By appropriate identification, assessment and intervention of victims of interpersonal violence you will SAVE time in your practice!