Domestic Violence: Reducing Barriers to Care

By Arline Kaplan © 2001 (All Rights Reserved)


"It is very compelling when you see a women in a domestic violence situation that was unrecognized, and then she gets murdered," said psychiatrist Marjorie Braude, M.D.

Braude is founding chair of the Los Angeles City Domestic Violence Task Force and course director of the American Medical Women’s Association’s (AMWA) domestic violence online education course <www.dvcme.org>.

"I started on a committee at the Los Angeles Police Department and developed an awareness of how prevalent domestic violence is in my community. Then, of course, since I’m a physician, I sought to extend it [awareness] to the medical community," she said. "When I discovered how little screening and appropriate treatment is done, I felt a great need to try to improve the state of the art."

As defined in the AMWA course, domestic violence is "a pattern of assaultive and coercive behaviors, including physical, sexual and psychological attacks, as well as economic coercion that adults or adolescents use against their intimate partners."

The incidence and prevalence of domestic violence is high, according to Braude. Findings from the National Violence Against Women Survey reveal that approximately 1.5 million women and .8 million men are raped and/or physically assaulted by an intimate partner annually in the United States. Because many victims are victimized more than once a year, researchers estimate that some 4.8 million intimate partner rapes and physical assaults are perpetrated against women each year and approximately 2.9 million physical assaults are committed against men annually (Tjaden and Thoennes, 2000). One in four women and one in 13 men have been victims of intimate partner violence in their lifetime (Tjaden and Thoennes, 2000).

Domestic violence also is linked to homicide, injuries, suicide, as well as depression and many other psychiatric disorders. According to Federal Bureau of Investigation reports, 1,218 women and 424 men in 1999 were murdered by their intimate partners (i.e., spouses, ex-spouses, boyfriends and girlfriends) (Fox and Zawitz, 2000). In studies of female trauma patients treated in an emergency department, nearly one-third were identified as having injuries caused by battering (McLeer and Anwar, 1989; McLeer et al., 1989).

Additionally, domestic violence is a factor for one in three women who attempt suicide and may be the "single most important cause of female suicidality, particularly among black and pregnant women," according to Stark and Flitcraft (1995). In a study of psychiatric emergency room patients, 49% (22/36) of the female patients and 8% (4/48) of the male patients reported being the victim of spouse abuse when interviewed by clinicians who had received a trauma awareness training (Currier and Briere, 2000).

Based on findings like these, Braude believes the psychiatric community should be doing much more to increase awareness of the frequency and dangers of domestic violence and to give psychiatrists some tools for diagnosing and treating it effectively.

A recent study by Garimella and colleagues (2000) substantiated the need for increased training among psychiatrists and other physicians. The investigators assessed the training in domestic violence of specialists in psychiatry, emergency medicine, family practice, and obstetrics and gynecology. Surveys were sent to 150 physicians affiliated with an urban hospital in Virginia, and 76 (51%) responded. Of the respondents, 21% received no training about domestic violence while in medical school, 59% received little training and 20% received moderate training. None said they received a great deal of training. Additionally, 80% of the respondents said they had never received a postgraduate training about domestic violence.

The study authors also used previously validated scales to measure physicians’ attitudes about their roles in domestic violence cases, beliefs about victims and beliefs about resources available to them to assist victims. While all 10 of the psychiatrists who responded said is was part of their role to assist victims of domestic violence, only 40% held supportive (non-blaming) attitudes toward victims of spouse abuse. Of the four specialties, psychiatrists were the least supportive; 56% of family practice practitioners, 57% of emergency room physicians and 88% of obstetricians and gynecologists had supportive attitudes toward the victims.

Responses to selected items on the attitude scales proved instructive. Of all the physician respondents, 55% said they had patients "whose personalities cause them to be abused," 49% said the victim’s "passive-dependent personality often leads to abuse" and 34% said "a victim must be getting something out of the abusive relationship or else she would leave."

Psychiatrists were significantly more likely to believe they have resources available to them to assist battered women than were physicians in other specialties. Ramani Garimella, M.D., principal author of the study, said she found psychiatrists scored much higher than other specialists did on verbal statements reflecting behaviors toward domestic violence victims.

For example on a question probing whether they had enough time to ask about spouse in their practice, 100% of the psychiatrists said yes, as compared to 91% of emergency room physicians, 84% of OB-GYNs and 67% of family physicians. On a question of whether they would suspect domestic violence in patients presenting with chronic pain, depression or other illnesses, 40% of the psychiatrists said yes, as compared to 46% of OB-GYNs, 20% of emergency room physicians and 6% of family practitioners.

Taking Action
Braude was asked what individual psychiatrists and other mental health professionals could do to increase the recognition and treatment of patients experiencing domestic violence.

They need to recognize that any patient who is depressed, anxious or suicidal may be responding to a crisis in domestic violence, she said. Additionally, clinicians need to take the history that will discover the domestic violence, and, "give it profound consideration in the treatment plan," she said.

Possible questions that can elicit such information include:
&Mac183; Have you recently experienced violence at the hands of someone close to you?
&Mac183; Is there someone in your immediate environment that you are afraid of?
&Mac183; Do you have any history of violence from a significant other?

It is important that patients be interviewed in private, apart from a spouse or any significant other.

"If the other is present, the patient is not free, [since] telling the truth may precipitate another episode of violence," Braude said. "It is also very important that where the physician knows both parties—the perpetrator, and the victim—that they be interviewed and treated separately. Because …that is the only way the victim can feel free to pursue her own therapeutic needs. And the perpetrator needs to be approached separately from the point of view of his needs."

While she identified most victims of domestic violence as female, Braude did acknowledge that at least 10% of the victims are male.

Clinicians also need to carefully assess the danger to the victim and others in the household, such as whether the perpetrator abuses alcohol or drugs, whether there is a gun in the house, whether the violence is escalating, whether children or pets as well as the victim are being abused and whether there have been threats of murder. If the victim is not ready to leave the abuser, she will need help in formulating a safety plan to keep her and others in the household out of danger. That plan might include identifying a support network and prearranging help, teaching children to call the police if necessary, becoming familiar with basic legal options and becoming familiar with local emergency resources.

Braude also advised mental health professionals against a rush to diagnosis, noting that it is preferable and diagnostically more accurate to defer diagnosis until the person is out of danger and has had the opportunity to heal. She particularly warned against an early diagnosis of personality disorder.

"It is my belief that you cannot diagnose a personality disorder in someone who is being terrorized, for two reasons. First, I have seen a person’s personality and responses change remarkably when the source of the terror is removed. Second, one needs to be cautious, since the personality disorder label implies that the patient has some basic flaw in how she as a personality meets with situations in her life. That [label] can be used by the perpetrator in court who wants to assign the responsibility to the victim," Braude said.

She added that "victims of domestic violence are slow to come to psychiatrists, because they fear (and their fear is often justified) that any psychiatric records will be used against them if they confront the perpetrator in court."

Because the records may be subpoenaed, psychiatrists need to keep very good and careful records and to make sure that the records recognize that the patient is a victim of domestic violence.

Prescribing of psychotropic medications is also a concern. In AMWA’s course, clinicians are advised to evaluate the victim for substance abuse (alcohol and drugs often play a role in episodes of violence between intimates) and to obtain a detailed list of prescribed and over-the-counter psychotropic medications that the victim is taking, before prescribing any further medications.

Antidepressants and, to a limited extent, antianxiety medications can be useful in treating victims of domestic violence, Braude said. Still, they must be given in the context that the victim has realistic reasons for terror and may benefit from medication that enables her to feel sufficiently less paralyzed by anxiety and depression, so that she can function and cope with her situation. At the same time, it is important not to overmedicate her, because she needs to have all of her alertness and awareness available to her in case of further attack and in order to plan how she is going to handle her situation.

It is also very important that clinicians be aware of community resources to which they can refer the victim in an emergency, such as shelters and hotlines, Braude said. Even when patients do not initially admit to being victims of domestic violence, they can be helped. The AMWA course suggests a generic form given to all patients providing the numbers of local, state and national domestic violence hotlines. The National Domestic Violence Hotline number is (800) 799-SAFE (7233). That number will patch into the closest local domestic violence hotline. Posters with appropriate referral numbers can also be placed in waiting rooms.

Physicians and other health professionals can obtain significant guidance, Braude said, by taking AMWA’s domestic violence education online course. The course, led by Braude and co-director Peggy Goodman, M.D., with Carole Warshaw, M.D., as project consultant, is based on the manuals of the Family Violence Prevention Fund. The course covers such issues as the nature and dynamics of domestic violence, screening and clinical presentations, safety planning, legal aspects, effects of violence on children and interacting with the perpetrator. There are also hyperlinks to video and audio clips, case studies and reference charts.

"It is a continuing medical education course for physicians, but we are also getting a very substantial response from nurses, psychologists, social workers, other health care professionals who work with this population," she added.

Garimella, who worked with victims of domestic violence in India and completed an internship at a domestic violence-training program in New York City, also has some recommendations for physicians.

"Ultimately, women make their own decisions as to when they are ready to leave a violent situation," said Garimella. "Physicians can help by listening to the victims without feeling embarrassed, by acknowledging that a problem exists rather than say overlooking the black eye when a patient says she bumped into a wall and by assuring the patient that they can help in specific ways."

Domestic violence training for physicians needs to be revamped, according to Garimella.

In our study, we found that training (either in medical schools or postgraduate) does not affect physician attitudes, she said.

"This [lack of change] may be because most domestic violence curricula are didactic in nature and are theory driven," she said. "Many physicians I’ve talked with feel hopeless about making a difference in the lives of victims of domestic violence. They are frustrated, believing that they have given the victims a prescription to leave the violent environment, and the victims are being noncompliant…there needs to be some way to have a positive association between medical intervention and outcomes of ending the violence. It might be more useful to have former victims of domestic violence talk with physician groups about how medical services have helped them."

Other components suggested by Garimella and her study co-authors include the use of interactive learning strategies (e.g., role-playing, the use of simulated patients and computer-based models to reinforce information given in a didactic manner). Also valuable to physicians is a list of local domestic violence resources and face-to-face contact with representatives of those resources.

"It is best to have representatives from shelters, for example, speak to physicians about specifics, such as the number of beds they have available and the health and social services they provide," Garimella said.

Hospitals, too, need to provide additional help to victims of domestic violence, Garimella said. Because of Joint Commission on Accreditation of Healthcare Organization requirements, most hospitals are asking patients whether they are victims of violence on the admission questionnaires.

"Unfortunately, most of time, the patient’s answer just goes into the file and that’s all. There is no follow-up. That adds to the patient’s hopelessness. She’s assuming that someone is reading this information, but nobody is doing anything. So the next time, she doesn’t even want to tell someone she has been beaten, because nothing happened the last time. It would help if hospitals provided referrals to community resources that assist victims of domestic violence."

References
American Medical Women’s Association (1999), The On-Line Domestic Violence Health Care Provider Education Project. Available at www.dvcme.org. Accessed on Jan. 19, 2001.

Currier GW, Briere J (2000), Trauma orientation and detection of violence histories in the psychiatric emergency service. J Nerv Ment Dis 188(9):622-624.

Fox JA, Zawitz MW (2000), Homicide trends in the United States. U.S. Department of Justice, Bureau of Justice Statistics. Available at www.ojp.usdoj.gov/bjs/homicide/homtrnd.htm. Accessed on Feb. 1, 2001.

Garimella R, Plichta SB, Houseman C, Garzon L (2000), Physician beliefs about victims of spouse abuse and about the physician role. J Womens Health Gend Based Med 9(4):405-411.

McLeer SV, Anwar R (1989), A study of battered women presenting in an emergency department. Am J Public Health 79(1):65-66.

McLeer SV, Anwar RA, Herman S, Maquiling K (1989), Education is not enough: a systems failure in protecting battered women. Ann Emerg Med 18(6):651-653.

Stark E, Flitcraft A (1995), Killing the beast within: women battering and female suicidality. Int J Health Serv 25(1):43-64.

Tjaden P, Thoennes N (2000), Extent, Nature and Consequences of Intimate Partner Violence: Findings from the National Violence Against Women Survey. Sponsored by the National Institute of Justice and Centers for Disease Control and Prevention.


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