Assessment of Intimate Partner Violence
The US Preventative Services Task Force states that screening instruments for intimate partner violence have not been evaluated against measurable violence or health outcomes and that there is no evidence that screening in a health care setting reduces harm.10 However, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Obstetricians and Gynecologists encourage screening of patients for domestic violence and appropriate referral.11-13 The American Academy of Family Physicians also advocates for their physicians “to teach parenting and conflict resolution skills to promote respectful and peaceful personal relationships.”14 Surprisingly, the American Psychiatric Association does not discuss routine screening in its policy statement on domestic violence.15 If the psychiatrist decides to screen for intimate partner violence, what would be the best way to do this and what treatments are recommended?
To detect and quantify intimate partner violence, most researchers use instruments such as the Conflict Tactics Scale16 or its shorter version.17 However, this is not practical in an office setting because it does not cover all the necessary elements for a clinical assessment. Couples, however, do report more intimate partner violence on self-report questionnaires than when asked directly, and perhaps a good clinical tool could be developed.18 In the interim, asking about specific behaviors, such as pushing, kicking, and slapping, will elicit a more positive response from patients than asking about violence. Asking about the potential impact of aggression, such as “Are you afraid of your partner?” yields important information that can direct treatment. It is important to ask about intimate partner violence in a sensitive way that does not shame the patient (Table 1). Neither men nor women may want to admit that they are being abused because of strong cultural bias against being seen as a victim.19
Treatment of Intimate Partner Violence
Treatment has traditionally been divided into separate treatments for victims and perpetrators. Simply assessing women for intimate partner violence and offering a referral can interrupt intimate partner violence.20 In a study by McFarlane and associates,20 360 female victims of intimate partner violence recruited from primary care clinics were compared on 2 interventions: a wallet-sized referral card and a 20-minute nurse case management protocol. After 2 years, both treatment groups reported significantly (P < .001) fewer threats of abuse and assaults. Compared with baseline, both groups adopted significantly (P < .001) more safety behaviors. Brief telephone intervention, 6 phone calls for an overall total time of 1 hour over 8 weeks, also increased safety-promoting behaviors that were still present at 18 months.21 Improving social support can also help women obtain needed resources and result in improved psychological well-being and health outcomes.22
In addition, specific interventions, such as a 6-week empowerment intervention, can result in higher physical functioning, less psychological abuse, less physical violence, and significantly lower depression scores.23 After a 10-week intervention using trained advocates, women were twice as likely to be free of violence as a control group at 2 years’ follow-up.24 However, after 3 years, the advocacy program’s effect on intimate partner violence did not continue, although the women had an improved quality of life and more social support.25 In summary, small interventions for female victims are effective.
Treatment for male batterers is generally court-ordered and delivered in sex specific (ie, all-male) groups. Sex-specific treatment follows the Duluth model, which focuses on educating the male perpetrators about different ways to express anger and reduce interpersonal, controlling behavior. According to the Duluth model, the primary cause of domestic violence is “patriarchal ideology and societal sanctioning of men’s use of power and control over women.” These programs are not considered to be therapy. Rather, group facilitators lead consciousness-raising exercises to challenge the men’s perceived right to control or dominate their partners.
A fundamental tool of the Duluth model is the Power and Control Wheel, which illustrates that violence is part of a pattern of behavior that includes intimidation, male privilege, isolation, and emotional and economic abuse, rather than isolated incidents of abuse or cyclical explosions of pent-up anger or painful feelings. The treatment goals of the Duluth model are to help men change from using the behaviors on the Power and Control Wheel, which result in authoritarian and destructive relationships, to using the behaviors on the Equality Wheel, which form the basis for egalitarian relationships.26 However, a meta-analysis of 22 studies of sex-specific treatment for batterers indicates that treatment effect sizes are small.27 Therefore, other treatments are being developed.
Several states have developed couples treatment for male batterers. In California, a comparison study of court-referred batterers found that sex-specific treatment and conjoint couples treatment were equally successful in reducing intimate partner violence.28 In Virginia, a model of conjoint treatment when used for couples in which the male partner has perpetrated mild to moderate violence and in which both partners want to remain together, has been shown to be successful.29 Six months after treatment, male violence recidivism rates were significantly lower for the multicouple group (25%) than for either the individual couples (43%) or the comparison group (66%).30 Women who have been arrested for perpetration of intimate partner violence may not have access to appropriate treatment.31 In summary, sex-specific treatment is not very effective in reducing the perpetration of violence, but couple or multicouple treatments show promise for mild to moderately violent male perpetrators.