Domestic Violence: On the Path to Safety

December 22, 2014

For us to intervene and prevent injury, we need to ask patients probing questions about their relationships, and whether they feel safe at home.

[[{"type":"media","view_mode":"media_crop","fid":"30650","attributes":{"alt":"domestic violence","class":"media-image","id":"media_crop_5251649745901","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3216","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image"}}]]Domestic violence (DV)-often referred to as intimate partner violence (IPV)-has captured national attention lately with several high-profile cases in the news. But DV does not always make the headlines. As a matter of fact, many of those who are the victims of violence at the hands of an intimate partner suffer in silence. They do not tell their friends, family, or even their psychiatrists or primary care physicians.

CASE VIGNETTE

Ms A is a 40-year-old woman who complained of symptoms of depression and anxiety to her psychiatrist. She described having problems with parenting her school-aged children and feeling devalued at work. Ms A’s husband is a prominent physician; she complained about his lack of support for her efforts at balancing domestic and work responsibilities. After Ms A’s second visit, the psychiatrist received a call from an emergency department (ED) physician: Ms A was unconscious with a severe traumatic brain injury after having been pushed by her husband. As she fell to the floor, her head hit a table edge. The ED physician had found the psychiatrist’s name on Ms A’s medication bottle. The ED physician related that Ms A had signs of past abuse, including old bruising on her chest. The psychiatrist had not seen the bruises, which were hidden under her clothes. Because the woman was the wife of a physician, the psychiatrist had not inquired about domestic violence.

 

According to the CDC, more than 12 million people a year in the US-some 24 people per minute-are victims of rape, physical violence, intimidation, or stalking by an intimate partner.1 DV accounts for 21% of all violent crime.2 The US Department of Housing and Urban Development reports that DV is the third leading cause of homelessness among families. Finding a safe place to live is often the most pressing concern for victims of DV.3

The numbers may underestimate the problem. Many victims do not report DV because they believe or have been convinced by their abuser that others will not believe them or that the police cannot help. They also may be embarrassed or feel that others will blame them for the abuse. In addition, victims of DV may have economic and financial fears. They worry about how they will provide housing and food for themselves and their children if they leave the abuser.

DV is preventable, and we need to help make it stop. There are things all of us-individuals, health care professionals, public officials, and organizational leaders-can do to address the issue.

Effects of domestic violence

DV does not discriminate on the basis of race, age, socioeconomic status, gender, or sexual orientation. It is often defined as a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner.4 DV can be physical, sexual, emotional, economic, or psychological. These behaviors can be used to manipulate, isolate, terrorize, blame, or injure someone.

Women are more likely to be victims of DV, but DV also affects men. According to the CDC, about 1 of 4 women (24.3%) and about 1 of 7 men (13.8%) aged 18 and older in the US have been victims of severe physical violence by an intimate partner in their lifetimes.1 When men are the victims, they are especially embarrassed and reluctant to report.

Direct victims are not the only ones who suffer; often entire families and the people around them are touched in some way. Children who witness DV are among those seriously affected by this crime. Exposure to violence in the home teaches children that violence is a normal way of life and increases their risk of becoming the next generation of victims and abusers.

Abuse can play a role in the way people think and interact with those around them. The constant feeling of fear can leave an individual with mental stress that affects thoughts, feelings, and behaviors. Victims of IPV may turn to drugs, alcohol, smoking, or overeating to cope. IPV can contribute to a range of physical and mental health problems, such as headaches, chronic pain, asthma, diabetes, anxiety, depression, and PTSD. Living in an environment in which a person is being controlled by another can create feelings of hopelessness. A perpetrator can chip away at a person’s self-esteem with insults or criticisms and take away a sense of safety.

Victims of DV may also be victims of their partner’s less obvious but persistent efforts to undermine their health and well-being-tactics sometimes known as “mental health coercion.” This may involve such things as efforts to control medication or treatment, limit access to support and resources, undermine credibility with authorities, or prevent the victim from seeking help. A recent survey of callers to the National Domestic Violence Hotline found that 89% had experienced some type of mental health coercion and 43% had experienced some type of substance use coercion.

Steps to help prevent domestic violence

Victims must be empowered to know that they can leave a violent situation, even if it means seemingly giving up everything to finally feel safe. Often just picking up the phone is difficult, for fear that the abuser will find out. Some abusers threaten to kill their victims and/or their children and other family members, friends, or even pets if they leave. Sometimes the violence escalates when victims leave and the abuser finds them.

The National Domestic Violence Hotline (800-799-7233, www.thehotline.org) is an important resource for victims or those who need to help victims of DV. Information and resources are offered to get victims on the path to safety and a new life. Anyone in immediate danger should call the police. There are safe houses where victims and their families can stay.

As clinicians, what can we do? We can ask about current conflict at home and past experience with trauma, create an environment in which individuals feel safe, and have local resource information available (shelter, safety, support). Even if a patient initially denies abuse, we should continue to inquire as we develop a stronger therapeutic alliance and obtain more information that makes us suspect that abuse may be occurring. The American Psychiatric Association’s official position on DV encourages psychiatrists to take an active role in prevention by:

• Participating in development of protocols to identify family violence

• Understanding all applicable laws

• Advocating for increased funding for prevention and treatment

• Participating in research

• Helping to educate medical students, residents, and physicians

The bottom line is that it takes a whole community to end DV. The headlines may sensationalize the problem or make IPV feel remote, but the sad fact is that it is all too common and very real. But it is also an issue we can do something about. I would encourage clinicians to trust their instincts if they suspect a case of DV.

For us to intervene and prevent injury, we need to ask patients probing questions about their relationships, and whether they feel safe at home.

In October, during Domestic Violence Awareness Month, many advocacy groups used the Twitter hashtag #SeeDV. It contains an important thought: do not look past victims and those who could be living in danger and fear. Because victims often live in isolation, please reach out and offer support and resources. It could make all the difference.

Disclosures:

Dr Binder is President-Elect of the American Psychiatric Association. She is Professor of Psychiatry, Associate Dean, and Director of the Psychiatry and Law Program at the University of California, San Francisco. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Black MC, Basile KC, Breiding MJ, et al. National Intimate Partner and Sexual Violence Survey: 2010 Summary Report. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; November 2011. http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf. Accessed November 5, 2014.

2. Truman JL, Morgan RE. Special report: nonfatal domestic violence, 2003-2012. Washington, DC: US Department of Justice; April 2014. http://www.bjs.gov/content/pub/pdf/ndv0312.pdf. Accessed November 4, 2014.

3. Clough A, Draughon JE. ‘Having housing made everything else possible’: Affordable, safe and stable housing for women survivors of violence. Qualitative Soc Work. 2014;13:671-688. http://qsw.sagepub.com/content/13/5/671.abstract. Accessed November 5, 2014.

4. US Department of Justice. Domestic violence. http://www.justice.gov/ovw/domestic-violence. Accessed November 5, 2014.

5. National Center on Domestic Violence, Trauma, and Mental Health; National Domestic Violence Hotline. Mental Health and Substance Use Coercion Surveys Report. 2014. www.nationalcenterdvtraumamh.org/publications-products/mental-health-and-substance-use-coercion-surveysreport. Accessed November 5, 2014.