DOMESTIC VIOLENCE UPDATE 2.0 CE Hr.
Successful completion of this packet meets the Florida 2 Hr requirement for nurses. PROGRAM GOALS AND OBJECTIVES
Upon completion of this continuing education self-study module, the learner is expected to demonstrate enhanced understanding of domestic violence (DV) as evidenced by a score of at least 75% on a post-test related to the following objectives:
Florida statutes define domestic violence as “Assault, battery, sexual assault, sexual battery, or any criminal offense resulting in physical injury or death of one family or household member by another who is or was residing in the same single dwelling unit” (fs section 741.28).
Domestic violence is a significant public health concern, as many victims sustain permanent disability or die as a result. The morbidity, mortality and financial burden resulting from DV are tremendous. It is estimated that between 3-5 billion yearly is spent for domestic violence-related services including ER visits, clinical visits, lost work, hospital stays, mental health counseling and DV services. This figure does not include the legal expenses or law enforcement and incarceration costs for detaining and convicting the abusers.
While DV statutes in Florida focus upon physical abuse, there are other forms of abuse, which may take place in addition to physical abuse, or in the absence of physical abuse. It is often difficult to screen for verbal or emotional abuse, which may include isolation, intimidation, humiliation, criticism, derogatory remarks, and withholding warmth and affection. Emotional abuse kills the spirit and may permanently hinder emotional contacts with others. Financial abuse may also be present, which isolates the victim and prevents them from receiving adequate emotional, nutritional or health services.
A more comprehensive description of DV may be the intentional infliction of physical injury or mental anguish upon another individual living in the same domicile or involved in a personal or intimate relationship.
How common is it?
DV is the leading cause of injury to women in the United States. Some of the recent statistics:
Who are the victims?
Anyone can be a victim. Abuse victims can be from any walk of life and any age group, from the unborn (fetal abuse in utero is common during pregnancy) to the very aged. Approximately 95 to 98% of the victims are women and children. In fact, a woman is more likely to be raped, murdered or abused by a domestic partner than a stranger. Victims and their abusers can be from any race, religious preference, educational level, socioeconomic status, ethnicity, and having any sexual preference. Separated, divorced and single individuals have a higher incidence of domestic violence. Individuals involved in interracial relationships or relationships in which each partner is from a religiously different background are also at higher risk.
Contributing Factors
A significant contributing factor to DV is the mixed message that society receives from the media related to violence. Violence has been glorified and glamorized in the media to the point where many individuals are desensitized to it. Human devaluation has developed and individual significance has eroded.
Nowhere else is the lack of a line between love and hate more obvious than in incidents of DV. In fact, violence, love, caring and pain are often fused together in a psychological dynamic that is often impossible for an individual not involved in a domestic violence situation to clearly understand. It is this fact that often makes caring for victims and perpetrators of DV a difficult task.
Sexual assault presents a unique dilemma, which hinders reporting by the victims and may unintentionally encourage the perpetrators because they believe that the punishment would be minimal or entirely unlikely. It has been estimated that only 1 in 10 sexual assaults are reported. Sexual assault is the only crime in which the victim is required to prove their innocence and that they attempted, if at all possible, to resist their attacker.
Factors related to abusers
The number one psychodynamic factor behind abuse is power. Abusers need to gain and maintain control. Abusive behavior is often learned through observation of relationships within an individual’s own family or through socialization while growing up. The perpetrators of DV who have experienced violence in their families of origin often do not learn effective relationship skills from their dysfunctional role models. They often are told how to act and feel, and have diminished autonomy while growing up. As a result, they develop ineffective problem-solving strategies, and often become distrustful and hostile. A low tolerance for frustration often develops which leads to emotional instability, rage or jealousy, and aggressive behaviors, often with little provocation. They may exhibit unrealistic demands, being domineering, meticulous, a perfectionist or over-controlling.
These individuals may be antisocial and sadistic, lack emotional responsiveness, and exhibit little or no remorse. They may be violent in other non-domestic interactions, or they may exhibit dual behavior, being very controlling in private, but when in public they will appear to be controlled by their significant other.
Combined with, or being the characteristic of DV may be passive abuse, where the abuser distances themselves from their victim, withholding affection, warmth or any other contact.
All these factors or tendencies may be in place long before the perpetrator of DV ever begins their first relationship. These motivational factors and tendencies, however, often do not surface until a relationship has been established and is past the so-called “courtship” phase.
Cultural factors relating to male dominance and female subservience also play a significant role in DV.
Contributing factors can be related to substance abuse, ineffective coping mechanisms, personality disorders, stress or a previous history of DV or child abuse.
Abuse is self-perpetuating and reinforcing. The behaviors are learned through past success at maintaining control. Power and a sense of “wholeness” often only come to abusers after and episode of violence.
Factor related to victims
Victims often lack autonomy and are highly dependent on their partners for validation. They often have not established their own individual identities. Victims often have a significant fear of rejection and are easily manipulated. They are often immobilized emotionally or captive in their own homes since their own abilities are minimized or criticized. This is often identified as a form of learned helplessness.
Victims are often disconnected, particularly with respect to sexual relations. They often have no control, even over their own reproductive destiny. Many abused women become pregnant by their abusers who use the mother-child bond and maternal dependency as another aspect to maintain their control.
Victims themselves are often from family situations where violence was present. They have been conditioned to accept abuse as a normal and expected behavior. Their families of origin may also have conditioned acceptance of an unequal distribution of power, typically one in which a patriarchal relationship was in place.
Patterns and theories of abuse
Several theories have been developed to examine the phenomenon of DV, two of which will be outlined in this article. The Cycle of Violence Theory and the Power and Control Theory both seek to clarify patterns and forms of domestic violence.
The Cycle of Violence Theory describes three “phases” which occur in an abusive relationship: 1) A phase in which tension is building, 2) the actual battery, and 3) the “honeymoon” phase.
The Power and Control Theory is visually depicted by a wheel. At the center of the wheel lies the major motivational factor behind abuse, power and control. Each spoke of the wheel separates eight different mechanisms which abusers employ to gain control over their victims: 1) using intimidation, 2) using emotional abuse, 3) using isolation, 4) minimizing, denying, and blaming, 5) using children, 6) using male privilege, 7) using economic abuse, and 8) using coercion and threats. Note that each of these behaviors or acts described inside the wheel does not involve physically touching the victims, but constitute verbal and emotional abuse. The outside of the wheel (the tire) is represented by physical and sexual violence. This portion is often the only “clue” that a healthcare provider may observe related to domestic violence (and that is if the victim seeks treatment and the healthcare provider performs an appropriate screening exam!!). Imagine all of the factors listed inside the wheel that may be taking place at the same time in a victim’s life and it is easy to understand all of the emotional problems that they may have.
While these factors and theories bring clarity to explain DV, they do not justify the behaviors. Abusing another person is a conscious decision that an individual makes in order to gain and maintain control over that individual.
Healthcare provider responsibility
Healthy People 2010, a governmental plan for healthcare goals for the nation, have a specific goal related to DV and list it as #15 in its focus area. The objective states that ED’s should have protocols for routine identification, treatment, and referral of victims of sexual assault and spousal assault. Notice the wording “routine.” It should be a commonly practiced screening technique, not just with individuals who are highly suspected of being abused. The Joint Commission of Accreditation of Hospital Organization’s (JCAHO) requirements mandate policy and procedure related to dealing with victims of DV as well as an educational plan for the staff.
Screening for DV is as essential as screening for hypertension (by routinely taking B/P), for fever (by taking temp.), and for respiratory distress (by taking respiratory rate). It should become an automatic assessment technique implemented with every patient contact.
The nurse is often the first healthcare contact for a victim of DV. Universal screening practices should be a standard procedure in all healthcare facilities. The assumption that victims of violence typically visit only emergency rooms and public health clinics is incorrect. Many seek treatment for DV related injuries at private physicians’ offices, particularly obstetricians during pregnancy.
Unfortunately, research has shown that healthcare providers inconsistently assess for DV, if at all. In addition, the primary focus has been on physical injury and not emotional or psychological abuse.
It is imperative to maintain a high index of suspicion and to keep current on the policies and procedures for notification and reporting to authorities the various types of abuse upon individuals of different ages. Remaining educated and aware is important, as is practicing a standard dialogue and therapeutic approach to screen for abuse. Incorporating screening questions into every healthcare history and assessment increases the comfort level for healthcare practitioners in asking these sensitive questions.
Maintaining a current referral source sheet to give to identify or suspected victims can save time and lives. Be cautious, however, not to “force” a suspected victim to take a sheet with them. They may fear retaliation from the abuser if the sheet is discovered among their belongings.
Charting thoroughly and accurately is imperative. Subjective data is best charted by using exact patient quotes when possible. Objective data must be defined in as much detail as possible, using conscious and clear wording and body maps when appropriate to convey the size and location of physical of physical injuries. Well-kept records are the best assistance the medical profession can give the courts to seek justice and protection for DV victims.
If photos are to be taken, at least one must contain the face of the victim. All should be labeled clearly and optimally signed by the victim at the time of photographing (an instant camera is obviously ideal). To maintain clarity, a ruler should be placed beside the injury area for reference.
Screening for abuse
Reinforce that the victim does not deserve to be abused, that they did not cause the abusive situation, and that there is help available. Your approach should not be confrontive but rather accepting and empathetic. Providing privacy during the screening process is crucial. Have the partner or others leave the room. Many abusers, however, refuse to leave their victim alone, and are also noted to answer questions for them. If the partner refuses to leave and the patient is ambulatory, take her to the bathroom to obtain a urine specimen and screen her while you are in there with her and give her instructions. Be sure to actually collect the specimen so as not to tip off the suspected abuser as to your intent.
Refrain from deferring the screening process to social workers or to other “specialists.” The patient may never again see these individuals and you may represent their only chance for an intervention at that particular time.
Guilt and depression are commonly seen with victims of DV, particularly female abuse victims. Do not compound this guilt by screening with insensitivity. Individuals, particularly females who present for treatment with multiple injuries, should always be screened for DV, no matter how plausible their description of the accident that caused the injuries. Research has shown that females are more likely to sustain multiple injuries as a result of DV.
Mechanisms for injury seen in abuse may include punching, kicking, slapping, shoving, hitting with objects, or any combination of these. The most frequent site of injury is the head and face (89%), followed by the abdomen and chest (32.5%), and the extremities (18.1%). Injuries seen may include abrasions, contusions, lacerations, burns, internal injuries or fractures. Injuries associated with DV are usually “central” (located on the trunk/head), where accidental injuries are usually “peripheral” (arms/legs). One exception is “defensive posture,” injuries of the palms and the ulnar aspects of the forearm (incurred when the victim acts to shield their face and torso).
Any trauma or burn, which is inconsistent with the reported history, should raise the index of suspicion for abuse. Some signs and symptoms seen in abused individuals are listed below, but are not present with all victims:
Assessment for DV should include maintaining a nonjudgmental attitude, validating the victim’s experience, and assessing his or her plan for safety, regardless of whether or not they plan to leave at that time. Don’t worry about offending non-victims by asking screening questions. You should never “discount” your screening approach by stating something like “I know that this probably is not true in your case, but I have to ask everybody.” This will render your screening practically worthless with most individuals, and convey that you really do not want to help them. If the patient is offended or upset, simply explain that DV is a major problem affecting many individuals, and that you are hear to assist if they are indeed a victim of DV.
There are many techniques and screening questions formats which have been proven successful for DV. Some are detailed here. Most healthcare professionals adapt a screening process which they are comfortable with and which includes a combination of questions. The assessment should include asking baseline questions related to potential DV or harm, best presented in an indirect manner such as:
“Stress develops in many relationships and often partners hurt each other. Has anything like this happened to you?”
“Sometimes we see injuries like those that you have received after couples argue. Is that what happened to you?”
“Have you ever been slapped, hit, kicked or otherwise hurt by your partner? Have you ever been forced to have sex when you did not want to?”
“Do you feel safe at home? How do you and your partner resolve conflicts? Are you afraid or abused?”
The following approach works well with pregnant patients who seek prenatal care late:
“When women start prenatal care late in a pregnancy, sometimes it is because their partner prevents them from coming in or there is a difficult situation at home. Is this why you have not sought care sooner?
Barriers to intervention
Domestic violence thrives upon silence. There are personal, social, and systematic barriers which impact screening and intervening for DV. Unfortunately, some healthcare providers still misunderstand their responsibility to assess and intervene in DV. Some are hesitant to become involved or fear legal reprisal if their suspicions are incorrect. This reasoning for hesitancy is not validated if the healthcare provider consistently screens for DV and documents the finding clearly and professionally.
The victim may also see mandatory reporting as yet another paternalistic approach that takes away their choice as an individual to control their own destiny. Report abuse with respect to each victim’s verbalized choice and in compliance with policy/procedure and laws. You should respect the patient’s autonomy, but clearly document your observations and findings in the medical record, should they decide to change their mind and your observations would assist in supporting their charge of abuse.
When screening is performed, it is often from a less than therapeutic approach, often consisting of questioning the victim as to why they remain in the abusive situation. This approach usually does not serve to enhance the therapeutic relationship, invoke insight or motivate change. It does, however, provide for re-victimization of the victim. An abused victim now has been made to feel that they are doing wrong by staying in the situation, and may have added feeling of guilt and shame when relating to the healthcare provider performing the screening. Their feeling of isolation and shame may escalate, diminishing the therapeutic relationship and further interventions. This secondary “blaming” often serves to promote silence. The responsibility and any “blame” for domestic violence should be placed where it belongs, on the perpetrators, not the victims.
Some view issues in the home as a personal or private matter, contending that if abuse is present, the victim has made their choice to remain in the situation. Inappropriate intrusion into the personal circumstances of individuals is often cited as a reason not to screen, however, this line of thought is inconsistent with the process used to screen for other illnesses of injuries. We ask the most intimate details regarding sexual practices and preferences, alcoholic abuse, and the recreational use of illegal or mind altering substances, yet it is difficult to ascertain if an individual is the victim of a crime or a circumstance which may ultimately lead to death.
Another barrier is accepting responsibility for the screening process. It is not the work of the social workers, therapists, or law enforcement officials. As healthcare workers, and particularly nurses who often provide the first healthcare contact for the patient, it is your job and your responsibility.
Many healthcare providers are hindered by their own personal experiences or exposure to DV. Being victims or survivors themselves, they may find it difficult or painful to interact or care for suspected or actual abuse victims. It is difficult, if not impossible, to help a victim of abuse when an individual healthcare provider has not been able to make an intervention for themselves. If a healthcare provider is unable to be therapeutic and provide screening for DV, they should seek help and defer the screening process to another individual until they can be therapeutic.
Even healthcare workers who have not personally experienced DV may have difficulty dealing with individuals who have. Discuss you hesitancy with peers and support them in making interventions when you cannot. One way to enhance your therapeutic abilities with abuse victims is through exposure. Consider volunteering in a shelter. If you are in school, consider clinical experiences with the homeless or within a crisis center.
Many healthcare providers become frustrated problem solvers. Be realistic – you cannot solve it all. Futility and disgust often cloud healthcare workers adequate screening and provision of support for actual or suspected victims, especially if a pattern has been demonstrated. It is all too familiar to adopt the “why bother, they go back anyway” attitude. It is true that many abuse victims do go back to their abusive situation, however, some do leave.
The patient care area layout is often a barrier to screening, as it is often busy and affords little privacy. The patient may have to be relocated to a quieter room or area to adequately screen and offer assistance or interventions.
Denial is the greatest barrier to the truth. Many victims will not admit that they are the victims of abuse either as a result of guilt, shame, fear, hope for change or continued love of their abuser.
Patients themselves are often viewed as unreliable historians because they are emotional, intoxicated, or abusing drugs. “If they can not give valid information, why ask?” is often an excuse for admitting the screening process.
Unfortunately, the healthcare system has created barriers to reporting DV, which may have life-long consequences for the abused individual. Up to 23% of healthcare plans (insurance, HMO, PPO, etc.) are now using history of DV as a screening tool to deny insurance eligibility!
Interventions
Solutions for a DV situation are not discovered or considered until problems are disclosed and confronted. A comprehensive screening within a therapeutic relationship prompt the victim to realize that they do not deserve to be abused and they there are alternatives available to them. The incidence for an abused individual to act immediately to leave their abusive situation is, unfortunately, not highly likely. This factor, however, should not discourage the healthcare provider from providing the victim with information and options should they decide to use them at some time in the future. The goal is to encourage a transition from victim to survivor. This process may require vast differences in time and levels of assistance or supports to take place.
It is important to build a rapport with the patient and practice active listening skills and to communicate with sensitivity. Empathize with the victim’s dilemma. Validate their painful experiences, and encourage them to consider seeking help.
Encourage the victim to assess and build upon the positive aspects of their life, including their strengths, abilities and support systems. Refrain from acting as a “single rescuer,” but act as a guide to lead the victim to others and to support systems that can provide the comprehensive assistance that will be needed. It takes much work to encourage and build self-esteem and to learn relational development in a positive manner.
Safety is the #1 concern for victims of DV and their children. Have the victim mentally review and rehearse an escape plan that would be feasible for their given situation.
Provide information related to sources for help, but understand that many victims are not able to take this information with them because their abuser may discover it and punish them further.
Why do they stay (or go back again… and again… and again)
The “average” victim of abuse leaves their relationship two to five times before they end the relationship permanently. It has been correctly stated that abused individuals often do not chose to leave a relationship. Rather, they escape it.
Many factors contribute to maintaining an abusive relationship including social, financial and emotional reasons. Most victims fear retaliation or the lack of being able to provide for themselves and their children. A sense of immobility often develops. It is important to understand (as depicted within the power and control wheel) that many abusers use their children as “bargaining chips” to force their victims to stay in an abusive situation. The decision to stay if often based upon survival needs and not character flaws.
The victim may have a diminished self-esteem, often to the point of dehumanization. They may sense that they are different and less important than other individuals as a result of the treatment and conditioning by their abusers. The victim may be desensitized and unable to deal with their own feeling and emotions. Many women fear being “alone.” They do not value or have never experienced their independence or have been conditioned to believe that they cannot exist without a relationship. They may feel as if having an abusive partner is better than having not partner at all.
Attempting to leave the abusive situation has been identified as the most dangerous time for a victim of DV. Victims often fear retaliation. They do not want to experience the past punishment they may have endured for attempting to leave.
For a victim to actually leave and abusive relationship, they must be ready to alter the course of their life and become empowered, establishing new, and often very frightening, boundaries themselves, their environment and their significant others. They must deal with painful and strange new feelings. They may be required to take on new responsibilities. Many victims may not know how to perform necessary tasks required for survival such as banking, working and relating socially to others. Deciding to leave, therefore, is not simply an easy decision to “get out.”
Again, many victims do not leave. While this decision is frustrating, you must support them in their right to make their decision. In supporting their right, you recognize their autonomy. It is important to remember that the victim feels controlled by their abusive partner. The last thing that they need is to feel controlled in a so-called “therapeutic intervention” by a healthcare worker that they just met.
What if the answer is “yes” I’m abused…help me
Report the incident and support the victim during necessary questioning and photography (if required). Clearly document everything for future prosecution of the perpetrator.
Assess the current safety:
The “exit plan” should include gathering important papers such as medical and school records, immunization records, identification, legal documents, valuables, any money or assets available to them, an extra set of keys, and personal items.
Restraining orders may be obtained, but are often ineffective in protecting victims if their abusers are intent upon retaliation.
Counseling is recommended for all victims of DV, regardless of how effectively they appear to be dealing with their circumstances. Psychotherapy for female victims is aimed at encouraging empowerment and minimizing the impact of secondary victimization by others (“why did you stay?” “what were you thinking?” “what was wrong with you?”).
DOMESTIC VIOLENCE REFERRAL SOURCES:
BROWARD:
Women in Distress:
(954) 760-9800 Outreach Center
(954) 761-1133 Crisis Hotline
* Provides support for women and their families
Family Service Agency:
(954) 587-7880
* Provides support for gay and lesbian victims of domestic violence
DADE
Metro-Dade Advocates for victims
Safe Space (North Dade):
(305) 758-2546
(305) 758-1347 (Hotline)
Safe Space (North Dade):
(305) 247-4249
*Provides support for female victims of domestic violence
Domestic Intervention Program for Batterers:
(305) 643-8533
*Provides a support program for the abusers
WEST PALM BEACH:
YMCA Harmony House:
(561) 655-6106
* Support for battered women
STATE OF FLORIDA:
Domestic Violence Hotline:
1-800-500-1119
(for referrals to shelter and counseling)
National Hotline:
1-800-799-SAFE
Florida Crimes Compensation Act:
1-800-226-6667
This provides up to $2500 for counseling for children who witness domestic violence. The child’s name must be listed on a domestic violence police report.
Additional Patient resources:
Family Violence Prevention Fund: 1-800-313-1310
National Council on Child Abuse and Family Violence:
1-800-222-2000
Selected References Feminist Majority Foundation (2007). Domestic Violence Hotlines and Resources. Retrieved 3/29/09 from http://feminist.org/911/crisis.html.
FL Department of Law. Total domestic crime by county, 2008 Available at: www.fdle.state.fl.us/Content/FSAC/Data---Statistics-(1)/UCR-Domestic-Violence-Data/UCR-Domestic-Violence-Data.aspx Accessed: October 16, 2009
Joint Commission on Accreditation of Healthcare Organizations. (2009). Assessment of the Patient, The Comprehensive Administrative Manual for Hospitals, Chicago.
National Coalition against Domestic Violence. (2007). Retrieved 4/5/09 from http://www.ncadv.org/files/DomesticViolenceFactSheet(National).pdf.
US Department of Justice. (2009). About Domestic Violence. Retrieved 4/5/09 from http://www.ovw.usdoj.gov/domviolence.htm.
CDC. (2006). Understanding Intimate Partner Violence, Fact Sheet. Retrieved 4/5/09 from http://www.cdc.gov/ViolencePrevention/pdf/IPV-FactSheet.pdf.
TAKE THE TEST>>
Successful completion of this packet meets the Florida 2 Hr requirement for nurses. PROGRAM GOALS AND OBJECTIVES
Upon completion of this continuing education self-study module, the learner is expected to demonstrate enhanced understanding of domestic violence (DV) as evidenced by a score of at least 75% on a post-test related to the following objectives:
- Define DV as described in FL statutes
- Identify the incidence, contributing factors, varied context and significance of all forms of DV including physical, verbal, emotional and sexual abuse.
- Describe screening techniques for DV and relate health care worker’s responsibility for reporting DV
- Identify factors, which contribute to victims remaining in abusive relationships/circumstances
- Identify local community resources for victims
Florida statutes define domestic violence as “Assault, battery, sexual assault, sexual battery, or any criminal offense resulting in physical injury or death of one family or household member by another who is or was residing in the same single dwelling unit” (fs section 741.28).
Domestic violence is a significant public health concern, as many victims sustain permanent disability or die as a result. The morbidity, mortality and financial burden resulting from DV are tremendous. It is estimated that between 3-5 billion yearly is spent for domestic violence-related services including ER visits, clinical visits, lost work, hospital stays, mental health counseling and DV services. This figure does not include the legal expenses or law enforcement and incarceration costs for detaining and convicting the abusers.
While DV statutes in Florida focus upon physical abuse, there are other forms of abuse, which may take place in addition to physical abuse, or in the absence of physical abuse. It is often difficult to screen for verbal or emotional abuse, which may include isolation, intimidation, humiliation, criticism, derogatory remarks, and withholding warmth and affection. Emotional abuse kills the spirit and may permanently hinder emotional contacts with others. Financial abuse may also be present, which isolates the victim and prevents them from receiving adequate emotional, nutritional or health services.
A more comprehensive description of DV may be the intentional infliction of physical injury or mental anguish upon another individual living in the same domicile or involved in a personal or intimate relationship.
How common is it?
DV is the leading cause of injury to women in the United States. Some of the recent statistics:
- 3 to 4 million are abused each year by a partner
- Strangers kill only 3% of women who are killed in their home
- According to the most recent domestic violence studies, between 22% and 25% of all women will experience domestic violence at some time in their life.
- At least ½ of all couples are violent at some time in their relationship
- Domestic Violence crimes reported to the police in Florida in 2001 were 124,016 as opposed to 121,834 in 2002.
- Domestic violence has a reciprocal relationship with homelessness and substance abuse.
- The family may be one of the most violent institutions in our society.
Who are the victims?
Anyone can be a victim. Abuse victims can be from any walk of life and any age group, from the unborn (fetal abuse in utero is common during pregnancy) to the very aged. Approximately 95 to 98% of the victims are women and children. In fact, a woman is more likely to be raped, murdered or abused by a domestic partner than a stranger. Victims and their abusers can be from any race, religious preference, educational level, socioeconomic status, ethnicity, and having any sexual preference. Separated, divorced and single individuals have a higher incidence of domestic violence. Individuals involved in interracial relationships or relationships in which each partner is from a religiously different background are also at higher risk.
Contributing Factors
A significant contributing factor to DV is the mixed message that society receives from the media related to violence. Violence has been glorified and glamorized in the media to the point where many individuals are desensitized to it. Human devaluation has developed and individual significance has eroded.
Nowhere else is the lack of a line between love and hate more obvious than in incidents of DV. In fact, violence, love, caring and pain are often fused together in a psychological dynamic that is often impossible for an individual not involved in a domestic violence situation to clearly understand. It is this fact that often makes caring for victims and perpetrators of DV a difficult task.
Sexual assault presents a unique dilemma, which hinders reporting by the victims and may unintentionally encourage the perpetrators because they believe that the punishment would be minimal or entirely unlikely. It has been estimated that only 1 in 10 sexual assaults are reported. Sexual assault is the only crime in which the victim is required to prove their innocence and that they attempted, if at all possible, to resist their attacker.
Factors related to abusers
The number one psychodynamic factor behind abuse is power. Abusers need to gain and maintain control. Abusive behavior is often learned through observation of relationships within an individual’s own family or through socialization while growing up. The perpetrators of DV who have experienced violence in their families of origin often do not learn effective relationship skills from their dysfunctional role models. They often are told how to act and feel, and have diminished autonomy while growing up. As a result, they develop ineffective problem-solving strategies, and often become distrustful and hostile. A low tolerance for frustration often develops which leads to emotional instability, rage or jealousy, and aggressive behaviors, often with little provocation. They may exhibit unrealistic demands, being domineering, meticulous, a perfectionist or over-controlling.
These individuals may be antisocial and sadistic, lack emotional responsiveness, and exhibit little or no remorse. They may be violent in other non-domestic interactions, or they may exhibit dual behavior, being very controlling in private, but when in public they will appear to be controlled by their significant other.
Combined with, or being the characteristic of DV may be passive abuse, where the abuser distances themselves from their victim, withholding affection, warmth or any other contact.
All these factors or tendencies may be in place long before the perpetrator of DV ever begins their first relationship. These motivational factors and tendencies, however, often do not surface until a relationship has been established and is past the so-called “courtship” phase.
Cultural factors relating to male dominance and female subservience also play a significant role in DV.
Contributing factors can be related to substance abuse, ineffective coping mechanisms, personality disorders, stress or a previous history of DV or child abuse.
Abuse is self-perpetuating and reinforcing. The behaviors are learned through past success at maintaining control. Power and a sense of “wholeness” often only come to abusers after and episode of violence.
Factor related to victims
Victims often lack autonomy and are highly dependent on their partners for validation. They often have not established their own individual identities. Victims often have a significant fear of rejection and are easily manipulated. They are often immobilized emotionally or captive in their own homes since their own abilities are minimized or criticized. This is often identified as a form of learned helplessness.
Victims are often disconnected, particularly with respect to sexual relations. They often have no control, even over their own reproductive destiny. Many abused women become pregnant by their abusers who use the mother-child bond and maternal dependency as another aspect to maintain their control.
Victims themselves are often from family situations where violence was present. They have been conditioned to accept abuse as a normal and expected behavior. Their families of origin may also have conditioned acceptance of an unequal distribution of power, typically one in which a patriarchal relationship was in place.
Patterns and theories of abuse
Several theories have been developed to examine the phenomenon of DV, two of which will be outlined in this article. The Cycle of Violence Theory and the Power and Control Theory both seek to clarify patterns and forms of domestic violence.
The Cycle of Violence Theory describes three “phases” which occur in an abusive relationship: 1) A phase in which tension is building, 2) the actual battery, and 3) the “honeymoon” phase.
The Power and Control Theory is visually depicted by a wheel. At the center of the wheel lies the major motivational factor behind abuse, power and control. Each spoke of the wheel separates eight different mechanisms which abusers employ to gain control over their victims: 1) using intimidation, 2) using emotional abuse, 3) using isolation, 4) minimizing, denying, and blaming, 5) using children, 6) using male privilege, 7) using economic abuse, and 8) using coercion and threats. Note that each of these behaviors or acts described inside the wheel does not involve physically touching the victims, but constitute verbal and emotional abuse. The outside of the wheel (the tire) is represented by physical and sexual violence. This portion is often the only “clue” that a healthcare provider may observe related to domestic violence (and that is if the victim seeks treatment and the healthcare provider performs an appropriate screening exam!!). Imagine all of the factors listed inside the wheel that may be taking place at the same time in a victim’s life and it is easy to understand all of the emotional problems that they may have.
While these factors and theories bring clarity to explain DV, they do not justify the behaviors. Abusing another person is a conscious decision that an individual makes in order to gain and maintain control over that individual.
Healthcare provider responsibility
Healthy People 2010, a governmental plan for healthcare goals for the nation, have a specific goal related to DV and list it as #15 in its focus area. The objective states that ED’s should have protocols for routine identification, treatment, and referral of victims of sexual assault and spousal assault. Notice the wording “routine.” It should be a commonly practiced screening technique, not just with individuals who are highly suspected of being abused. The Joint Commission of Accreditation of Hospital Organization’s (JCAHO) requirements mandate policy and procedure related to dealing with victims of DV as well as an educational plan for the staff.
Screening for DV is as essential as screening for hypertension (by routinely taking B/P), for fever (by taking temp.), and for respiratory distress (by taking respiratory rate). It should become an automatic assessment technique implemented with every patient contact.
The nurse is often the first healthcare contact for a victim of DV. Universal screening practices should be a standard procedure in all healthcare facilities. The assumption that victims of violence typically visit only emergency rooms and public health clinics is incorrect. Many seek treatment for DV related injuries at private physicians’ offices, particularly obstetricians during pregnancy.
Unfortunately, research has shown that healthcare providers inconsistently assess for DV, if at all. In addition, the primary focus has been on physical injury and not emotional or psychological abuse.
It is imperative to maintain a high index of suspicion and to keep current on the policies and procedures for notification and reporting to authorities the various types of abuse upon individuals of different ages. Remaining educated and aware is important, as is practicing a standard dialogue and therapeutic approach to screen for abuse. Incorporating screening questions into every healthcare history and assessment increases the comfort level for healthcare practitioners in asking these sensitive questions.
Maintaining a current referral source sheet to give to identify or suspected victims can save time and lives. Be cautious, however, not to “force” a suspected victim to take a sheet with them. They may fear retaliation from the abuser if the sheet is discovered among their belongings.
Charting thoroughly and accurately is imperative. Subjective data is best charted by using exact patient quotes when possible. Objective data must be defined in as much detail as possible, using conscious and clear wording and body maps when appropriate to convey the size and location of physical of physical injuries. Well-kept records are the best assistance the medical profession can give the courts to seek justice and protection for DV victims.
If photos are to be taken, at least one must contain the face of the victim. All should be labeled clearly and optimally signed by the victim at the time of photographing (an instant camera is obviously ideal). To maintain clarity, a ruler should be placed beside the injury area for reference.
Screening for abuse
Reinforce that the victim does not deserve to be abused, that they did not cause the abusive situation, and that there is help available. Your approach should not be confrontive but rather accepting and empathetic. Providing privacy during the screening process is crucial. Have the partner or others leave the room. Many abusers, however, refuse to leave their victim alone, and are also noted to answer questions for them. If the partner refuses to leave and the patient is ambulatory, take her to the bathroom to obtain a urine specimen and screen her while you are in there with her and give her instructions. Be sure to actually collect the specimen so as not to tip off the suspected abuser as to your intent.
Refrain from deferring the screening process to social workers or to other “specialists.” The patient may never again see these individuals and you may represent their only chance for an intervention at that particular time.
Guilt and depression are commonly seen with victims of DV, particularly female abuse victims. Do not compound this guilt by screening with insensitivity. Individuals, particularly females who present for treatment with multiple injuries, should always be screened for DV, no matter how plausible their description of the accident that caused the injuries. Research has shown that females are more likely to sustain multiple injuries as a result of DV.
Mechanisms for injury seen in abuse may include punching, kicking, slapping, shoving, hitting with objects, or any combination of these. The most frequent site of injury is the head and face (89%), followed by the abdomen and chest (32.5%), and the extremities (18.1%). Injuries seen may include abrasions, contusions, lacerations, burns, internal injuries or fractures. Injuries associated with DV are usually “central” (located on the trunk/head), where accidental injuries are usually “peripheral” (arms/legs). One exception is “defensive posture,” injuries of the palms and the ulnar aspects of the forearm (incurred when the victim acts to shield their face and torso).
Any trauma or burn, which is inconsistent with the reported history, should raise the index of suspicion for abuse. Some signs and symptoms seen in abused individuals are listed below, but are not present with all victims:
- bruises in varied stages of healing
- history of frequent emergency visits
- accident prone
- chronic pain
- sleep disorders
- pregnancy complications
- early labor/miscarriage
- alterations in nutrition
- suicide attempts or ideation
- homicidal ideation
- uncontrolled emotions
- anxiety
- depression
- Alcohol/drug abuse
- eating disorders
- emptiness
- passive behavior
- poor communication skills
- poor self esteem
- disconnections
- non-compliance with medications/therapies (they may not be permitted to obtain them or attend therapy sessions)
- psychosomatic, vague, or repetitive complaints inconsistent with organic disease
Assessment for DV should include maintaining a nonjudgmental attitude, validating the victim’s experience, and assessing his or her plan for safety, regardless of whether or not they plan to leave at that time. Don’t worry about offending non-victims by asking screening questions. You should never “discount” your screening approach by stating something like “I know that this probably is not true in your case, but I have to ask everybody.” This will render your screening practically worthless with most individuals, and convey that you really do not want to help them. If the patient is offended or upset, simply explain that DV is a major problem affecting many individuals, and that you are hear to assist if they are indeed a victim of DV.
There are many techniques and screening questions formats which have been proven successful for DV. Some are detailed here. Most healthcare professionals adapt a screening process which they are comfortable with and which includes a combination of questions. The assessment should include asking baseline questions related to potential DV or harm, best presented in an indirect manner such as:
“Stress develops in many relationships and often partners hurt each other. Has anything like this happened to you?”
“Sometimes we see injuries like those that you have received after couples argue. Is that what happened to you?”
“Have you ever been slapped, hit, kicked or otherwise hurt by your partner? Have you ever been forced to have sex when you did not want to?”
“Do you feel safe at home? How do you and your partner resolve conflicts? Are you afraid or abused?”
The following approach works well with pregnant patients who seek prenatal care late:
“When women start prenatal care late in a pregnancy, sometimes it is because their partner prevents them from coming in or there is a difficult situation at home. Is this why you have not sought care sooner?
Barriers to intervention
Domestic violence thrives upon silence. There are personal, social, and systematic barriers which impact screening and intervening for DV. Unfortunately, some healthcare providers still misunderstand their responsibility to assess and intervene in DV. Some are hesitant to become involved or fear legal reprisal if their suspicions are incorrect. This reasoning for hesitancy is not validated if the healthcare provider consistently screens for DV and documents the finding clearly and professionally.
The victim may also see mandatory reporting as yet another paternalistic approach that takes away their choice as an individual to control their own destiny. Report abuse with respect to each victim’s verbalized choice and in compliance with policy/procedure and laws. You should respect the patient’s autonomy, but clearly document your observations and findings in the medical record, should they decide to change their mind and your observations would assist in supporting their charge of abuse.
When screening is performed, it is often from a less than therapeutic approach, often consisting of questioning the victim as to why they remain in the abusive situation. This approach usually does not serve to enhance the therapeutic relationship, invoke insight or motivate change. It does, however, provide for re-victimization of the victim. An abused victim now has been made to feel that they are doing wrong by staying in the situation, and may have added feeling of guilt and shame when relating to the healthcare provider performing the screening. Their feeling of isolation and shame may escalate, diminishing the therapeutic relationship and further interventions. This secondary “blaming” often serves to promote silence. The responsibility and any “blame” for domestic violence should be placed where it belongs, on the perpetrators, not the victims.
Some view issues in the home as a personal or private matter, contending that if abuse is present, the victim has made their choice to remain in the situation. Inappropriate intrusion into the personal circumstances of individuals is often cited as a reason not to screen, however, this line of thought is inconsistent with the process used to screen for other illnesses of injuries. We ask the most intimate details regarding sexual practices and preferences, alcoholic abuse, and the recreational use of illegal or mind altering substances, yet it is difficult to ascertain if an individual is the victim of a crime or a circumstance which may ultimately lead to death.
Another barrier is accepting responsibility for the screening process. It is not the work of the social workers, therapists, or law enforcement officials. As healthcare workers, and particularly nurses who often provide the first healthcare contact for the patient, it is your job and your responsibility.
Many healthcare providers are hindered by their own personal experiences or exposure to DV. Being victims or survivors themselves, they may find it difficult or painful to interact or care for suspected or actual abuse victims. It is difficult, if not impossible, to help a victim of abuse when an individual healthcare provider has not been able to make an intervention for themselves. If a healthcare provider is unable to be therapeutic and provide screening for DV, they should seek help and defer the screening process to another individual until they can be therapeutic.
Even healthcare workers who have not personally experienced DV may have difficulty dealing with individuals who have. Discuss you hesitancy with peers and support them in making interventions when you cannot. One way to enhance your therapeutic abilities with abuse victims is through exposure. Consider volunteering in a shelter. If you are in school, consider clinical experiences with the homeless or within a crisis center.
Many healthcare providers become frustrated problem solvers. Be realistic – you cannot solve it all. Futility and disgust often cloud healthcare workers adequate screening and provision of support for actual or suspected victims, especially if a pattern has been demonstrated. It is all too familiar to adopt the “why bother, they go back anyway” attitude. It is true that many abuse victims do go back to their abusive situation, however, some do leave.
The patient care area layout is often a barrier to screening, as it is often busy and affords little privacy. The patient may have to be relocated to a quieter room or area to adequately screen and offer assistance or interventions.
Denial is the greatest barrier to the truth. Many victims will not admit that they are the victims of abuse either as a result of guilt, shame, fear, hope for change or continued love of their abuser.
Patients themselves are often viewed as unreliable historians because they are emotional, intoxicated, or abusing drugs. “If they can not give valid information, why ask?” is often an excuse for admitting the screening process.
Unfortunately, the healthcare system has created barriers to reporting DV, which may have life-long consequences for the abused individual. Up to 23% of healthcare plans (insurance, HMO, PPO, etc.) are now using history of DV as a screening tool to deny insurance eligibility!
Interventions
Solutions for a DV situation are not discovered or considered until problems are disclosed and confronted. A comprehensive screening within a therapeutic relationship prompt the victim to realize that they do not deserve to be abused and they there are alternatives available to them. The incidence for an abused individual to act immediately to leave their abusive situation is, unfortunately, not highly likely. This factor, however, should not discourage the healthcare provider from providing the victim with information and options should they decide to use them at some time in the future. The goal is to encourage a transition from victim to survivor. This process may require vast differences in time and levels of assistance or supports to take place.
It is important to build a rapport with the patient and practice active listening skills and to communicate with sensitivity. Empathize with the victim’s dilemma. Validate their painful experiences, and encourage them to consider seeking help.
Encourage the victim to assess and build upon the positive aspects of their life, including their strengths, abilities and support systems. Refrain from acting as a “single rescuer,” but act as a guide to lead the victim to others and to support systems that can provide the comprehensive assistance that will be needed. It takes much work to encourage and build self-esteem and to learn relational development in a positive manner.
Safety is the #1 concern for victims of DV and their children. Have the victim mentally review and rehearse an escape plan that would be feasible for their given situation.
Provide information related to sources for help, but understand that many victims are not able to take this information with them because their abuser may discover it and punish them further.
Why do they stay (or go back again… and again… and again)
The “average” victim of abuse leaves their relationship two to five times before they end the relationship permanently. It has been correctly stated that abused individuals often do not chose to leave a relationship. Rather, they escape it.
Many factors contribute to maintaining an abusive relationship including social, financial and emotional reasons. Most victims fear retaliation or the lack of being able to provide for themselves and their children. A sense of immobility often develops. It is important to understand (as depicted within the power and control wheel) that many abusers use their children as “bargaining chips” to force their victims to stay in an abusive situation. The decision to stay if often based upon survival needs and not character flaws.
The victim may have a diminished self-esteem, often to the point of dehumanization. They may sense that they are different and less important than other individuals as a result of the treatment and conditioning by their abusers. The victim may be desensitized and unable to deal with their own feeling and emotions. Many women fear being “alone.” They do not value or have never experienced their independence or have been conditioned to believe that they cannot exist without a relationship. They may feel as if having an abusive partner is better than having not partner at all.
Attempting to leave the abusive situation has been identified as the most dangerous time for a victim of DV. Victims often fear retaliation. They do not want to experience the past punishment they may have endured for attempting to leave.
For a victim to actually leave and abusive relationship, they must be ready to alter the course of their life and become empowered, establishing new, and often very frightening, boundaries themselves, their environment and their significant others. They must deal with painful and strange new feelings. They may be required to take on new responsibilities. Many victims may not know how to perform necessary tasks required for survival such as banking, working and relating socially to others. Deciding to leave, therefore, is not simply an easy decision to “get out.”
Again, many victims do not leave. While this decision is frustrating, you must support them in their right to make their decision. In supporting their right, you recognize their autonomy. It is important to remember that the victim feels controlled by their abusive partner. The last thing that they need is to feel controlled in a so-called “therapeutic intervention” by a healthcare worker that they just met.
What if the answer is “yes” I’m abused…help me
Report the incident and support the victim during necessary questioning and photography (if required). Clearly document everything for future prosecution of the perpetrator.
Assess the current safety:
- safety of individual?
- safety for kids?
- weapons in the home?
- others to turn to?
- suicidal/homicidal ideation?
- substance abuse a problem?
- Safe place
- Resources
- Counseling
The “exit plan” should include gathering important papers such as medical and school records, immunization records, identification, legal documents, valuables, any money or assets available to them, an extra set of keys, and personal items.
Restraining orders may be obtained, but are often ineffective in protecting victims if their abusers are intent upon retaliation.
Counseling is recommended for all victims of DV, regardless of how effectively they appear to be dealing with their circumstances. Psychotherapy for female victims is aimed at encouraging empowerment and minimizing the impact of secondary victimization by others (“why did you stay?” “what were you thinking?” “what was wrong with you?”).
DOMESTIC VIOLENCE REFERRAL SOURCES:
BROWARD:
Women in Distress:
(954) 760-9800 Outreach Center
(954) 761-1133 Crisis Hotline
* Provides support for women and their families
Family Service Agency:
(954) 587-7880
* Provides support for gay and lesbian victims of domestic violence
DADE
Metro-Dade Advocates for victims
Safe Space (North Dade):
(305) 758-2546
(305) 758-1347 (Hotline)
Safe Space (North Dade):
(305) 247-4249
*Provides support for female victims of domestic violence
Domestic Intervention Program for Batterers:
(305) 643-8533
*Provides a support program for the abusers
WEST PALM BEACH:
YMCA Harmony House:
(561) 655-6106
* Support for battered women
STATE OF FLORIDA:
Domestic Violence Hotline:
1-800-500-1119
(for referrals to shelter and counseling)
National Hotline:
1-800-799-SAFE
Florida Crimes Compensation Act:
1-800-226-6667
This provides up to $2500 for counseling for children who witness domestic violence. The child’s name must be listed on a domestic violence police report.
Additional Patient resources:
Family Violence Prevention Fund: 1-800-313-1310
National Council on Child Abuse and Family Violence:
1-800-222-2000
Selected References Feminist Majority Foundation (2007). Domestic Violence Hotlines and Resources. Retrieved 3/29/09 from http://feminist.org/911/crisis.html.
FL Department of Law. Total domestic crime by county, 2008 Available at: www.fdle.state.fl.us/Content/FSAC/Data---Statistics-(1)/UCR-Domestic-Violence-Data/UCR-Domestic-Violence-Data.aspx Accessed: October 16, 2009
Joint Commission on Accreditation of Healthcare Organizations. (2009). Assessment of the Patient, The Comprehensive Administrative Manual for Hospitals, Chicago.
National Coalition against Domestic Violence. (2007). Retrieved 4/5/09 from http://www.ncadv.org/files/DomesticViolenceFactSheet(National).pdf.
US Department of Justice. (2009). About Domestic Violence. Retrieved 4/5/09 from http://www.ovw.usdoj.gov/domviolence.htm.
CDC. (2006). Understanding Intimate Partner Violence, Fact Sheet. Retrieved 4/5/09 from http://www.cdc.gov/ViolencePrevention/pdf/IPV-FactSheet.pdf.
TAKE THE TEST>>