Domestic violence is a major public health problem with physical and psychological sequelae for women, as well as a serious violation of human rights. One in every three women worldwide has been beaten, coerced into sex, or otherwise abused in her lifetime. (1) The home is considered a place where people should be safe, but it may be one of society's most violent social institutions. Intimate partner violence or abuse is a pattern of coercive control that may result in physical and/or sexual assault and may include emotional abuse and economic control. One person uses abuse to exert power and control over another in a domestic relationship. Although women can be abusive, and abuse does exist in same-sex relationships, the vast majority of abuse is perpetrated by men against their female partners. (2)
Behavioral health therapists and counselors can make a difference in this epidemic and save lives by identifying and treating people in abusive relationships. By asking simple questions and providing information, death may be prevented and injuries and chronic stress may be lessened.
The Scope of the Problem
Between three and four million women are battered every year in the United States. Between 8 and 14% of all American women report physical abuse in the previous year by a husband, boyfriend, or ex-partner. Research indicates that the actual annual prevalence may be between 4 and 14%. (3) Incidence may be higher among poor women. Lifetime prevalence is reported between 33 and 39%.
All women are at risk. Leaving the relationship or home doesn't always guarantee safety, as women may be stalked and are often in more danger when they leave an abusive relationship.
Battering often escalates in frequency and severity during pregnancy. Abuse may be the biggest cause of maternal mortality in this country. Krulewitch et al reported that 11% more homicides occur among pregnant women as compared with nonpregnant women. (4) Teen pregnancies are particularly susceptible to abuse, and as many as 29% of pregnant teens experience abuse. (5) Abuse can result in miscarriages, pregnancy complications, and postpartum depression. Twenty-five to 45% of battered women have been battered during pregnancy.
Sexual abuse often occurs in abusive relationships. Vaginitis, urinary tract infection, substance abuse, depression, trauma, post-traumatic stress disorder (PTSD), pelvic pain, and sexually transmitted diseases including HIV may result. (6)
Abused women often have more functional gastrointestinal illnesses, pelvic pain, and incidences of surgery in their lifetime than women who don't experience abuse. Teens and college students are also susceptible to intimate partner violence, with prevalence rates ranging from 12 to 22%, according to experts. (7) Battering occurs in psychiatric patients, and abuse can result in suicide or homicide. (6)
Mental health professionals may observe signs of abuse among their patients. The patient may appear physically well, but pain, depression, and anxiety are common responses to the chronic stress experienced in an abusive relationship. Signs to look for commonly found among abused women include:
* eating disorders or appetite changes
* weight problems
* dizziness
* fatigue
* joint pain
* back pain
* sleep problems
* headaches (8)
Women and children affected by domestic violence may develop PTSD. (9) The range of mental health effects of domestic violence includes:
* shame
* guilt
* anxiety
* low self-esteem
* insomnia
* suicidality
* homicidal thoughts
While some women approach healthcare providers with these issues, others approach counselors or spiritual advisers. Some may be too embarrassed to admit to the violence, while other women may not feel safe discussing domestic violence, and some women don't seek assistance at all. (10)
Victims do not fit a distinct personality type but are at risk for depression, anxiety disorders, suicide, substance abuse, and eating disorders, along with physical and sexual risks. (11) They may be afraid to even seek assistance because of threats that have been made. Battered women often hope that someone will offer assistance. Therapists and counselors can increase a victim's safety by offering information and support in a confidential and private way that ensures that the person abusing the woman will not learn of the discussions or shared resources. (12)
Why Men Batter and Why Women Stay
Abusers batter because their behavior is often effective. Abusive men see their roles in a traditional manner and believe it is their job to 'keep the woman in line.' Abusers need motivation and often counseling to change their behavior. Unfortunately, counseling with batterers has been found to be less successful than hoped. (13)
Counselors and healthcare providers often find it very frustrating when women choose to stay with an abusive and dangerous partner. It's helpful to remember that leaving can be the most dangerous time for an abused woman. She may be killed, her children may be abducted, or her parents may be hurt. Shelter workers are familiar with these dangers and work with women to put safeguards in place before they leave a violent home. Some women are dependent economically on their abusers and legitimately fear homelessness and poverty. Very few women are eager to break up a family without many efforts to make the relationship work. Abusers may be excellent providers and fathers despite their abusive behavior. Some abusers fervently promise to change their behavior and may seem believable and sincere.
Identifying and Screening for Abuse
Questions about domestic violence should only be asked when a counselor or therapist is alone with a woman in a quiet and confidential setting where the conversation cannot be overheard. Women are not offended when asked about abuse, particularly if questions are preceded by an explanation such as, 'Many women are hurt by those who they live with. We can be of assistance if this is happening to you.' Women need to be asked about violence routinely. During pregnancy, screening should take place at least once in each trimester and during postpartum follow-up, as abuse often begins during pregnancy or following the baby's birth.
Other suggestions for questions include:
* 'Your partner seems very jealous. Sometimes possessive partners are very controlling and can be physically rough. Have you ever been hurt by your partner?'
* 'You mentioned that you are under a lot of stress. Has anyone threatened you?'
* 'Many women are afraid of their partners at times. Are you ever afraid that your partner will hurt you?'
* 'You seem anxious about your pregnancy. Has anyone been hurting you in any way?'
Women often are embarrassed to discuss the problems in their relationship
and often are unsure what will ensue if they disclose abuse.
Asking about abuse is also a matter of simple professional courtesy. Many patients who have been harmed physically or emotionally have difficulty trusting other people. Asking about abuse before and during therapy offers the patient an opportunity to share prior trauma and assists the therapist in treatment.
Reporting Abuse
Reporting requirements vary from state to state. All therapists should be familiar with their state laws related to domestic violence. Most states require reporting of severe injuries or use of weapons. Six states require healthcare providers to report domestic violence and the others do not. The Family Violence Prevention Fund provides a listing and evaluation of mandatory reporting laws for all states (see www.fvpf.org/statereport).
Most domestic violence experts believe that reporting may increase risk, as safety cannot be guaranteed. Ethically, reporting may increase risk, destroy confidentiality, destroy trust in the patient-provider relationship, and subvert independence and autonomy. Those with paternal/maternal health instincts may want to report and change a battered woman's life immediately when they learn about the abuse that is occurring. It is more important to provide support and information than to 'take over.'
Currently, no evidence supports or refutes the benefit or risk of mandatory reporting, and further research is needed. (14) Counselors need to use their professional judgment on a case-by-case basis. If a patient seems to be in serious danger, counselors should consider consulting a shelter or domestic violence professional, or notifying police.
Helping to Combat Abuse
Counselors may be of the most help to abused women when they consider that abuse is a crime and more of a safety issue than a mental health problem. By identifying abuse in a relationship and providing empathy and safety information, lives may be saved and mental health may be improved.
Paul articulates the goals of care among counselors and therapists working with patients at risk for domestic violence. Paul says to screen routinely, and when abuse is present or suspected:
* discuss and assess safety;
* state your belief that violence is wrong and the fault of the batterer;
* counsel couples individually when abuse is present;
* support and empower the victim;
* clear up misconceptions that induce self-blame; and
* evaluate for PTSD. (15)
Patients should be safer because of their encounters with the healthcare system. When a woman discloses that she is in an abusive relationship, therapists can begin care by keeping a few simple management techniques in mind. Acknowledge her loneliness, fear, and isolation with a simple statement, such as, 'This must be so difficult for you,' which is empathetic and helpful. Let the patient know that the abuse is not her fault and that it is a crime. Articulating that abuse is wrong and is the batterer's fault may help relieve possible guilt and shame.
Providing education about community resources can be lifesaving. Ask the patient if she knows:
* about resources available for her;
* the number to a 24-hour hot line that she can call if she is in trouble;
* about her legal options, such as obtaining a restraining order; and
* about shelter options and services in her immediate community.
Ask if she would like to call a shelter in her area. Most shelters offer residence at a hidden location, legal assistance, counseling for women and children, moral support, and safety at a difficult time. The National Coalition Against Domestic Violence represents a nationwide network of shelters and services for battered women (see www.ncadv.org). The Texas Council on Family Violence operates a national toll-free hot line that provides information and referrals: (800) 799-SAFE (also see www.ndvh.org).
If a woman does not choose to leave the abusive situation, discuss a safety plan. She should leave her counseling encounter safer and more prepared for escape. A safety plan is similar to a fire drill in that it helps a woman create and practice a plan of escape with essential needed information, if necessary. Steps she can take to create a safety plan can include packing a bag with important documents and a few comfort objects for her children in case she needs to get away. She can alert neighbors to call the police if they hear sounds of conflict. Some shelters offer counseling groups for women who choose to stay with abusers. Information on local shelters should be made available.
Counselors and therapists should create opportunities to raise awareness of domestic violence. Visible posters related to abuse and safety can be posted in waiting rooms and in women's bathrooms. Educate staff to let women know that their healthcare or counseling site is a safe place and a place where violence can be discussed. Literature on domestic violence should be placed in restrooms, where it can be reviewed in privacy. Couples counseling for abusive relationships is not advised by shelter professionals, as disclosure with a counselor present may feel safe to the abused, but discussing violence with the abuser present may actually put a woman at risk for battering later. (16)
Counselors and therapists need to be able to assess if a woman may be in potentially fatal danger. Signs that the next incident of abuse may be fatal include if her partner has threatened her with death, has a weapon, or has tried to choke her in the past, or if threats have been escalating. Women need to be informed that abuse usually becomes more severe and more frequent over time; women often are unaware that they are in a potentially lethal situation (17) and may underestimate their risk of being killed.
Some abusers also abuse children. Mothers with children need to be asked if the children are being hurt. Abuse of children must be reported to legal authorities.
Conclusion
Women in abusive relationships often travel a difficult path to a safe existence. As healthcare professionals, we can offer assistance in this process by identifying the problem of violence, increasing awareness of options, providing support and empathy, and offering safety precautions. Listening, caring, supporting, and teaching are lifesaving interventions.
Kathleen K. Furniss, RNC, MSN, is a Women's Health Nurse Practitioner at the Mountainside Hospital Breast Center in Montclair, New Jersey, and Drew University Health Service, Madison, New Jersey. She frequently writes about domestic violence for the Association of Women's Health, Obstetric and Neonatal Nurses. To send comments to the author and editors, e-mail furniss0206@behavioral.net.
References
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BY KATHLEEN K. FURNISS, RNC, MSN
RELATED ARTICLE: SUGGESTED READING
* Campbell JC. Abuse during pregnancy: A quintessential threat to maternal and child health--So when do we start to act? CMAJ 2001;164:1578-9.
* Campbell JC, ed. Empowering Survivors of Abuse: Health Care for Battered Women and Their Children (SAGE Series on Violence Against Women). Thousand Oaks, Calif.: SAGE Publications, 1998.
* Campbell JC, Block CR, Campbell D, et al. Risk factors for intimate partner femicide: Results from a cross-national case control study. Paper presented at: American Public Health Association; November 14, 2000; Boston.
* Campbell JC, Soeken KL. Forced sex and intimate partner violence: Effects on women's risk and women's health. Violence Against Women 1999;5:1017-35.
* Campbell J, Torres S, Ryan J, et al. Physical and nonphysical partner abuse and other risk factors for low birth weight among full term and preterm babies: A multiethnic case-control study. Am J Epidemiol 1999;150:714-26.
* Haggerty LA, Kelly U, Hawkins J, et al. Pregnant women's perceptions of abuse. J Obstet Gynecol Neonatal Nurs 2001;30:283-90.
* McFarlane J, Soeken K, Wiist W. An evaluation of interventions to decrease intimate partner violence to pregnant women. Public Health Nurs 2000;17:443-51.
* Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: Practices and attitudes of primary care physicians. JAMA 1999;282:468-74.
