Physician Training Improves Domestic Violence Outcomes

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

The incidence and prevalence of domestic violence is high, according to Braude. Findings from the National Violence Against Women Survey estimate that approximately 1.5 million women and 834,732 men are raped and/or physically assaulted by an intimate partner annually in the United States. Because many victims are assaulted more than once a year, researchers estimate that, annually, some 4.8 million intimate-partner rapes and physical assaults are perpetrated against women and approximately 2.9 million physical assaults are committed against men (Tjaden and Thoennes, 2000).

Domestic violence is also linked to homicide, injuries and 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 past or present intimate partners (Fox and Zawitz, 2000). In a study of female trauma patients treated in an emergency department (ED), nearly one-third were identified as having injuries caused by battering (McLeer et al., 1989). Furthermore, 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 ED patients, 49% (17 of 36) of the female patients and 8% (4 of 48) of the male patients reported being the victim of spousal abuse when interviewed by clinicians who had received 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 should give psychiatrists some tools for diagnosing and treating it effectively.

A recent study by Garimella and colleagues (2000) assessed the domestic violence training 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, approximately 80% of the respondents said they had never received 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 part of their role was to assist victims of domestic violence, only 44% held supportive (non-blaming) attitudes toward victims. Of the four specialties represented, psychiatrists were the least supportive; 56% of family practice practitioners, 57% of ED physicians and 88% of obstetricians and gynecologists had supportive attitudes toward 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 in an interview with PT that psychiatrists also scored much higher on verbal statements reflecting behaviors toward domestic violence victims. For example, on a question probing whether they had enough time to ask about spousal abuse, 100% of the psychiatrists said yes, compared to 91% of ED 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, compared to 46% of OB-GYNs, 20% of ED physicians and 6% of family practitioners.

In order to increase the recognition and treatment of patients experiencing domestic violence, mental health care professionals need to recognize that any patient who is depressed, anxious or suicidal may be responding to a crisis in domestic violence, Braude said. In addition, clinicians need to take a history that will discover domestic violence and "give it profound consideration in the treatment plan," she added.

Possible questions that can elicit such information include:

• Have you recently experienced violence at the hands of someone close to you?
• Is there someone in your immediate environment of whom you are afraid?
• Do you have any history of violence from a significant other?

It is important that patients be interviewed in private, Braude added.

"If the [significant] other is present, the patient is not free, [since] telling the truth may precipitate another episode of violence. It is also very important that in cases in which the physician knows both the perpetrator and the victim that they be interviewed and treated separately...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."

Clinicians need to carefully assess the danger to the victim and others in the household by determining if the perpetrator abuses alcohol or drugs; if there is a gun in the house; if the violence is escalating; if, in addition to the victim, children or pets are being abused; and if 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 other household members out of danger. That plan might include identifying a support network and prearranging help, teaching children to call the police if necessary, and becoming familiar with basic legal options and local emergency resources.

Braude also advised mental health care 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, ensuring that the patient is recognized as a victim of domestic violence.

Prescribing 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 further prescribing 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 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 the victim, because she needs to be fully alert and aware in case of further attack and in order to plan how to handle the situation.

It is also important that clinicians are aware of community resources to which they can refer the victim in an emergency, such as shelters and hotlines, Braude said. (For more information on this topic, please visit www.psychiatrictimes.com/dvhelp.html and "National and State Responses to Domestic Violence Challenge" in this month's Special Report-Ed.) Even when patients do not initially admit to being victims of domestic violence, they can be helped. Courses such as the AMWA's online course can provide significant guidance to mental health care professionals. For instance, it suggests a generic form providing the numbers of local, state and national domestic violence hotlines be given to all patients as well as placing posters with appropriate referral numbers in waiting rooms.

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 believes that training for physicians needs to be revamped.

In their study, Garimella and colleagues found that training (either in medical schools or postgraduate) does not affect physician attitudes. "This [lack of change] may be because most domestic violence curricula are didactic in nature and are theory driven," she explained.

"Many physicians I've talked with feel hopeless about making a difference in the lives of victims of domestic violence," she added. "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 and 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.

"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...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."

References:

References1. 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 [letter].
2. 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 Feb. 1, 2001.
3. 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.
4.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.
5. Stark E, Flitcraft A (1995), Killing the beast within: woman battering and female suicidality. Int J Health Serv 25(1):43-64.
6. 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.