Psychiatrists and Mandatory Reporting of Domestic Violence

As psychiatrists, we can do a tremendous amount for patients suffering from domestic violence, but mandatory reporting is seldom necessary. Some of the things we can do include specifically inquiring about the presence of domestic violence and whether children, elders or other members of the household are victims. We can treat the patient's symptoms; we can support their efforts to improve the situation; and we can refer the batterer to treatment and the patient to resources that can help.

To do this, we must be knowledgeable about the resources in our own communities. The National Domestic Violence Hotline can be called at (800)799-SAFE (7233) and will connect a patient to the nearest local resource. The number for the hearing impaired is (800)787-3224. Reporting can be most helpful if the patient desires it, but otherwise it plays a minor role for psychiatrists. The patient may have already reported the abuse and come to the psychiatrist for treatment, in which case reporting becomes a nonissue.

In strong contrast to child abuse reporting laws, which in most states require reporting of a history or suspicion of child abuse, domestic violence statutes require limited, if any, reporting. Alabama, Louisiana, South Carolina, Washington and Wyoming have no reporting requirement. California, Kentucky, New Hampshire, New Mexico and Rhode Island have laws specific to domestic violence. California, for example, only requires reporting of an immediate physical injury, which psychiatrists seldom, if ever, see. The accounts of patients who want help with the stress symptoms of domestic violence and support in dealing with this difficult and dangerous situation are not reportable. I am a Californian who has treated patients in many domestic violence situations, but I have never had to make a report. I would only do so if the patient requested it or we mutually decided it would be beneficial, which has not yet happened.

Other states have extensions of laws that require the reporting of firearm injuries and assaults, but in most states those also are reportable only in an acute situation. Most states that do require reporting require that it be reported to law enforcement, but a few states require reporting or referral to social services. As all of these laws apply to all physicians and licensed health care professionals, it is useful for each of us to learn and understand our own state's laws.

Let me say a word about reporting to law enforcement. A large metropolitan police department will give immediate response priority to a crime in progress, that is, a call from a location where a victim is in danger. If such a crime is in progress, the police should be called for potentially life-saving assistance. They will give lower priority to a report of a past crime and, unless the victim is in danger at your medical office or facility, may take days to respond to your report. This may or may not be advantageous to the victim. The police, victim advocates and shelters in small cities may have a close relationship in which they personally know each other and work together to assist the victim. For any situation in which a report is made, it is useful to know how the system operates and what is likely to happen.

Any mandatory reporting is a potential breach of patient-physician confidentiality, the crucial cornerstone of our treating role. For this reason, physician organizations including the American Medical Association, the American Medical Women's Association, the American College of Emergency Physicians, and the American College of Obstetricians and Gynecologists have taken positions against it. The American Psychiatric Association has no position.

What is critical is not that we report but that we treat. Domestic violence patients come to us with histories of anxiety disorders, depression, suicide attempts, headache, insomnia and any of the physical symptoms of chronic stress. They may be self-medicating and abusing substances. We need to ask about abuse and obtain careful histories of it. We need to understand the difficulties and dangers of the patient's situation and support the patient's attempts at solution. We need to know about the domestic violence resources in our communities and make referrals to them. We need to know that many of the patient's symptoms can be resolved when the patient is able to get help and develop protection from abuse and assault. A Web site course that presents detailed knowledge of all aspects of domestic violence is available at <www.dvcme.org>.

We, of course, should apply the same protections against future harm for domestic-violence patients that we apply to all patients. Domestic violence shelters, whose locations are protected from the abuser, exist for this purpose and provide important assistance. Unless the abuser creates an immediate incident on our premises, to which a police response is necessary, we have much more to offer the patient by understanding, continued support, treatment of symptoms and referral to shelters where necessary.