When I began
my training as a marriage and family therapist, I never imagined I would work
in a healthcare setting. My misguided
preconceptions about the separation of mental and biomedical treatment clouded
my ability to truly provide therapy from a biopsychosocial lens. Since the first semester of my master’s
program, my research interests seemed to gravitate toward domestic violence and
its impact on couple and family relationships.
One of the recommendations included in the discussion section of my
master’s thesis, which examined the influence of attachment and aggression in
couples, was for MFTs to include attachment screenings during the intake
process to aid in identifying women experiencing intimate partner violence
(IPV). Even then, I believed in the
value of screening for IPV, but never consider the role of screening outside
the box of the traditional family therapy setting.
healthcare providers treat diverse groups of patients on a daily basis as part
of an integrated team. As patients continue
to present with various comorbid medical and psychosocial problems, which
mutually influence one another, the need for provider competence in responding
to psychosocial issues is sizeable.
Patients experiencing IPV represent a particularly vulnerable population
to which family-oriented clinicians and systemic therapists alike can provide help and resources. The process of identifying and responding to
IPV in integrated care is often difficult to maneuver, and for some providers,
when it comes to their patients’ experiences with IPV, sometimes it is easier not
to ask than to ask and not know what to do.
|IPV is a
serious public health problem (Garcia-Moreno, Jansen, Ellsberg, Heise, &
Watts, 2006) with substantial consequences for women’s physical, sexual, and
mental health (Campbell, 2002). One
source indicates that more than 25% of women experience IPV at some point in
their lives (Black et al., 2011). Despite
the prevalence of IPV and recommendations for universal screening from various
professional organizations and the Institute of Medicine (IOM 2011), most
providers choose not to screen their patients for IPV victimization (Jonassen
& Mazor, 2003). Some sources
indicate that only 1.5% to 12% of female patients were screened about possible
physical abuse from their partner (Caralis & Musialowski, 1997; Hamberger,
Saunders, & Hovey, 1992).||Choosing not to seek out and lend aid to women in abusive
relationships would be contradictory to our calling as healthcare
providers have tremendous potential to identify women experiencing IPV and to
lend aid. Their cautionary positions
toward IPV screening seem to be based upon concerns that screening for IPV may
(a) be overly invasive; (b) isolate patients; and potentially (c) increase
violence (Todahl & Walters, 2011). Although
most physicians receive training on IPV in medical school (Jonassen &
Mazor, 2003), barriers to IPV screenings remain, such as lack of provider education
regarding IPV (Waalen et al., 2000), and lack of self-assessed competence in
identifying IPV (Jonassen & Mazor, 2003).
Women experiencing IPV have identified
barriers as well – most of which pertain to the screener and screening
environment. Specifically, women tend to
prefer to be screened by a woman, someone of the same race, a provider aged 30
to 50 years, and without anyone present (Thackeray, Stelzner, Downs, &
Miller, 2007). It is probable that many
physicians are unaware of these patient boundaries. I contend that collaborative healthcare
providers have the potential to break down these barriers that providers and
patients have constructed.
care settings are ideal for identifying and providing assistance to women
experiencing IPV. Physicians, nurses,
mental health workers, medical assistants, and every other provider within the
system have the ability to "bridge the gap,” so to speak, between the
identification of women experiencing IPV and responding appropriately with
necessary resources. Women are typically
screened via a formal written assessment or a single question on their intake
paperwork. The American College of
Obstetrics and Gynecologists (ACOG, 2012, pg. 3) compiled a list of screening
protocols based upon the preferences of their patients regarding written
- Screen for
IPV in a private and safe setting with the woman alone and not with her
partner, friends, family, or caregiver.
professional language interpreters and not someone associated with the patient.
- At the
beginning of the assessment, offer a framing statement to show that screening
is done universally and not because IPV is suspected. Also, inform patients of the confidentiality
of the discussion and exactly what state law mandates that a physician might
screening for IPV into the routine medical history by integrating questions
into intake forms so that all patients are screened whether or not abuse is
and maintain relationships with community resources for women affected by IPV.
- Keep printed
take-home resource materials such as safety procedures, hotline numbers, and
referral information in privately accessible areas such as restrooms and
examination rooms. Posters and other
educational materials displayed in the office also can be helpful.
- Ensure that
staff receives training about IPV and that training is regularly offered.
group of researchers indicated that women preferred a patient-centered
screening approach more than a written screening approach (McCord-Duncan et
bottom of this blog entry, I’ve included a few helpful links to consider for
those willing to screen for IPV among their patients. The "HITS” domestic violence-screening tool
(Sherin, Sinacore, Li, & Zitter, 1998) is a simple 4-item screening tool
with demonstrated reliability and validity (see Sherin et al., 1998). For a thorough list of screening tools
available, I would encourage you to review the systematic review published by
Rabin, Jennings, Campbell, & Bair-Merritt (2009), which summarized IPV
screening tools tested in healthcare settings and discussed psychometric data
of each tool.
I’ve also included contact
information for the National Domestic Violence Hotline, which, on the date of
this blog entry, is open 24 hours a day.
Providers are encouraged to make themselves aware of the local resources
available in their regions – particularly shelters for battered women and any
local resources to provide further assistance. Representatives from the local
shelters or family violence centers are typically more than happy to come and
give a formal or informal talk about what resources are available in your
there is much still to be learned about IPV screening, we are knowledgeable
enough that choosing not to seek out and lend aid to women in abusive
relationships would be contradictory to our calling as healthcare
providers. Without our assistance as
physicians, nurses, systemic therapists, or any other healthcare provider, the
violence experienced by these women will continue. Family-oriented clinicians, especially those
in integrated care settings, can pave the way for higher identification rates
of IPV and, more importantly, increased aid for women experiencing IPV.
screening methods do you use in your practice? How is collaboration a part of
your protocol? Did you have an experience with IPV in your practice that was
transformative in the way you work with patients experiencing IPV? If so, what
happened and what did you learn through that experience?
Domestic Violence Hotline: 1-800-799-SAFE
(7233) or www.thehotline.org
ACOG. (2012). Intimate partner violence: Committee
opinion no. 518. Obstetrics & Gynecology, 119, 412–417.
M. C., Basil, K. C., Breilding, M. J., Smith, S. G., Walters, M. L., Merrick,
M. T., Chen, J., et al. (2011). National intimate partner and sexual
violence survey (NISVS): 2010 summary report. Atlanta, GA.
J. C. (2002). Health consequences of intimate partner violence. The Lancet,
359, 1331–1336. doi:10.1016/S0140-6736(02)08336-8
PV, Musialowski R. (1997). Women’s experiences with domestic violence and their
attitudes and expectations regarding medical care of abuse victims. Southern Medical Journal, 90, 1075-1080.
C., Jansen, H. A. F. M., Ellsberg, M., Heise, L., Watts, C. H., & Study, W.
H. O. M. (2006). Prevalence of intimate partner violence : Findings from the
WHO multi-country study on women’s health and domestic violence. Lancet,
368, 1260–1269. doi:10.1016/S0140-6736(06)69523-8
LK, Saunders DG, Hovey M. (2002). Prevalence of domestic violence in community practice
and rate of physician inquiry. Family
Medicine, 24, 283-287.
of Medicine. (2011) Clinical preventive services for women: closing the gaps.
Washington, DC: The National Academy of Sciences.
J. A., & Mazor, K. M. (2003). Identification of physician and patient
attributes that influence the likelihood of screening for intimate partner
violence. Academic Medicine, 78(10), S20–S23.
McCord-Duncan, E. C., Floyd, M., Kemp, E. C.,
Bailey, B., & Lang, F. (2006). Detecting potential intimate partner
violence: Which approach do women want? Family Medicine, 38(6),
416–22. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16741840
Rabin, R. F., Jennings, J. M., Campbell, J. C.,
& Bair-Merritt, M. H. (2009). Intimate partner violence screening tools: a
systematic review. American Journal of Preventative Medicine, 36(5),
Sherin, K. M., Sinacore, J. M., Li, X., &
Zitter, R. E. (1998). " HITS ” A domestic violence screening tool for use in
the community. Family Medicine, 30, 508–512.
J., Stelzner, S., Downs, S., & Miller, C. (2007). Screening for intimate
partner violence. Journal of
Interpersonal Violence, 6, 569-670.
J., & Walters, E. (2011). Universal screening for intimate partner
violence.: A systematic review. Journal
of Marital and Family Therapy, 37, 355-369.
J., Goodwin, M. M., Spitz, A. M., Petersen, R., & Saltzman, L. E. (2000).
Barriers and Interventions. American Journal of Preventative Medicine, 19,
|Jonathan Wilson is a licensed marriage and
family therapy associate and provisional certified family life educator. He received his master’s degree in Marriage
and Family Therapy from Oklahoma State University and is currently enrolled in
the doctoral degree program in Medical Family Therapy at East Carolina
University. His interests include
intimate partner violence, psychopathology/psychopharmacology, and family
therapy training outcomes.|