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Intimate Partner Violence in Integrated Care

Posted By Jonathan Wilson, Tuesday, April 23, 2013

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.

Collaborative 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.

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.

Integrated 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 screenings:

  • Screen for IPV in a private and safe setting with the woman alone and not with her partner, friends, family, or caregiver.
  • Use 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 disclose.
  • Incorporate 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 suspected
  • Establish 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.
Another group of researchers indicated that women preferred a patient-centered screening approach more than a written screening approach (McCord-Duncan et al., 2006).

At the 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 community.

Although 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.

What 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?

Resources

Link: "HITS” Screening Tool

National Domestic Violence Hotline: 1-800-799-SAFE (7233) or www.thehotline.org

 

References

ACOG. (2012). Intimate partner violence: Committee opinion no. 518. Obstetrics & Gynecology, 119, 412–417.

Black, 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.

Campbell, J. C. (2002). Health consequences of intimate partner violence. The Lancet, 359, 1331–1336. doi:10.1016/S0140-6736(02)08336-8

Caralis 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. doi:10.1097/00007611-199711000-00003

Garcia-Moreno, 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

Hamberger LK, Saunders DG, Hovey M. (2002). Prevalence of domestic violence in community practice and rate of physician inquiry. Family Medicine, 24, 283-287.

Institute of Medicine. (2011) Clinical preventive services for women: closing the gaps. Washington, DC: The National Academy of Sciences.

Jonassen, 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. doi:10.1097/00001888-200310001-00007

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), 439–445. doi:10.1016/j.amepre.2009.01.024

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.

Thackeray, J., Stelzner, S., Downs, S., & Miller, C. (2007). Screening for intimate partner violence. Journal of Interpersonal Violence, 6, 569-670.

Todahl, J., & Walters, E. (2011). Universal screening for intimate partner violence.: A systematic review. Journal of Marital and Family Therapy, 37, 355-369. doi:10.1111/j.1752-0606.2009.00179.x

Waalen, J., Goodwin, M. M., Spitz, A. M., Petersen, R., & Saltzman, L. E. (2000). Barriers and Interventions. American Journal of Preventative Medicine, 19, 230–237. doi:10.1016/S0749-3797(00)00229-4

 

Jonathan Wilson
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.

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