Module Objectives

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Module Objectives

• As a result of completing this module, learners
  will
• Discuss barriers in conducting domestic violence
  (DV) assessments for victims and providers
• Recognize the common misconceptions involved with
  DV assessments
• Recognize strategies to overcome these barriers
  and misconceptions.

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Barriers for the Victim

• Victim attitudes and beliefs
• Child protection issues
• Safety
• Health care system

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Victim Barriers Attitudes/Beliefs

• Feels shamed and humiliated
• Why do I let him/her treat me this way?
• Feels she/he deserved the abuse
• He/she tells me I cant do anything right, Im
  an awful person.
• Feels protective of partner
• He/she is really a great parent and I love
  him/her.

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Victim Barriers Attitudes/Beliefs

• Despair
• Worry
• Uncertainty
• Humiliation
• Denial

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Victim Barriers Attitudes/Beliefs

• Minimizes, denies or normalizes abuse
• Its not that bad, and doesnt happen that
  often.
• Language, culture and religion
• I cant get divorced.
• Immigration status
• The authorities will find out we are
  undocumented.
• Sexual orientation
• I dont want to out my partner.

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Victim Barriers Children

• Fear of losing the children
• I dont want child protection to take my kids.

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Victim Barriers Safety

• Fear for safety/violence escalation
• What if abuser finds out I talked?
• Abuser threatens and controls
• If you tell anyone, you are dead.
• No one would believe you.
• Ill take the kids.

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Victim Barriers System

• Perceptions of the health care system
• They cant help me.
• They wont believe me.
• They will judge me.
• I disclosed before and nobody helped.
• Told to leave
• Provider too pushy

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Victim Barriers System

• Actual health care system obstacles
• Long wait times
• High costs
• Referral to and/or involvement with other systems
  (police, CPS)

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Victim Barriers System

• Perceptions of the health care provider
• Lack time
• Judging
• Pitying
• Blaming
• Trivializing the violence
• Disinterested
• Unsympathetic

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Are DV Assessments Acceptable?

• Pregnant women (n879) were asked how they felt
  about being asked about violence by their
  midwife
• 80 found screening acceptable
• 17 unsure
• 3 found screening unacceptable
• Stevenson, 2006

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Are DV Assessments Acceptable?

• Mothers with children (n553) in a Pediatric
  setting were asked to respond to the following
  statement
• I think it is a good idea for pediatricians to
  ask mothers about DV.
• 83 agreed or strongly agreed
• Parkinson, 2001

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Provider Barriers

• Lack Skills/ Knowledge
• Insufficient Time
• Process Issues
• Concerns about Efficacy and Outcome
• Personal Reasons
• Misperceptions

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Provider Barriers Skills

• Providers often do not know how to ask
• Dearth of curriculum on DV assessment
• Most health care settings do not have DV protocol
• Lack of experience in asking about DV
• If DV is identified, provider does not know what
  to do next

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Provider Barriers Knowledge

• Lack knowledge of symptoms in children that may
  indicate exposure to violence in the home
• Dont know when and to whom to refer a child who
  has witnessed violence.
• When do I need to call child protection?

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Provider Barriers Time

• Too busy
• Too many other questions to ask
• Will take too much time
• No time to establish the rapport necessary to ask

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Provider Barriers Process

• Concerned about privacy and confidentiality
• Lack of availability of a private room
• How do I get the abuser to leave the room?
• Afraid to ask in front of children
• Documentation in the childs chart about a
  parents abuse is accessible to the perpetrator
  if the he/she is a parent or guardian for the
  child

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Provider Barriers Outcomes

• Patient/ victim wont follow through
• Do local advocacy resources really meet the
  needs of the victim?
• Dont have good resources in my community
• No data on effectiveness of asking and referring

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Provider Barriers Personal

• Fear of opening a Pandoras Box
• Caring for DV victims is difficult and
  frustrating.
• Fear of offending patient
• I dont want to annoy my patient by asking.
• Over identification with the victim

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Common Misconceptions

• Providers assume victim will volunteer a history
  of violence
• Many victims often wont disclose DV even when
  asked
• Asking about DV is educational and sends a
  message

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Common Misconceptions

• Victim causes the violence
• Providers may screen patients with injuries, but
  dont screen prenatal patients, periodic
  check-ups, patients with mental health issues or
  chronic physical health care issues.

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Common Misconceptions

• MYTH
• Battering is caused by drinking and drugs.
• TRUTH
• Alcohol and drugs can make abuse more severe.

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Common Misconceptions

• MYTH
• Abusers are out of control when they batter.
• TRUTH
• Abusers chose when and where to abuse/injure the
  victim. A hidden bruise, so only the victim
  knows. Or a public display that humiliates the
  victim.

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Common Misconceptions

• MYTH
• If a mother is being abused, I need to report
  her situation to child protection.
• TRUTH
• Laws vary from state to state. Only a few
  states consider domestic violence a mandatory
  report like child or elder abuse.

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Common Misconceptions

• MYTH
• Victims can leave an abusive relationship if
  they really wanted to leave.
• TRUTH
• There are many barriers to leaving. Each victim
  has barriers unique to their situation.

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Why Doesnt The Victim Just Leave?

• My doctor asked me why I just didnt leave in a
  very irritated, demeaning way. He looked at me
  like I was stupid. It never occurred to him that
  I had left, but that my husband just tracked me
  down again. He doesnt know my husband keeps
  threatening to kill the kids and me if I leave. I
  am afraid and I am scared.

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Obstacles to Leaving

• Fear
• Family
• Faith and culture
• Finances
• Hope
• Isolation

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• Change does not necessarily equate with leaving

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Stages of Change Model

• Change is a process, not an event
• Individuals are at varying levels of readiness to
  make a change.
• Key Point
• Individuals at different levels of readiness
  benefit from different therapeutic messages and
  interventions.

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Stages of Change Model

• Five distinct stages
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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References

• Barriers for the Victim
• Burke J. (2001) The process of ending abuse in
  intimate relationships. Violence Against Women.
  7(10)1144-1163.
• Davies J. (1998) Safety Planning with Battered
  Women. Thousand Oaks SAGE Publications, Inc.
• Gerbert B. (1996) Experiences of battered women
  in health care settings A qualitative study.
  Women Health. 24(3), 1-17.
• Hamberger L. (1998) Physician interaction with
  battered women The women's perspective. Archives
  of Family Medicine. 7, 575-582.
• McCauley J. (1998) Inside "Pandora's box" Abused
  women's experiences with clinicians and health
  services. J Gen Intern Med.13(8)549-555.

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References

• Barriers for the Victim (Continued)
• Physicians for a Violence Free Society. (2003)
  Abuse Assessment Response Course. CD Rom San
  Francisco CA FVPF. Available at
  http//fvpfstore.stores.yahoo.net/abasrecosyap.htm
  l
• Rodriguez MA. (1996) Battered womens
  perspectives on medical care. Arch FM. 5153-8.
• Rodriguez MA. (2001) The factors associated with
  disclosure of intimate partner abuse to
  clinicians. J Fam Prac. 50338-44.
• Zink. (2004) Medical Management of Intimate
  Partner Violence Considering the Stages of
  Change Precontemplation and Contemplation.
  Annals of FM. 2(3) 231-239.

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References

• Barriers for the Screener
• Borowsky IW. (2002) Parental screening for IPV by
  pediatricians and family physicians. 110509-16.
• Coker A. (2002) Missed opportunities IPV in
  family practice settings. Prev Med.34445-54.
• DAvolio D. (2001) Screening for abuse Barriers
  and opportunities. Health Care for Women
  International. 22349-62.
• Elliott B. (2002) Barriers to screening for DV.
  JGIM. 17112-6.
• Erickson MJ. (2001) Barriers to DV screening in
  the pediatric setting. Pediatrics. 10898-102.

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References

• Barriers for the Screener (Continued)
• Fishwick NJ. (1998) Assessment of women for
  partner abuse. J of OB,Gyn,Neonatal Nursing. 27
  448-92.
• Minsky-Kelly D. (2005) Weve had training, now
  what? JIV 201288-1309.
• Rodriguez MA. (1999)Screening and intervention
  for intimate partner abuse. JAMA. 282468-74.
• Sugg N. (1992) Primary care physicians response
  to DV. JAMA. 267 3157-60.
• Sugg N. (1999) DV and primary care. Arch FM.
  8301-6.
• Waalen J. (2000) Am J Prev Med. 19230-7.

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Additional References

• Feder G. (2006) Women exposed to IPV. Arch Intern
  Med. 16622-37.
• Parkinson GW. (2001) Maternal domestic violence
  screening in an office-based pediatric practice.
  Peds.108(3). URL http//www.pediatrics.org/cgi/co
  ntent/full/108/3/e43.
• Stenson K. (2001) Womens attitudes to being
  asked about exposrue to violence.
  Midwifery.172-10.