________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Culture Some patients may come from cultures where leaving a mar- riage is shameful or virtually unheard of, regardless of how unsatisfying or even dangerous the relationship may be. If a survivor leaves, they would become even more socially isolated as a result. Prior lack of intervention All too often, survivors of abuse are either blamed for the violence or not taken seriously by family, healthcare profession- als, social service providers, and law enforcement authorities, leaving survivors feeling even more helpless and vulnerable.
not know about or understand the dynamics of violence and abuse, may not take the situation seriously, may not believe them, or may even blame the survivor for the abuse. As a result, survivors may exhibit a variety of problematic responses to the stress of ongoing or prior abuse (e.g., hypervigilance from PTSD, substance abuse), many of which make them “less than ideal” patients in a busy medical practice. When interviewed about their beliefs about partner abuse, and about their personal experiences of victimization, many primary care providers expressed fear of “opening Pandora’s Box” by broaching the topic of IPV with patients [20]. Associ- ated with this metaphor were five strong themes identified as distinct challenges. The first was “too close for comfort,” relat- ing to the finding that 14% of male physician respondents and 31% of female physician respondents in the study disclosed a previous personal experience of abuse. Other themes were fear of offending, powerlessness, loss of control, and “tyranny of the time schedule.” PATIENT BARRIERS TO DISCLOSURE Patients may hesitate to disclose current or past abuse to a healthcare provider for a variety of reasons [21]: 1. Fear of: ‒ The healthcare provider confronting the perpetrator. ‒ Retribution if the perpetrator learns of the disclosure. ‒ A breech in confidentiality if medical records are accessed by the perpetrator, child protective services, employers, police, or immigration authorities. 2. Shame and humiliation that abuse is taking place, or took place in the past, or not wanting to be perceived as a “victim.” 3. Belief that they deserved the abuse. 4. Protective feelings for the partner. 5. Inability to fully comprehend the situation. 6. Assumptions that: ‒ The doctor and staff are not knowledgeable or do not care about IPV because IPV may not be viewed as a medical issue. ‒ The doctor is too busy to spend time talking about IPV. ‒ The doctor can’t help with this problem or that it is inappropriate to discuss it. ‒ Same-sex abuse is not recognized, screened for, or treated. 7. Language, culture, and religion: ‒ Language barriers when communicating with providers, and fear of losing confidentiality with the use of an interpreter. ‒ Religious customs pushing survivors to stay silent about abuse.
IPV SCREENING AND ASSESSMENT
THE CLINICIAN’S ROLE The healthcare encounter can be invaluable for those in abu- sive relationships. Although survivors of IPV access medical services more frequently than non-abused individuals, most do not volunteer a history of abuse even to their primary care clinicians. Sensitive inquiry about IPV during an annual physi- cal examination, scheduled visit, or non-acute appointment, may reveal previously undisclosed abuse or can shed light on the underlying cause of an established chronic medical prob- lem. In addition, research has shown that most patients both welcome and appreciate inquiry about violence and abuse in the course of the medical visit when questions are asked in a manner that is sensitive, respectful, and confidential [19]. Abused individuals are more likely to disclose a history of abuse to their healthcare provider if the provider is perceived to be knowledgeable, nonjudgmental, respectful, and support- ive. Patients prefer that their clinicians take the initiative to inquire, as a matter of standard practice, about violence and abuse during the course of clinical encounters. The gender of the physician is not an important factor in the willingness of most patients to disclose or discuss abuse. The physician may need to ask on multiple occasions and over time, as a patient may need to feel they have a safe relationship to disclose their status. The physician can then help the patient develop a safety plan to prime the patient’s next leave attempt. It’s important to reiterate that a patient who remains in a dangerous or potentially dangerous relationship should not be labeled as a treatment failure or non-compliant. As noted ear- lier, choosing not to leave usually reflects the limited resources available to the survivor, or the patient’s reasonable assessment of available options and safety needs.
CLINICIAN BARRIERS TO EFFECTIVE, COMPASSIONATE CARE
Some healthcare providers find it challenging to address IPV, as well as other forms of violence and abuse. Survivors present frequently for medical care, and/or may come across as difficult patients. Many survivors believe that healthcare providers do
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