”Yes, he hit me but it’s my fault. I made him angry.” Viewing an instance of abuse as a result of one’s own actions is more empowering than if the person has no control. So justifying the abuser’s actions is one way to legitimize his actions. Additionally, with the cyclic nature of the IPV relationship, the terrorism and intimidation often build up prior to the event and usually become so intolerable that the abused does something to end the terrorism and initiate the abuse. “She presents with arm pain and odd injuries, but always denies IPV.” Reluctance on the part of a patient to disclose information about current or past abuse, even when specifically asked, may be due to embarrassment, shame, hope that the relationship can improve, or fear of retaliation by the perpetrator. External factors can also play a role: for example, the social pressure to avoid “losing” a partner or economic dependency. “We just fight. I hit him and he hits me.” Abuse occurs most often in a one-way direction. However, survivors may strike back in self-defense, which can then be used to excuse the behavior of the abuser. “He seems to be such a caring guy – there with her every visit and won’t leave the room.” Caring and controlling can manifest as similar, or even identical, behaviors that can be difficult or impossible to distinguish without long-term observation. “He’s losing his job and now, for the first time in 20 years, he hit me.” Abuse may evolve from non-violent to violent in tandem with stressors experienced by the perpetrator. Pregnancy, which can refocus a woman’s exclusive attention away from her partner, can also serve as a trigger. Obstacles to Leaving an Abusive Relationship Survivors of IPV may face many barriers to leaving an abuser or to taking steps to prevent further abuse. The abuser may threaten to hurt or kill the victim, for example, or take away or hurt the children if the victim attempts to leave. Other potential obstacles include: Economic and Logistical Constraints Abusers often control the financial resources of the household as well as access to telephones, computers, passwords, car keys, and even medication and food, making it difficult for survivors to leave because they cannot (or believe they are unable to) independently support themselves and their children. They may track their partner electronically or call and text hundreds of times a day. Survivors may not know where to seek shelter or may be afraid to ask.
Social Isolation The abuser often prevents the victim from communicating with friends and family. Isolation leaves abused individuals psychologically dependent on the abuser as the sole source of social support and the only person who explains or interprets what is happening in the relationship. Feelings of Failure Many survivors have been made to feel, by the abuser as well as by others, that they are failures and are responsible for having brought on the mistreatment. Survivors may also believe that their children need or deserve a two-parent family, even at the expense of their own safety. Social pressures, e.g. “not keeping your man” can also play a role. Promises of Change A victim may believe the abuser’s expressions of remorse and subsequent promises that it will never happen again. He or she may feel that the abuser can change. Some survivors also feel it is somehow their responsibility to change or redeem their abusers. While some survivors may want the relationship to continue, most also clearly want the violence to stop. Religion Some victims may expect to endure sacrifices in life, and that suffering in this life will be rewarded in the next life, or that their current situation is due to acts committed in a past life. Others believe deeply in forgiveness and the power and grace it brings them to forgive the transgression of others. Some people view the breaking of marriage vows as sinful, or interpret religious texts as reinforcing control and domination. Religiously based support may not embrace personal safety and resources for abused women. Influences by religious leaders may reinforce a subordinate role for wives. Culture Some patients may come from cultures where leaving a marriage 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 professionals, social service providers, and law enforcement authorities, leaving survivors feeling even more helpless and vulnerable. IPV Screening and Assessment The Clinician’s Role The healthcare encounter can be invaluable for those in abusive 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 physical 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 problem. 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 supportive. 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 earlier, 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 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 Associated with this metaphor were five strong themes identified as distinct challenges. The first was “too close for comfort,” relating 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.”
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