Health Care Responses to Perpetrators of Domestic Violence

CHAPTER 3

HEALTH CARE RESPONSES TO PERPETRATORS OF DOMESTIC VIOLENCE

BY ANNE L. GANLEY, PH.D. HEALTH CARE RESPONSES TO PERPETRATORS OF DOMESTIC VIOLENCE1

BY ANNE L. GANLEY, PH.D.

INTRODUCTION

atients who batter their intimate This chapter is divided into six P partners appear in a variety of health sections. The first addresses strategies for care settings, including emergency depart- maximizing the safety of the victim when ments, specialty clinics and primary care interacting with a patient who is the perpe- settings. Some seek medical care for issues trator. The second section reviews the directly related to their abusive behavior, multiple ways clinicians learn that their while others seek assistance for issues that patient is a perpetrator of domestic are unrelated to their violence. While the violence. The third is an overview of the major thrust of the health care effort is information gathered as the practitioner appropriately focused primarily on domes- interacts with perpetrators. The fourth tic violence victims and their children, this discusses the specific factors to consider in chapter is written to assist health care evaluating the lethality of the domestic providers in determining when and how to violence and the risk of future injury or respond when they encounter perpetrators death. The fifth presents crisis intervention of domestic violence in their practice. strategies. The chapter ends with a discus-

1 This chapter was taken from a longer article, Identification, Assessment, and Interventions with Perpetrators of Domestic Violence, by the same author. The author gratefully acknowledges the editing of Patrick Letellier for this current version. 89 CHAPTER 3 sion of additional health care strategies ples used in responding to victims of that may be implemented when treating domestic violence. perpetrators. These principles are discussed in Figure When the patient is a perpetrator of 3-1. Ultimately, the health provider will be battering, the health care provider should more effective in responding to perpetra- be guided by the same understanding of tors when these principles are followed. domestic violence and by the same princi-

FIGURE 3-1

GUIDING PRINCIPLES

1. Regarding the safety of victims and their children as a priority

2. Respecting the integrity and authority of each battered woman over her own life choices

3. Holding perpetrators responsible for the abuse and for stopping it

4. Advocating on behalf of victims of domestic violence and their children

5. Acknowledging the need to make changes in the health care system to improve the health care response to domestic violence

I. STRATEGIES FOR INCREASING THE SAFETY OF VICTIMS WHEN INTERACTING WITH PERPETRATORS OF DOMESTIC VIOLENCE

Perpetrators of domestic violence react their responsibility for their violence. in multiple ways to discussions of their Unfortunately, there is no way to predict abusive behavior with health care from the initial presentation of the patient providers. Some use such conversations which perpetrators will benefit from a with clinicians as one more excuse to retali- discussion about their behavior and which ate against victims, while others are recep- will not. Regardless of the response of the tive to such discussions. Some perpetrators individual perpetrator, all interactions with express relief that the issue has been raised batterers must be made with the safety of and others become angry or indignant. victims as the highest priority. The follow- Certain perpetrators will use the informa- ing are strategies for increasing the safety of tion provided by the practitioner to start victims when talking with patients who are the process of changing their abusive perpetrators. conduct. Others reject the information and

90 RESPONSES TO PERPETRATORS A. Information from the which information will be shared and how the discussion will take place. Victim Must Be Kept What is also problematic and danger- Confidential ous is revealing to the perpetrator what a third party (e.g., an EMT worker) has said, Relaying any information provided by when the comments are based on victim the victim about the abuse to the perpetra- reports. This information should not be tor may put that victim in danger. Victims revealed to the perpetrator. Obviously, use may talk about the abuse in hopes of of information provided by the victim getting help. Some want all information would be an exception rather than a rule kept confidential, some want part of the and in even these limited circumstances information kept confidential, while others would be used only for victim safety and want the information they provide raised advocacy. with the abuser. Given the lethality of domestic violence, the practitioner should avoid repeating to the abuser what victims have said. The victim’s wishes about confi- B. Discussions with the dentiality must be respected (principle 1 in Figure 3-1). Furthermore, respecting her Perpetrator About request for confidentiality (whether or not Domestic Violence she is the health care provider’s patient) Should Never Be Done conveys to her that she has the right to make decisions about her own life and to in the Presence of the have others abide by those decisions Victim (principle 2 in Figure 3-1). Even when a victim asks the provider to talk directly with the abuser about the When the health care provider wishes abuse, the health care worker should first to discuss abuse with the perpetrator, the explore with her the possible consequences discussion should be carried out with him of such action. The clinician should review in private. Victims, children, friends, and with the victim how the perpetrator would family should not be present during these respond to knowing that she has revealed interviews. Since medical personnel often the abuse. Is she in danger? Will he retali- see patients privately for assessment or ate? Will she be safe if the health care treatment procedures, domestic violence provider discusses the topic directly with issues can be discussed during that individ- the abuser? The health care provider ual time. Discussing the abuse with the should not presume that talking directly perpetrator alone is one more way that the with perpetrators will automatically provider can emphasize the perpetrator’s decrease or increase her safety. Some responsibility for the abuse and for victims have not considered the outcome stopping it. and may, with further thought, want the information to remain confidential. Sometimes victims have carefully considered the consequences and want the health C. Taking Care in How care provider to proceed (e.g., the victim who says, “I told him I was going to tell Domestic Violence is you and if you don’t say anything, he will Discussed with think you agree with him that I am crazy”). Perpetrators If the health care practitioner is going to communicate any of a victim’s information directly with the abuser, there should be a The health care professional must specific agreement with the victim about exercise care in how the discussions are 91 CHAPTER 3 carried out. Some approaches will increase is a crime, the primary role of the health the likelihood that the perpetrator will care provider is to meet the health care become defensive and retaliate against the needs of patients. If the health care worker victim, while others lower the risk. Even functions as a police officer, prosecutor, or when the clinician uses all of the judge then some perpetrators’ defensive- approaches described below, there is no ness will increase and they may retaliate guarantee that the victim will be safe. against the victim or health care worker. Unfortunately, simply remaining silent in the face of batterers’ reports of their abusiveness may also endanger the victims. 3. FOCUS ON DESCRIPTIONS OF Some batterers use the silence of those THE ABUSER’S BEHAVIORS. whom they know are aware of the abuse as further justification for it. And sometimes When initially talking with perpetra- they will batter their partners with state- tors of domestic violence, the provider ments such as “I told the doctor that you should use descriptions of their behaviors deserved what I did, and he agrees. He rather than terms like domestic violence, knows about my hitting you, but he has abuse, or battering. It is helpful with perpe- never said anything to you about it, right?” trators to make comments such as: “When The health care provider should use you threw her to the couch” rather than approaches that: “when you abused your wife,” or “you hit your girlfriend with a closed fist” rather than “you beat her,” or “your use of physi- 1. VIEW DOMESTIC VIOLENCE AS cal force against your partner” rather than A HEALTH CARE ISSUE. “your domestic violence.” Terms like “wife beater,” “perpetra- When talking directly with the perpe- tor,” “batterer,” and “abuser” should also trator about the abuse, the health care be avoided in initial contacts about this practitioner should emphasize that such issue. When the health care provider has issues are discussed with patients in order had multiple contacts with the patient and to best meet their health care needs. The has established a working relationship with issue of abuse is a health care issue for the him about the domestic violence, those patient who is abusive as well as for victims terms can be used, but not when first and their children, and this should be encouraging the patient to discuss the communicated to that patient who is a abuse. perpetrator.

4. FOCUS ON THE ABUSER’S 2. EMPHASIZE THE ROUTINE BEHAVIOR RATHER THAN THE NATURE OF THESE DISCUSSIONS. VICTIM’S. As with all health care issues, the health As abusers talk about their domestic care provider is often in the position of violence, they often focus on the victim’s educator, providing patients with informa- behavior rather than their own. They gloss tion necessary for their health. The over their actions and will go into long purpose of the discussion is not to investi- stories blaming victims or others for their gate or prosecute a crime. While it is problems. It is easy to be confused by some appropriate at times (e.g., when there is a of these rationalizations and to uninten- duty to warn, state mandatory reporting tionally reinforce the abuser’s behavior by requirements, or victims seeking legal making sympathetic comments about these protections) to refer specific domestic explanations (e.g., “I can understand why violence cases to legal entities and to you are mad at her”). The discussion remind perpetrators that domestic violence should avoid such commentary and be

92 RESPONSES TO PERPETRATORS focused on the abusers’ behaviors and their D. When Perpetrators negative consequences (e.g., “hitting never solves problems,” “your violence is Display Anger, Resist or destroying all of you”). Reject the Discussions Even when the victim is available and of Abuse has given specific permission for the clinician to share information with the perpetrator, it is safer for the victim when the If the perpetrator is not open to talking provider’s comments focus on the abuser’s about this issue with the health care practi- behaviors rather than on the victim (e.g., tioner, then forcing the issue will raise resis- “you said you threw your wife” rather than tance in the patient and may endanger the “your wife told the police officer you threw victim. As stated earlier, some perpetrators her”). The provider can also focus on what are willing to talk and listen about abuse the health care worker or third party when it is presented as a health care issue directly observes (e.g., “your injuries look by a concerned provider while others will like someone tried to free themselves from reject this or any other approach to the a hold” rather than “your wife said she did topic. While principle 3 is holding the this when you were choking her”). abuser, not the victim, responsible for the abuse, it is important to remember that the health care system’s role is not to force 5. USE A DIRECT AND CALM patients, but to educate them about how to APPROACH. care for themselves and, ultimately, for others. The perpetrator’s display of anger Care should be taken to approach the and other tactics of control in the session topic directly, matter-of-factly and calmly. with the health care provider indicates that A health care practitioner who vents his or the perpetrator is not motivated to change her anger, disgust or shock about this issue at that time. It is more productive to make to the perpetrator may well endanger the a summary statement, calmly bring the victim. While the health care practitioner subject to a close, and then move back to can take a stand against the use of force in the presenting medical issue: intimate relationships and can point out to patients who are perpetrators their respon- “Your using force against your partner sibility for making changes, the methods and property is damaging both of you. I selected to convey those points can increase am concerned and will be glad to make a or lower defensiveness. For some batterers, referral whenever you want it.” their defensiveness with the health care provider translates into retaliation against “You’ve indicated that you are their victim. concerned about your violence with your wife. Let me (or a referral) know when you want to talk about it further.”

“Unfortunately, drinking or drugging is only part of the problem. I would like you to think about how your abusiveness is damaging to you and your family.”

93 CHAPTER 3

II. LEARNING THAT YOUR PATIENT IS A PERPETRATOR

Perpetrators of domestic violence are care issue in perpetrators’ medical records. identified in a variety of ways by the health As health care systems are integrated and care system: become more comprehensive (HMO’s, managed care systems, etc.) then notes about domestic violence may appear from A. Medical Records or other parts of the health care system (e.g., substance abuse programs, domestic Written Referrals violence programs).

The domestic violence perpetrator may have been identified by another health care practitioner and this may be noted in the B. Reports by Victims or medical records. Such information may be indicated by a clinician in the following Children ways: Sometimes victims or children accom- ■ “patient violent with spouse,” pany the perpetrators to their medical appointments and are present with the ■ “patient broke (hand, leg, arm, ribs, perpetrator patients. Victims or children etc.) when attacking spouse,” may also be patients in the same setting (such as a family practice). The victim or ■ “patient missed appointment; in jail for children accompanying the perpetrator domestic violence assault,” may tell the provider directly that the patient is abusive. In the course of giving a ■ “patient’s wife unable to participate as medical history about the patient, the caregiver following the bone marrow victim may describe his violent behavior transplant due to no contact order, (e.g., “His asthma attacks have been more secondary to spouse abuse,” frequent since he got arrested for assaulting me,” “My daddy broke his hand hitting ■ “patient referred to clinic by domestic mommy,” “Something is wrong with him, violence program, requests evaluation he drinks and hits me,” “He just kept for high blood pressure (or any other throwing furniture out the front window. I medical condition),” told him he would injure his back”). The victim or children may talk about ■ “counseling note in chart from an on- abuse with the health care practitioner in site domestic violence perpetrators the presence of the abuser or privately. group,” etc. They provide such information seeking medical help for the problem, believing that The more knowledgeable health care the abuser’s behaviors are caused by a providers and referral sources become medical issue, or believing that health care about domestic violence, the more frequent professionals have the authority or influ- such notations may appear in medical ence to stop the violence. It is critical to records. In medical facilities serving large treat the information seriously and respect- numbers of male patients, such as Veterans fully and to be aware that all parties will Administration Medical Centers or U.S. observe how the situation is handled by the military medical facilities, trained practi- provider. tioners note domestic violence as a health If the victim tells the provider about the

94 RESPONSES TO PERPETRATORS abuse in front of the abuser, it is important party such as the responding police officer, for the provider to respond calmly to the the Emergency Medical Technician, the information and indicate (a.) that some person accompanying him to the patients act in these ways, (b.) that the emergency department, or through phone provider appreciates knowing about it, and calls by other family members or friends. (c.) that the provider will be glad to be of as For example, the EMT worker states that much assistance as possible because this when he arrived at the house, he observed kind of behavior hurts the health of all the patient lying unconscious, the wife with family members. At this stage the clinician a split lip and swollen left eye, and the is welcoming all information and is not Christmas tree lying outside, having been attempting an intervention. Additional thrown through the picture window. The information will be needed before taking wife told the EMT that the husband had a further action. The clinician should speak, chronic heart condition and that he had then or later, separately and confidentially passed out during the assault against her. with the victim. She had called the hospital emergency If the victim or the children discuss the room for medical help for “his heart abuse privately with the practitioner, the attack.” clinician should inform the victim that their conversation is confidential unless she requests otherwise or unless the health care practitioner is required to make a report D. Self-Reports by (see section on mandatory reporting on page 100). In addition to referring the Perpetrators victim for a confidential follow-up conver- Some patients who are perpetrators sation for further assessment and safety self-disclose their abusiveness. They may planning (see victim’s chapter), the health do this because they are seeking help for the care practitioner should ask victims if they problem or because they believe that their want their conversations to remain confi- abusive behavior is a symptom of some dential. It is essential to obtain the victim’s medical condition (e.g., patients report permission to discuss the abuse with the increasing fights with their partners in perpetrator, and the victim’s perspective of which they strike out or “lose it,” report the risks of talking with the perpetrator incidents where they hit their partners or about abuse. The practitioner should also furniture, or reports that family members give the victim a referral to a local domestic are afraid of them). For those batterers violence program. who are not in total denial and who are Always advise the family member that troubled by their behaviors, the health care the information is valuable and that you system may be their choice for seeking are glad they shared it with you, even when assistance. While they may be minimizing the information is provided by telephone their behaviors and may not use the terms and the victim is asking for strict confiden- domestic violence or abuse, they describe tiality. Such reports provide opportunities behaviors that clearly fit the definition of for responding to the victim’s needs and domestic violence and ask for help for their may help the health care practitioner to “tempers,” “marital problems,” etc. understand what a perpetrator may be Occasionally because of public education struggling to conceal or disclose. or the intervention of another party, the patient may actually identify his behavior as domestic violence and turn to the health care system for assistance (e.g., “I saw this C. Reports by Third Parties program on TV and realized that I am a wife beater and I thought you could give The patient may be identified as a me some medications for it”). perpetrator of domestic violence by a third Sometimes patients self-disclose 95 CHAPTER 3 abusive behaviors not to seek assistance the nurse entered the cubicle to prepare but because they do not believe that what him for stitches for a minor cut over his they are doing is wrong. For example, in eye, the man threatened to kill his partner the course of the medical treatment a if she told the doctor what had really patient acknowledges using force against happened.” family members. “I had to give her a pop When the violence and/or threats of or two to keep her in line.” “She pulled a violence occur within the health care knife when I threw her down the hall. setting, health care providers should inter- That’s how I got cut.” “We were arguing vene to immediately stop that particular in the car. I just wanted to scare her so she abusive episode by calling security and by would shut up. I lost control of the car separating the victim and perpetrator. and we hit the embankment.” The victim should be provided emergency Perpetrators will talk about their assistance while still at the medical facility violence in many different ways. They (see victim’s chapter). The victim should will minimize, justify, or blame their also be given information about the local violence on others. Some will brag about domestic violence program and assisted in the violence, while others will deny or lie contacting the program while still in the about it. Whether or not the patient sees it health care setting if she wishes. Direct as domestic violence, the practitioner can observation of violence and/or threats of matter-of-factly characterize the patient’s violence should be noted in the perpetra- behaviors (“popping her,” “driving to tor’s medical records. The information is frighten someone,” “throwing someone,” relevant to the continued treatment of this etc.) as a serious and potentially life- patient and is essential to the safety of the threatening problem for him as well as for victim. Copies of police reports should other family members. Once again, a also be included in the patient’s records. matter-of-fact approach is important in When the health care provider gathering information about battering observes incidents of non-violent, and conveying to the patient the coercive control used by the batterer provider’s concern about abuse. against his partner (e.g., during treatment, the staff observe the perpetrator conduct- ing surveillance of his partner through excessive telephone checks), further E. Observation of assessment would be necessary to determine if that patient is a domestic violence Perpetrators’ Abusive perpetrator before a provider can Behaviors in a Health respond. Care Setting Health care providers may identify patients who are perpetrators of domestic F. Observation of the violence by direct observation of their abusive behavior. Emergency department Effects of Abusive personnel have described incidents where Behavior a perpetrator followed the victim into the health care setting and continued the There may be no observable incident beating. “While they were waiting to be or direct report that clearly identifies a seen by the emergency doc, he started patient as a perpetrator of domestic yelling at her to stop bleeding and violence. However, the health care suddenly he started punching her.” “One worker may observe the results of possible battered woman ran into the emergency domestic violence: scratches, cuts, or department yelling for help, followed by bruises to the perpetrator’s face, arms or her knife wielding boyfriend.” “Just as hands secondary to his own violent

96 RESPONSES TO PERPETRATORS

behavior; injuries to his body caused by his the effects of the perpetrator’s abuse on attempts to terrorize the victim (e.g., victims or children who accompany the reckless driving, suicide attempts, breaking perpetrator to his health care appoint- windows, doors); or a medical condition ments: visible injuries, their fear of the that is aggravated by his abusive behavior patient, their excessive attention to his toward the victim (e.g., asthma attacks, every move or wish, his attempts to control heart attacks, etc.). As the patient talks them, etc. These may be indicators that the about the presenting medical concern, the patient is abusive, but they alone would not domestic violence may be revealed. warrant a patient being positively identi- The health care provider may observe fied as violent.

III. ASSESSMENT OF LETHALITY WHEN THE PATIENT IS THE PERPETRATOR

One of the major issues in responding violence for injury or death. Unfortunately, to identified domestic violence cases is the there are similar difficulties when attempt- reality that domestic violence is lethal. ing to predict injuries or death due to Domestic violence dramatically increases domestic violence as those found in predict- the risk for serious injury or death to any ing homicides. Overpredictions of injury family member. Injury or death occurs or death and underestimations of risk are either through the acts of the abuser, the always possible. Nonetheless, since domes- victim, or the children. Typically it is tic violence can result in significant injury abusers’ violent conduct against victims or death, the responsible health care that results in serious injuries or death to provider should, at a minimum, attempt to victims. Sometimes in pursuit of control- determine the danger of immediate harm. ling victims, perpetrators also injure or kill Assessment of risk for injury or death children, others, or themselves. Sometimes should be conducted every time the health it is the victim or children who injure or kill care provider has contact with an identified themselves or others as a response to the perpetrator or victim of domestic violence. violence of the perpetrator. The lethality assessment is used to deter- Assessment of risk for injury or death is mine whether or not there is immediate difficult as illustrated by the controversy danger and what steps can be taken to about the efficacy of assessments for reduce the danger level. The primary predicting homicides.2 The debate stems source of the information is the patient from the fact that ultimately we cannot present, whether perpetrator or victim. A know with absolute certainty which batter- complete assessment of lethality involves ers will commit homicide. Dangerousness gathering information from all who have assessments are not precise, scientific tools; information relevant to the lethality they are attempts to identify batterers who question. are more likely to kill their partners. While more research is needed to Furthermore, predicting homicides is only improve predictions of danger in domestic one way to understand the risk in domestic violence cases, the lethal nature of the violence makes it imperative that clinical assessments of lethality are routinely 2 Hart, B. J. & Gondolf, E. W. (June 1994). carried out, using clinical judgment as a Lethality and dangerousness assessments. guide. The following are factors to Violence UpDate, 4(10), 7-10. consider in assessing the lethality of the 97 CHAPTER 3 domestic violence (see Appendix K for C. Factors that Reduce Lethality Assessment with the Perpetrator). Each of these factors is important individu- Cognitive Controls ally and in interaction with the others. ■ alcohol/drug dependence or abuse

■ certain medications A. Pattern of Abuse ■ psychosis or brain damage While it is difficult to predict which perpetrator will escalate the severity of his For perpetrators, any one of these physically abusive behaviors, an examina- factors combined with their violence tion of the current pattern will reveal who increases the risk for injury or death. is already engaging in high risk behaviors Certain prescribed medications (e.g., anti- such as choking, use of weapons, burning, anxiety drugs) as well as alcohol or illegal throwing, and beating. By considering the drugs may act as dis-inhibitors, making the following areas, the health care provider use of physical force against partners more can assess danger based on the current level dangerous. For example, while under the of violence: influence, perpetrators may become less concerned about potential negative conse- a. frequency and severity of abusive acts quences, which have served as deterrents in current, concurrent, and past for some of the more lethal acts of abuse. intimate relationships; possible escala- As previously noted, alcohol and other tion of frequency and severity; drugs do not cause domestic violence. However, by reducing inhibitions they may b. availability of and use of weapons; increase a batterer’s potential to commit serious harm or murder. If present, c. threats to kill self or others; credible psychosis or brain damage may lessen the plans and means to kill; abuser’s cognitive controls over his behavior, and those perpetrators may engage in d. hostage taking behavior; more dangerous behaviors. Victims who are substance abusers, e. use of violence outside family; who are on certain medications, or who have psychosis or brain damage may be at f. stalking behavior; higher risk for serious injury or death. Any of these factors may compromise their ability to protect themselves from their partner’s violence. For example, these B. Perpetrator’s Access to factors make it more difficult to escape or the Victim carry out any part of a safety plan.

When the batterer’s level of current violence is high and the perpetrator has D. Perpetrator’s State of access to the victim, the danger potential is high. Reduced access, such as when the Mind victim is in hiding or the perpetrator is in jail, reduces the risk of injury or death. ■ obsession with victim Since battering is about having the opportunity to abuse, then not having access ■ increased risk taking by perpetrator reduces the opportunity.

98 RESPONSES TO PERPETRATORS

■ ignoring negative consequences to his most dangerous periods for the victim of abusiveness domestic violence is the point of separation. Some batterers will go to extreme ■ depression; desperation measures to maintain their control over victims, by escalating their violence and Batterers who seem obsessed and even committing homicide. Even when preoccupied with controlling their victims, there is not an obvious, physical separa- who have been taking increasing risks (e.g., tion, the batterer may perceive the victim as assaulting partner in public, being more increasing her autonomy (e.g., returning to public with their tactics of control by school, getting a work promotion, being including family and friends in the abusive more focused on parenting) and may tactics, stalking), who have been ignoring attempt to re-establish control by resorting negative consequences (e.g., arrests for to increased violence. Since many batterers violations of no contact orders), and who expect victims to take responsibility for are expressing more depression or despera- virtually everything in the batterer’s life, tion (e.g., repeated, public displays of situational stresses like lost jobs, conflicts crying, agitation, etc.) are escalating their with friends, and increasing financial tactics of control and becoming more pressures can become excuses for the dangerous. perpetrator to increase attacks against the victim.

E. Suicide Potential of Perpetrator, Victim, or G. Past Failures of the Children Community to Respond

Suicide potential in domestic violence One factor often overlooked in evalu- cases also needs to be evaluated using the ating danger is the previous encounters same techniques as any suicide assessment batterers have had with the community (threats, attempts, plans and means for about the abuse. For example, when suicide). In domestic violence cases, suicide batterers are rewarded (e.g., peer support, assessments should be done for all family jokes by responding police officers) or not members, including the victim, children, held responsible for their abuse (e.g., and perpetrator. charges are dismissed, guns are returned, court orders are not enforced, others engage in victim blaming), then batterers come to believe that they can do anything F. Situational Factors to their partners and they will suffer no consequences. Their abuse escalates. ■ separation violence While there has been concern about the potential for retaliation by some abusers ■ increased autonomy of victim against their victims when the community does act (e.g., by granting a protection ■ other major stresses order), equal attention needs to be given to the increased danger victims face when a As discussed in the overview chapter, community fails to act appropriately and there is growing evidence that one of the thereby sanctions the perpetrator’s abuse.

99 CHAPTER 3

IV. CRISIS INTERVENTION STRATEGIES

When the potential for injury or death tions, involuntary mental health commit- is high, there are multiple crisis interven- ments, and involuntary substance abuse tion strategies that can be used with the commitments, it is beyond the scope of this patient who is the abuser. The crisis inter- manual to make specific recommendations. vention strategy selected will depend on (1) Health care practitioners should become the nature of the threat, (2) who is in familiar both with local laws and the danger, and (3) the resources that are avail- policies and procedures of their practice able to deal with the crisis. This section settings. If there are no procedures in focuses on strategies to use with an abuser effect, they should be developed before the who represents a danger to victims or self. crisis emerges. While mandatory reporting is not a crisis intervention strategy, the issue is often raised in response to the most serious and A. Duty to Warn When the lethal situations of domestic violence. Since health care providers may be required Health Care to report injuries they suspect result from Professional Believes domestic violence, it is important that the Victim Is in Danger providers become familiar with their state’s reporting laws. Mandatory reporting laws Health care practitioners must be are widespread. For example, 40 states and aware of their legal and ethical responsibili- the District of Columbia mandate reporting ties to warn victims about potential by health care personnel under certain assaults against them. There is a duty to circumstances where the patient has an warn when there is a clear and present injury that appears to have been caused by danger to a specific victim or victims. In a deadly weapon. Statutory mandates domestic violence cases, a specific victim is regarding reporting vary greatly from state targeted and thus if the health care provider to state about who is required to report, believes that the patient is a serious threat, what kinds of injuries need to be reported, then the victim of that patient should be and penalties for failure to report and/or notified. In some circumstances other immunity from liability, and so forth. To appropriate authorities must be notified. find out more about individual practitioner Health care personnel should be aware of reporting responsibilities, contact the legal their facility’s policies and procedures for department of the facility and/or call the duty to warn. legal department of the state medical society. (Refer to Appendix N for a more lengthy discussion of the potential consequences of mandatory reporting and a B. Legal Recourses and summary of state statutes). In addition to duty to warn procedures Mandatory Reporting and legal interventions, practitioners can use a variety of other crisis intervention At some time, providers may be faced strategies, depending on whether the lethal- with the abuser who is likely to kill if not ity risk is from homicide or suicide and contained. Depending on the situation, a depending on who is in danger of harming mental health commitment or call to law whom. Some of the strategies require the enforcement may be appropriate. Given perpetrator’s cooperation and some do not the variance in law enforcement interven- (e.g., being jailed for crime, mental health

100 RESPONSES TO PERPETRATORS commitment, victim going to the battered D. Strategies to Diffuse the women’s shelter). Crisis

When the perpetrator refuses to even C. Recommending temporarily separate from the victim, the health care provider may recommend a Temporary Separation different set of strategies: those designed to defuse an immediate episode where the One cluster of crisis intervention strate- batterer is highly likely to strike out at the gies for domestic violence is designed to victim. Examples of diffusion strategies interrupt perpetrators’ access to victims by include: referrals to domestic violence having victims and abusers separate. intervention programs or substance abuse Health care providers can recommend that programs, recommendations to temporar- the perpetrator temporarily separate from ily discontinue use of alcohol or other the victim during a crisis period (e.g., the drugs until further interventions can be abuser moves in with a friend, sleeps in his established, advising perpetrators about car, or somehow stays separated from the the danger of weapons and recommending victim). The practitioner can engage the that weapons be removed from the crisis, patient in suggesting ways to temporarily and advising perpetrators about the poten- separate from the victim. Providers can tial for arrest and incarceration. All of also indicate to the perpetrator that they these crisis intervention strategies require support the victim’s decisions to temporar- the cooperation of the abuser to act to stop ily separate through protection orders or his violence. Some perpetrators will ignore through stays in a shelter. The patient whatever suggestions are made, while should be reminded that these temporary others will surprisingly comply simply steps are helpful in preventing injury and “because the doc told me to.” Since there is the perpetrator will need to take additional no way to predict which strategy to use steps to stop his violence permanently. By with which batterer, it is helpful for recommending crisis strategies the health providers to suggest several and to encour- care provider can emphasize to the perpe- age perpetrators to list out their own trator the serious nature of the current approaches to stopping their violence. crisis and his responsibility for stopping his abusiveness.

V. O THER HEALTH CARE INTERVENTIONS WITH PERPETRATORS

In addition to crisis intervention strate- Furthermore, the interventions used will gies, the health care practitioner can vary from individual patient to individual provide to the perpetrator important patient depending on what is learned about patient education and referrals to batterer the nature of the abuse, its impact on the intervention programs, where available. patient, other medical or mental health The practitioner’s interventions will vary issues of the patient, the patient’s motiva- according to the presenting issues, the tions, resources, and abilities to deal with practice setting, and the amount of contact his abusiveness, his willingness to take between the provider and patient. responsibility for his battering behavior, 101 CHAPTER 3 and the resources available to the practi- B. Patient Education: tioner. In spite of these variations there are basic steps that can be taken. Domestic Violence, Its Impact on Victims and Children, and Perpetrator’s A. Patient Education: Responsibility Abusive Conduct and Health Issues Because of their lies, distortion, and justifications for individual episodes of A health care provider treats the domestic violence, batterers are able to presenting medical (and/or mental health) keep themselves from looking at the true concerns of the patient. When the patient nature of their domestic violence. Patient is a perpetrator of domestic violence, part education about abusive conduct as well as of that treatment is evaluating how the the impact of that pattern on victims and abuse may be a causative factor in the the children should be explored with the presenting problem or how it may be a perpetrator. For some perpetrators, the factor in the patient’s recovery or how it reality that domestic violence is a crime and may lead to future injury or death. These that there are specific consequences must connections will have to be pointed out to be pointed out (“Did you know you could the perpetrator (e.g., “your violence is self- go to jail for hitting your wife?”). destructive,” “your behavior isn’t good for Most importantly, batterers need to be your heart,” “your violence leads to educated about their individual responsi- ____(medical condition)”). bility for battering. Because domestic In addition to seeing the connection violence is so embedded in social customs, between their behavior and their own this education may be the first time they health, batterers often need assistance in have heard from someone that they are acknowledging the destructive impact of responsible for what they are doing and for their abusiveness on victims, children and changing it. others. Those health care systems (e.g., This patient education can be direct family practitioners or HMO’s) that and brief. It can be presented calmly and respond to all members of the family are respectfully. well aware of how one person’s high risk behavior shows up as the injury or illness of ■ Your behavior is damaging to every- a family member in another part of the thing that is important to you and the system. Conveying to perpetrators general fastest way to stop that damage is for information about the health impact of you to change those behaviors (listing victimization can assist some to identify specific examples of physical abuse their behavior as an issue worth address- disclosed to the practitioner). ing. ■ Using force will never solve the problems in a relationship or family. In fact it makes them worse.

■ I see other patients with this problem and they said they were able to change only when they started taking responsibility for what they were doing.

Patient education can be repeated during future appointments, and if

102 RESPONSES TO PERPETRATORS combined with other community efforts ■ injuries and other health issues may result in some individual batterers ■ depression, withdrawal, rage, fear changing their abusive patterns. At a ■ impact on her relationship with minimum such patient education by a others practitioner ends the silence of the health care system and its perceived collusion with ■ employment and legal issues (See the batterer. Victim’s Chapter regarding impact on the victim.)

C. Listening to the Patient’s 3. IMPACT OF THE ABUSE ON Concerns CHILDREN: ■ injuries Listening to and working with abusers ■ behavior problems without colluding with them or participat- ing in their victim blaming is a very difficult ■ relationship problems task. Some batterers are highly manipula- ■ emotional difficulties tive and will attempt to engage the health care provider in blaming their victims. At this point it is crucial to keep the focus on MPACT OF THE ABUSE ON THE their abusive behavior and their responsi- 4. I bility to stop it. However, it is also impor- PERPETRATOR: tant for the practitioner to listen for what ■ health issues may be a motivation from the abuser’s perspective for him to change. Listening to ■ impact on his relationship with the perpetrator’s concerns about his victim and children conduct may reveal his awareness of the ■ legal issues legal consequences to his actions as well as ■ employment problems the negative impact on his partner, his ■ children, his job, his standing within his prior interventions or attempts to community, his health, etc. By identifying get assistance those negative consequences and connect- ing them to the abusive conduct he chooses to use, he starts the process of changing his 5. PERPETRATOR’S CURRENT destructive patterns. MOTIVATION TO VIEW HIS In listening to the perpetrator, the ABUSIVENESS AS A PROBLEM HE health care provider may hear information about all or some of the following: WANTS TO ADDRESS.

■ This information is useful in devel- 1. THE PATTERN OF ABUSIVE oping responses to individual CONDUCT: perpetrators and in engaging the perpetrator in taking responsibility ■ types of abuse for changing his behaviors. There ■ frequency and severity of the physi- are very real time constraints in cal force used health care contacts with perpetrators and consequently the information from one contact may be incomplete. Furthermore, many 2. IMPACT OF THE ABUSE ON THE perpetrators minimize, lie and deny VICTIM: and will not provide a complete 103 CHAPTER 3

picture of the abuse. Therefore, it tion or referrals to specialized programs, is is helpful to note any information to engage the patient in taking responsibil- about abuse in the chart. A more ity for changing his abusive conduct. accurate description of the domes- Abusers come from diverse backgrounds tic violence is more likely to emerge and have multiple issues (cultural, sexual, through the record of these multi- substance abuse, mental or physical abili- ple contacts. ties, HIV, etc.) which may relate to interventions for the domestic violence. Practitioners need to be sensitive about It is important to reflect back to him these without letting abusers use them as a the ways in which his behavior is having a way to avoid taking responsibility for their negative impact on him (list any of those he violence. The typical response of a batterer has already indicated in his discussion of is to make the victim responsible for fixing his concerns, such as the impact on the whatever is wrong in their life. Discussing children) as well as his power to change his options is one way to keep the focus of behavior and stop the abuse. These identi- responsibility for change on what the fied consequences may become motivators individual batterer can do. for change. If the provider joins the abuser in blaming the victim or some other exter- nal factor (e.g., drinking, stress) for his abusiveness, then the abuser will use the E. Making Appropriate health care practitioner’s comments or silence to shore up his belief that he has a Referrals right to use violence to control his family. It is important not to let the abuser use Unless the health care setting has on- the patient/doctor privilege as a way to site specialized programs for batterers,3 the further control the victim. The health care provider will most likely be referring provider has a unique and potentially batterers to available community programs. powerful role as one who helps the perpe- In making these referrals, the practitioner trator by holding him responsible for should exercise caution and care. changing this self destructive behavior. Traditional counseling (couples, individual, While this approach may not be successful or family) or traditional rehabilitation with all abusers, it can be very effective programs (substance abuse, mental health, with some and can become part of a etc.) do not appear to be effective. For this comprehensive, coordinated community reason, it is important for health care response to domestic violence. professionals not to encourage perpetrators to seek traditional couples counseling for their abusive behavior. Couples counseling may endanger victims of battering even D. Discussing Options further, as they face violence or threats of violence for revealing information about the abuse during therapy sessions. Part of the purpose of discussing Additionally, couples counseling may options such as safety planning with inappropriately indicate to both victims victims is to support their self-empower- and perpetrators that the perpetrator’s ment and their safety. That is not the violence is somehow a “relationship purpose of discussing options with batterers. Batterers are already powerful in their 3 For example, some Veterans Administration use of violence and abuse to control others. Medical Centers, some military medical facili- They are misusing that power. Instead, the ties, and certain substance abuse programs have purpose of discussing options with batter- specialized programs for perpetrators of domes- ers, such as time-outs or temporary separa- tic violence.

104 RESPONSES TO PERPETRATORS

problem” that the victim has some respon- the participation in the abuser groups, but sibility to fix. Unless the counselor is the coordinated effort of the community to skilled in keeping the responsibility for reinforce the message that batterers are changing the abusive behavior squarely responsible for their abuse and that abuse with the abuser, the traditional approaches has serious, negative, legal and social quickly become means for the abusers to consequences. continue to manipulate the victim. For some batterers no treatment The health care provider needs to program will be effective and incarceration know which community resources are may be the only way to protect their known to be effective in responding to victims. When making a referral to an batterers. The health care practitioner can outside agency, it is important to know that contact the state or local domestic violence at a minimum the perpetrator program coalitions for information about perpetra- follows the same guidelines as outlined at tor programs. A limited number of states the beginning of the chapter: victim safety, have established standards for abuser victim integrity and authority to direct her programs and some require a certification life, and abuser responsibility for the abuse process for those programs. If there are no and for stopping it. Furthermore, it is specialized domestic violence perpetrator important for the practitioner to tell the programs, the domestic violence coalitions patient directly that the purpose of the may know of other appropriate resources referral is to assist him in stopping his available for abusers. (See Appendix K for abusive behavior, and not to use Assessing Services for Perpetrators.) euphemisms like “anger management” or Specialized rehabilitation and educa- “family counseling” which masks the true tional programs have been evolving for nature of the problem and only plays into batterers. These programs use group treat- the abuser’s denial of his problem. ment and education for men who batter and focus on the responsibility of the abuser to change their abusive conduct. The outcome data on their effectiveness F. Establishing a Follow- remains limited. Those programs that seem to be the most effective are embedded Up Process in a coordinated community response that has both a legal and a rehabilitative Domestic violence is a pattern of component.4 For example, the batterers’ behavior that is supported by the victim- treatment program operated by the blaming tendencies rampant throughout Domestic Abuse Intervention Project of the community. Too often the response of Duluth, Minnesota involves a close peers or other community institutions working relationship with law enforcement reinforce the perpetrator’s abusive control. and the courts. The institutions work An individual’s abusive conduct does not together as part of a community-wide go away after one or two short interven- response to hold abusers accountable for tions. Consequently, it is important that their violence, to prosecute them for crimi- the health care practitioner follow up with nal conduct, and to provide them with the inquiry about abuse in future contacts with opportunity to seek educational groups for the patient. The health care practitioner their abusive behavior. What appears to be can raise the issue directly by statements changing their abusive behavior is not just such as: “The last time we talked, we were talking about how you could stop your 4Sheppard, M. (1988). Evaluation of the abusive behavior. I would like to check educational curriculum — Power and control: on how you are doing. Since I last saw Tactics of men who batter. Duluth, MN: you, have you used physical force Domestic Violence Intervention Project. against person or property in fights in 105 CHAPTER 3

the family? Any shoving, pushing, or tic violence is a problem that does not go throwing things? Any threats of away on its own. Encourage the patient to violence?” talk about it. This follow-up provides the practitioner with the opportunity to re- Also, if referrals were given, ask about assess the patient’s abuse pattern, to follow-through. If the patient claims that confront distortions when found, and to everything is fine, remind him that domes- reinforce progress if made.

CONCLUSION

There is still much evolving concerning community customs and institutions. The appropriate responses to patients who are interventions described in this chapter will perpetrators of domestic violence. While be most effective as they become part of an this chapter attempts to provide some overall coordinated community response, guidance for approaches, systematic study which places a priority on victim safety, is needed to determine which approaches victim integrity and authority, and perpe- are most effective with which perpetrators. trator responsibility. The interventions This chapter is written with an under- described in this chapter are only one way standing that no one system alone can stop to communicate that violence and coercive domestic violence. Perpetrators may control are criminal and never justified in change over time due to multiple, cumula- intimate relationships. There is no excuse tive experiences. Unfortunately, domestic for domestic violence and that message is violence remains embedded in many just the beginning of change.

106 CHAPTER 4

ESTABLISHING AN APPROPRIATE RESPONSE TO DOMESTIC VIOLENCE IN YOUR PRACTICE, INSTITUTION AND COMMUNITY

BY CAROLE WARSHAW, M.D. ESTABLISHING AN APPROPRIATE RESPONSE TO DOMESTIC VIOLENCE IN YOUR PRACTICE, INSTITUTION AND COMMUNITY

BY CAROLE WARSHAW, M.D.

INTRODUCTION

In order for clinicians to develop and community-based domestic violence sustain an appropriate response to domes- advocacy groups, child welfare and protec- tic violence, they must have the support of tive service agencies, and the civil and the institutions in which they practice. As criminal justice systems. This chapter will health care professionals attempt to incor- describe how to work within clinical practice porate routine inquiry about abuse into the settings, health care institutions, and commu- standard of care for all women patients, the nities to develop such a coordinated response. need for a coordinated institutional It will also describe strategies to assure that response to domestic violence becomes battered women receive appropriate care increasingly evident. This chapter addresses within individual practice settings. The follow- strategies for changing institutions and ing issues will be addressed: practice settings to support and encourage health care providers to meet the needs of ■ Creating a practice environment that victims of domestic violence. enhances rather than discourages Providers acting alone simply cannot identification of abuse. meet all of the needs of domestic violence victims and their children. The optimal ■ Educating health care staff about response to domestic violence requires the domestic violence intervention. coordinated efforts of all members of the community, including health care providers, ■ Developing an integrated response to 109