The prevalence of domestic violence is much higher for people accessing health, maternity and psychiatric services than in the general population, partly because they seek medical attention after abuse (Feder, et al., 2009.; Howard, et al., 2009). In a global systematic review of 134 prevalence studies, the highest rates were in psychiatric and gynecology clinics and in accident and emergency departments (Alhabib, et al., 2010). Studies are not always explicit about the relationship between victim and offender but people with mental disorders are between 4 and 11 times more likely to have experienced recent violence than people in the general population (Trevillion, et al., 2013). A systematic review of studies in mental health settings, albeit most based on small numbers (Oram, et al., 2013), found a median lifetime prevalence of intimate partner violence of 32% among female in-patients and 33% among female in-patients.
The higher prevalence of domestic violence for women accessing psychiatric services extends across different diagnoses and may be bidirectional. The median prevalence of lifetime intimate partner violence (IPV) amongst women was reported as 61% of those with post-traumatic stress disorder (PTSD), 46% of those with depressive disorder and 28% of those with anxiety disorders (Trevillion, et al., 2012). The review found that women with PTSD were seven times more likely [odds ratio (OR)= 7.34], women with anxiety disorders four times more likely [OR=4.08] and women with depressive disorders three times more likely [OR=2.77] to have experienced IPV than women without mental disorders. The few studies to date have been based on small sample sizes but the prevalence of IPV among women with schizophrenia and non-affective psychosis ranged between 42% and 83% (Trevillion, et al., 2013). In UK community mental health services, one study detected 60% of female service users had experienced IPV, 15% reporting abuse in the previous year (Morgan, et al., 2010).
Understanding the nature of domestic violence
Understanding what is meant by domestic violence will not only influence what health-care professionals look for (that is, help or hinder their detection of patients at risk) but will affect the nature of their enquiries and responses to disclosures. For example, it is not confined to abuse by a partner, which to date has constrained much of the research focused on intimate partner violence (IPV). This constraint is not matched by reality; for instance, over 2010/2011 22% of all homicides in London were domestic related, with the murder of a parent by a son being most prevalent (Metropolitan Police, 2011). Moreover, the term IPV itself can mislead a mental health professional to focus on the relationship, in a way they would not for another trauma, such as a road traffic accident or mugging.
It is critical to understand that domestic violence is a multifaceted problem, not simply concerned with inflicting physical pain. Psychological abuse often precedes, accompanies and follows physical abuse and may also be experienced by women whose partners are never physically abusive (Rivas, Kelly & Feder, 2013). It is almost always underpinned by psychological control and often characterized by sexual abuse or coercion (Stark, 2007). As such, the Home Office (2013) revised their definitions in 2013 to acknowledge the centrality of coercive control and to highlight the risks to 16- to 18-year-olds, as follows:
[Domestic violence is characterized by] Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality.
Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.
Coercive behaviour is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.
Evan Stark (2007) has expanded Johnson’s (2006) categories of “situational” or “common couple violence,” when equal force might be used in response to situationally specific stressors, and “intimate terrorism,” more akin to a pattern of torture. Terms like “coercive control” draw out the inequality within a relationship whereby one adult misuses their power to frighten and control what another thinks, feels or does. Most victims are afraid, comply with and can describe their abuser’s controlling behaviors or “rules.” There is empirical support (Agnew-Davies, 2006; Stark, 2007; Rivas et al., 2013) that women can be effectively held hostage (a useful metaphor) or become isolated at home through powerful dynamics such as:
Violence – to establish dominance, prevent escape, repress resistance;
Sexual abuse – through invading bodily integrity, inspections, accusations, coercion;
Intimidation – active threats (including to kill or hurt others), stalking (so he appears omnipresent) or passive threats (e.g., sulking); withholding money, food, medication;
Emotional abuse – public and private insults, swearing, criticism, degradation;
Shaming – marking ownership, enforcing behaviors against her values or standards;
Social isolation, deprivation of movement to hinder escape and induce dependency;
Control or micromanagement of the basic necessities of daily living and money.
There are specific, additional dynamics of domestic violence in some cultures that can overlap with child abuse including traditional practices such as pressures to maintain the so-called honor of the family (EACH, 2009), forced marriage (FCO, 2007), female genital mutilation and trafficking for exploitation (Zimmerman, et al., 2006).
The impacts of domestic violence on health
Domestic violence is life-threatening. Across England and Wales, about two women are killed every week by a partner or ex-partner (Povey, 2004), nearly always preceded by a history of abuse and coercive control (Richards, et al., 2008; Stark, 2007). The State of Victoria in Australia has identified intimate partner violence as the leading contributor to death, disability and illness in women aged 15 to 44, accounting for a higher proportion of the disease burden than diabetes, high blood pressure, smoking and obesity (Vos, et al., 2006). Mortality statistics related to domestic violence include deaths by suicide and the deaths of children, including by miscarriage and forced abortion.
Physical assaults often result in injury, ranging from minor abrasions to more serious trauma, typically to the head, face and neck (Wu, et al., 2010). Facial injuries range from zygomatic complex fractures and perforated tympanic membranes to dental damage. Common musculoskeletal injuries include sprains, fractures, dislocations and blunt-force trauma to the forearms, a product of trying to block being struck (Howarth & Feder, 2013).
Violence often increases in frequency and severity over time. The cumulative effect of frequent but relatively minor assaults can be just as damaging to an individual’s physical and emotional health as a more severe but one-off violent act (Hegarty, 2006). Living in fear day to day in the context of repeated, prolonged abuse is associated with a number of chronic physical health conditions. Reviews show that women experiencing domestic violence are at increased risk of gastrointestinal, neurological, musculoskeletal and cardiovascular symptoms (Ramsay, 2009). Women who experienced violence from a partner are two to four times more likely to report disability preventing them from work, chronic neck or back pain, arthritis, hearing loss, angina, bladder and kidney infections, sexually transmitted infections, chronic pelvic pain or irritable bowel syndrome (Coker, et al., 2002). A review of nursing studies has shown that women who are physically or sexually assaulted by partners suffer from significantly more gynecological problems, sexually transmitted infections, sexual difficulties and gynecological pain (Campbell, 2002).
Research shows that psychological abuse can have severe consequences, even after controlling for the effects of physical abuse (Arias & Pape, 1999; Marshall, 1996). Many victims of IPV rate the impact of emotional abuse on their lives and health as more profound than that of the physical abuse (Coker, et al., 2000; Follingstad, et al., 1990; Murphy & Hoover, 1999; O’Leary, 1999). For example, women exposed to psychological abuse were not significantly different from women exposed to physical and psychological abuse with regards to the severity and incidence of symptoms of depression, anxiety and PTSD, whilst both groups reported a higher incidence and severity than the control sample (Pico-Alfonso, et al., 2006).
Systematic reviews suggest that there is a causal association between domestic violence and mental disorder. People with mental disorders are also at increased risk of violence victimization (Trevillion & Howard, 2013). Golding (1999) found large associations between domestic violence and PTSD, depression, suicidality and problematic substance use. (PTSD avoidance behaviors can be exhibited in problematic substance use, with suicidal ideation at the extreme end of that spectrum.) The more severe and prolonged the violence, the greater the risk of mental disorder. There is also a temporal effect in that the violence typically precedes rather than postdates the mental illness and if the violence stops, mental health can recover. Women who are revictimized or who experience more than one form of abuse are at increased risk of mental illness and comorbidity (Jones, et al., 2001; Golding, 1999).
Depression and PTSD are prevalent and often comorbid conditions in victims of domestic violence and sexual violence (Warburton and Abel, 2006; Mechanic, 2004; Zimmerman, et al., 2006; Campbell, 2002). Systematic reviews have identified a 2-to-3-fold increase in the odds of depression in women who experienced partner violence, including for postnatal depression and domestic abuse during pregnancy, as well as increased odds of having experienced domestic violence among women with high levels of depressive, anxiety, and PTSD symptoms in both antenatal and postnatal periods (Howard, et al., 2013; Devries, et al., 2013).
More research is required on the associations between domestic violence and other mental health conditions, but there are indications that eating disorders are associated with a high prevalence and increased odds of lifetime IPV (Bundock, et al., 2013).
Judith Herman (1992) purports that violence against women involving repeated trauma, is followed by a complex form of PTSD, the symptoms of which include:
Difficulties regulating affect (emotion), including anger and mood;
Altered consciousness including amnesia, dissociation;
Altered self-perception, including a sense of helplessness, shame, guilt;
Altered perception of the perpetrator, including preoccupation with the relationship, unrealistic attribution of total power to the perpetrator, acceptance of their belief system;
Altered relationships, for example, mistrust, failures of self-protection, search for a rescuer;
Altered belief system, including altered faith, hopelessness, despair.
Along similar lines, in recognition of the wider impacts of trauma, the diagnostic criteria of PTSD within the revised DSM-5 now includes a symptom cluster of “negative cognitions and mood,” both highly likely to be affected by exposure to domestic violence (Chapter 17).
Understanding the causes of domestic violence
There have been many competing theories to account for domestic violence, often based on examining the associations between specific variables and the characteristics of abusers (e.g. Barnish, 2004). Although a number of factors have been correlated with abuse, no single theory can explain it or the variance (Howarth & Feder, 2013; Krug, et al., 2002). For example, most perpetrators do not have a personality disorder and have not been diagnosed with a serious mental illness. Most individuals exposed to violence as children do not go on to commit violence as adults, not all abusers have violent upbringings and witnessing domestic violence in childhood does not distinguish between perpetrators or victims as adults. There are likely multiple causes for its occurrence, some of which is captured in an integrative multidimensional approach or social ecology model (Heise, 1998).
Figure 14.1 illustrates the need for multi-level interventions to tackle and prevent domestic violence including through domestic violence advocacy, social work and education. It is a salutary lesson to medical professionals of the danger of focusing on personal history or characteristics, particularly of a victim. Discussions about abuse should hold an abuser accountable whilst acknowledging contributory factors and asking what is needed.
Questioning victims about “reasons” or what they have done to invite or trigger the abuse is akin to holding a rape victim responsible for contributory negligence and can verge on victim-blaming. The medical professional has an important role in asserting that no violence is justified and that every individual is responsible for his or her actions. Focusing on the behavior of the perpetrator rather than the victim can reattribute the problem to the abuse and can help reveal that a “loss of control” by the abuser (for instance, when intoxicated) is in fact a pattern of selective targeting of the victim to which other people (such as the bar manager or boss) are not subjected.
“Why doesn’t she leave?”
That domestic violence, harassment and stalking often continue after separation can be masked by questions as to why the victim does not leave, as if separation necessarily improves safety. In fact, data have shown that women are at greatest risk of violence from their partners when or just after they attempt to leave. In other words, advising victims to leave could put them at greater risk of serious injury or homicide. Practitioners should also understand that victims who do not leave their home are often deploying various strategies to minimize the risk of further abuse (Rivas, et al., 2013). These include legal action, help-seeking behaviors, escape strategies, appeals to the abuser, compliance with his rules, resistance and efforts to protect the children (Agnew-Davies, 2013b).
The role of health and mental health professionals
Domestic violence is a common problem that underlies victims seeking primary health care, especially to cope with the medical effects but sometimes in the hope of emotional support (Rivas, et al., 2013). Yet most victims do not identify or disclose their abuse as the causative agent, especially in the absence of direct questions, whilst health professionals frequently fail to ask about or recognize domestic violence as the primary etiological factor in their patient’s poor health and mental health (Hegarty, et al., 2006). Many clinicians report a variety of barriers that impede their identification of victims and feel that they lack training regarding how to ask victims appropriate questions about domestic violence or how to refer them appropriately for help (Warburton & Abel, 2006). In a sample of UK primary care clinicians, 80% said that their knowledge about local domestic violence services was inadequate (Ramsay, et al., 2012). Mental health-care professionals also do not ask routinely about domestic violence (Howard, et al., 2009).
Good practice guidelines for mental health professionals have been burgeoning over the last decade within the UK (e.g., Howard, et al., 2013) and globally (WHO, 2013). Women who experience domestic violence can have very different needs, depending on their circumstances and the severity of the violence and its consequences. Furthermore, women may need different types of support over time. Nevertheless, the WHO recommends a minimum set of actions to guide health-care responses. Thus, women who disclose any form of domestic violence should be offered immediate support. This includes:
ensuring consultation is conducted in private;
ensuring confidentiality (while being clear about the limits of confidentiality);
being non-judgmental and supportive and validating what the woman is saying;
providing practical care and support in response to the woman’s concerns;
asking about her history of violence;
listening carefully, without pressuring her to talk;
helping access to information about resources, including legal and specialist services;
assisting the victim to increase safety for herself and her children, where needed;
Improving practice is underpinned by better partnership work between mental health services and domestic violence services. For instance, even 4-hour training programs in domestic violence can improve the identification and referral practices of clinicians in mental health teams (Trevillion, et al., 2013).
Setting the scene
In the first instance, asking for materials such as posters or leaflets from local or national domestic violence services that are then made available in departments can increase the rate of self-referral to specialist services (Feder, et al., 2011).
Recognizing victims of domestic violence
An earlier section in this chapter reviewed the impacts of domestic violence on health and mental health. These effects can be harnessed to guide recognizing or identifying signs of abuse, as outlined in Table 14.1. Selective enquiry when these signs are evident is recommended (WHO, 2013).
1. Acute physical injuries following assault
Bruising and injuries, e.g., bi-lateral bruising, burns, bite marks; genital trauma; injuries to face, head, neck, chest
Breaks and fractures, e.g., broken bones, orbital fractures, lost teeth
Miscarriage, fetal trauma, abdominal trauma
Injuries or bruises in various stages of healing
Injury inconsistent with explanation offered
2. Chronic health problems
Gynecological problems, e.g., pelvic pain, vaginal bleeding, STIs
HIV
Heart and circulatory conditions
Complaints of aches and pains, e.g., headaches, back pain
Gastrointestinal disorders, e.g., irritable bowel syndrome
Stress-related symptoms, e.g., dizziness, chronic headache
3. Psychological indicators
Post-traumatic stress (PTSD)
Depression including suicide attempts and self-harming behaviors
Problematic substance use (including prescribed drugs and alcohol)
Anxiety disorders
Sleep problems
Exacerbation of psychotic symptoms
4. Indicators in the behavior of the victim
Covering the body to hide marks (long sleeves, trousers or scarves)
Attending late or often missing appointments
Frequent visits with vague complaints or different symptoms
Seeming anxious, fearful or passive (particularly in presence of others)
Giving inconsistent explanations for injuries or is evasive or embarrassed
Not wanting letters, visits or contact at home
5. Possible indicators in the behavior of partner/another person
Cancellation of appointments on patient’s behalf
Always attends, talking on behalf of patient or appearing overly protective
Bullying or aggressive; critical, judgmental or insulting about patient
Evasive or conversely, adamant about the cause of injury
Overvehement denial of violence or minimizes its severity
Does not consult patient about their wishes, needs or feelings
Selective enquiry about domestic violence
Questions to help practitioners enquire about physical abuse, sexual abuse and psychological control have been suggested elsewhere (Agnew-Davies, 2013a). Questions about abuse should always be asked in private to ensure the safety of the victim. An e-learning facility for mental health professionals to help develop confidence in asking service users questions and responding appropriately to promote their sexual and reproductive health as well as their recovery from abuse can be found on www.scie.org.uk/assets/elearning/sexualhealth/Web/Object3/main.html.
Questions to help tease out the dynamics of the abuse might explore whether the patient is frightened of anyone or what they might do. The patient may have been scared of, or hurt by, more than one person and the abuse is likely to have happened more than once. Some women face abuse from wider family and community networks so questions should not focus just on intimate partners. An alternative to explore the pattern of domestic violence is to ask someone who discloses about the first incident, the worst and the most recent.
The Power and Control Wheel (see Figure 14.2) is a useful tool for exploring psychological abuse. Simply providing a copy to the patient and asking whether they recognize any of these behaviors can help open up further discussion.
Power and Control Wheel
The Power and Control Wheel is a conceptual tool to represent the tactics typically used by perpetrators of domestic violence. It was developed in 1982 in Duluth, Minnesota (Pence & Paymar, 1986), but has been translated into forty languages and is used across the world. The tactics do not in and of themselves constitute domestic violence. Abuse involves the patterned and intentional use of these tactics to control the victim’s autonomy and instil fear and compliance. The wheel can help victims to see patterns in behavior and their unconscious significance. Simply showing them the wheel and asking if anyone treats or has treated them in any of these ways can be very powerful and helpful. Thinking about the wheel can help a patient to understand the multiple aspects of abuse, to identify behaviors as domestic violence and to counteract feelings of being alone or to blame.
Responding to disclosures of domestic violence
Victims of domestic violence often hope for emotional support from their health-care practitioners, and appreciate it when it is offered (Malpass, et al., 2014). The immediate response can be in the form of a key message to raise awareness, validate the patient’s reaction and name the problem (Agnew-Davies, 2013b). Box 14.1 outlines some examples of key messages in response to a disclosure of domestic violence.
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