Interpersonal Violence Resources for Healthcare Providers

In addition to physical trauma, victims of interpersonal violence may experience other medical and psychosocial problems as a result of on-going abuse including headaches, chest or abdominal pain, musculoskeletal complaints, sleep disorders, depression, and anxiety. As victims continue to be injured; they continue to require more and more medical interventions; their health deteriorates; and healthcare costs increase. To provide appropriate care to interpersonal violence victims, healthcare providers must be able to identify, assess, and intervene in culturally appropriate ways that directly address both the problem of interpersonal violence and its immediate health consequences.

The Joint Commission on the Accreditation of Healthcare Organization requires all providers to develop protocols that include a vehicle for screening, identification and assessment of patients who may be victims of interpersonal violence. Healthcare providers can play significant roles not only in improving the health of individual patients, but also in stopping interpersonal violence by participating in a coordinated community response. This is a public health issue and stopping it requires the efforts of all community institutions working together to:

• Increase the safety of interpersonal violence victims;
• Respect the autonomy of interpersonal violence victims, and;
• Hold interpersonal violence perpetrators, not victims, accountable for stopping the abuse.

Victims of abuse and neglect may come to the hospital through a variety of channels. The patient may be unable or reluctant to speak of abuse and it may not be obvious to the casual observer. Nevertheless, hospital staff members need to know if a patient has been abused, as well as the extent and circumstances of the abuse to give the patient appropriate care.

The hospital has objective criteria for identifying and assessing possible victims of abuse and neglect, and they are used throughout the organization. To review hospital policies see sections PM-06, PR-14, PV-21, and CP-35 of the BIDMC Policy Manual. 

Staff should be trained on the use of these criteria. The Center for Violence Prevention and Recovery is available to provide trainings on issues related to interpersonal violence.

The criteria focus on observable evidence and not on allegation alone. They address, at least the following situations:

• Physical assault
• Rape or other molestation
• Domestic abuse
• Abuse and neglect of elders and children

When used appropriately by qualified staff members, this criteria prevents any action or questions that could create false memories of abuse in the individual being assessed. Staff members are able to make appropriate referrals for victims of abuse and neglect.

Screen for interpersonal violence only when you have privacy with the patient, away from family or friends. Present the screening in a calm, routine way. Be matter-of-fact and non judgmental of the patient. The style of the interview approach often increases or decreases the patient's willingness to disclose.

If the patient denies interpersonal violence as an issue in his/her life, accept the response. Not all patients are domestic violence victims. Recent research indicates that most patients appreciate routine questions about their overall health.

You may suspect that there are interpersonal violence issues in the life of a patient who denies the abuse. That's OK. You have already established yourself as a resource by asking the questions and the patient may seek assistance from you.

If a patient admits interpersonal violence is an issue, stay calm and non-judgmental. Let the patient know that there are resources for him/her. Have materials available that he/she can read for more information. If you are practicing at BIDMC (East or West Campus) you may ask the patient if he/she would be willing to speak with a domestic violence advocate. If the patient agrees, call the Center for Violence Prevention & Recovery at 617-667-8141.

Example

Set the stage, normalize the question: "Since many people report experiencing some type of violence in their lives, we ask all our patients about their safety at home and in their communities."

Ask the questions:

• "Do you feel afraid in any of your relationships (partner or family members)?"
• "Have you ever been physically, sexually or verbally hurt by a person close to you?" 

There are a number of websites that provide valuable information for providers about the issue of interpersonal violence.

Code of Ethics

• American Medical Association (AMA) Code of Medical Ethics
• American Nurses Association (ANA) Ethics

Homicide

• Lewis D. Brown Peace Institute

Domestic Violence

• National Domestic Violence Hotline
• Futures Without Violence: A national non-profit organization dedicated to ending violence against women and children through education, prevention, and public policy reform.
• The Network/La Red

Sexual Assault

• Boston Area Rape Crisis Center
• Jane Doe Inc.
• California Coalition Against Sexual Assault

Trauma & Mental Health

• VARSA
• Trauma & Informed Care

1. Bancroft, Lundy. Why Does He Do That? Inside the minds of Angry and Controlling Men. Berkley Publishing Group, 2003 (paperback); G. P. Putnam's Sons, 2002 (hardcover).
2. Herman, Judith Lewis. Trauma and Recovery. Basic Books, 1992, 1997.
3. Island, David, and Patrick Letellier. Men Who Beat the Men Who Love Them: Battered Gay Men & Domestic Violence. Haworth Press, 1991.
4. Jones, Ann R., and Susan Schecter. When Love Goes Wrong: What to do When You Can't Do Anything Right. Harper Collins Publishers, 1992.
5. Katz, Judith. No Fairy Godmothers, No Magic Wands: The Healing Process After Rape. R&E Publishers, 1984.
6. Ledray, Linda. Recovering from Rape. Henry Holt & Company (Owl Books), 1994.
7. Levy, Barrie, ed. Dating Violence. Young Women in Danger. Seal Press, 1998.
8. Lobel, Kerry, ed. Naming the Violence: Speaking Out About Lesbian Battering. For the National Coalition Against Domestic Violence Lesbian Taskforce. Seal Press, 1986.
9. Neimeyer, Robert. Lessons of Loss, A Guide to Coping. Brunner Routledge, 2001.
10. Nicarthy, Ginny. Getting Free: You Can End Abuse and Take Back Your Life. Seal Press, 1997.
11. Noel, Brooke, and Pamela Blair. I wasn't Ready to Say Goodbye: Surviving, Coping and Healing After the Death of a Loved One. Champion Press, Ltd., 2000.
12. Scott, Kay. Sexual Assault: Will I Ever Feel Okay Again? Bethany House Publishers, 1993.
13. Warshaw, Robin. I Never Called It Rape. Harper Collins Publishers, 1998. Harper Perennial, 1994.
14. White, Evelyn C. Chain Chain Change: For Black Women in Abusive Relationships. Seal Press, 1995.

The Institute of Medicine describes interpersonal and domestic violence, including intimate partner violence and childhood abuse, as a pattern of coercive behaviors that may include progressive social isolation, deprivation, intimidation, psychological abuse, childhood physical abuse, childhood sexual abuse, sexual assault, and repeated battering and injury. These behaviors are perpetrated by someone who is or was involved in a familial or intimate relationship with the victim. The health consequences of violence are alarming.

Women who have experienced domestic violence are:

• 80% more likely to have a stroke,
• 70% more likely to have heart disease,
• 60% more likely to have asthma and,
• 70% more likely to drink heavily,

than women who have not experienced intimate partner violence.*

The Centers for Disease Control and Prevention estimates that the cost of intimate partner rape, physical assault and stalking totaled $5.8 billion each year for direct medical and mental healthcare services and lost productivity from paid work and household chores. Of this total, nearly $1.8 billion in the United States in 1995. Futures Without Violence, a national violence prevention organization notes that today, the costs associated with intimate partner violence would be considerably more than $8.3 billion.

Studies have shown that virtually all victims of violence have contact with the medical setting, whether in primary care, obstetrics and gynecology, medical specialties or emergency medicine. As it is located within healthcare, CVPR has the opportunity to intervene with victims and offer them access to safety options and ongoing support. The ultimate goal is to empower victims to know their rights and make active choices in their lives. The CVPR staff work within a strengths-based model of care, respecting autonomy while helping to ensure immediate safety and eventual recovery from violence.