REVIEW OF PSYCHOLOGICAL ISSUES IN VICTIMS OF DOMESTIC VIOLENCE SEEN IN EMERGENCY SETTINGS

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The Pentagon's policy on homosexuality vividly captures the attitude of many emergency department (ED) professionals toward the underlying situational, psychological, and behavioral problems of victims of domestic violence.41, 64, 74, 126 Screening to identify victims of violence has become a part of some, though by no means all1, 28, 34, 45, 92, 101 emergency services, partly in response to federal initiatives, state mandates, and the Joint Commission on Accreditation of Health Care Organizations (JCAHCO) standards.40, 72, 91, 98, 100 Nevertheless, except for careful documentation of history and injuries, ED clinicians often think they have little to offer someone with an immediate or recent history of assault by an intimate associate. Without readily available, effective interventions, it becomes difficult even to maintain screening protocols and standards of documentation over time.52, 64, 87, 103, 136 Some advocates and social scientists consider the medical response to battered women so inadequate that it appears among the factors that perpetuate rather than mitigate abuse.49, 120, 137

Certainly, room exists for improvement,135 especially in the emergency treatment of battered women. The ED is paradoxically the best and the worst setting for intervention with victims of domestic violence. Its deficiencies are obvious. Treatment is highly focused and moves at a fast pace. The technical resources of the ED do not match the social and psychological needs of victims seeking help. The authoritarian treatment relationship often required in an emergency discourages patient–victims from disclosing their status,51, 120, 138 about which they may be ashamed and confused.

Nevertheless, the ER is arguably the best place for intervention, at least medically informed intervention, in the lives of victims of violence. Battered women often list medical services as their main or preferred source of help.65, 93, 107 Although much domestic abuse occurs within a matrix of personal and social factors that resist change,33, 132 patients in the ED are by definition in a state of crisis. Illness or injury has disrupted their usual patterns of coping and relating, and they can be open to steps they have rejected in the past. The largest factor compelling ED intervention is more mundane: given the way batterers isolate their victims, the ED may be the only setting in which an abused spouse, partner, or child stands a chance of receiving help.20 As the apochryphal gambler explained when asked why he gambled at a casino where he knew the roulette wheel was rigged: “The wheel may be crooked, but it's the only wheel in town.”

Appropriate ED responses to domestic violence require clinicians to have a sophisticated understanding of abusive relationships and the psychological state of victims. This article provides a brief orientation to violent relationships and their medical/psychological consequences. The acronym RADAR (Routinely screen female patients, Ask direct questions, Document your findings, Assess patient safety, Review options and referrals) reminds clinicians of the overall shape of appropriate intervention.66 This article expands mainly on the last two steps of this protocol.

Prochaska's99 model of intentional, clinician-facilitated change in health-related behaviors provides a theoretic framework for responding to victims of domestic violence in the ED. This model emphasizes the need to tailor advice to the patient's degree of readiness to use it. Applied to victims of violence, intervention to promote change must take into account where the woman stands in the process of living with, confronting, escaping, or recovering from a violent relationship. The goal is not to persuade a woman to leave a violent partner, which may not be her best option, but to empower her to improve her safety and well-being.21, 24, 51, 107

Concretely, medical personnel should assess the victim's understanding of the role of violence in her life and especially in her medical condition, with particular emphasis on her current risk for further injury.21, 46 Clinicians should express concern and highlight the medical consequences of problem, if the patient is not already aware of them. Rather than prescribe a course of action, the clinician should then explore the woman's asessment of her choices and resources, offer information to help her revise her assessment if necessary, and determine her current need for or interest in specific medical, social, legal, or advocacy services.51, 98 Consistent with the principles of patient-centered interviewing in primary care90, 116 and of “woman-based advocacy” provided by specialized domestic violence services,33 ED staff must replace neglect or “one-size-fits-all” intervention with a flexible, respectful, and helpful stance toward any victim at any stage of handling the problem.*

Section snippets

GENDER AND VICTIMIZATION

In community surveys, men experience domestic assault at roughly half the rate that that women do.56, 102 Rates of male-directed violence in clinical populations and during courtship are even higher.22, 79 Although adult male victims are more likely to be attacked with knives, guns, or thrown objects56, 105 and suffer serious injury123 or death,16, 63, 73 they differ from female victims in important respects. At least in committed relationships, men are nearly always assaulted by women whom

RECOGNIZING VICTIMS OF DOMESTIC VIOLENCE

Medical recognition of the problem of domestic violence dates to the 1970s.119 Early researchers tried with limited success to develop a profile of victims that would make them easily recognizable.13 ED staff are most concerned with risk factors that are obvious in that setting. Demographic risk factors include age younger than 39 years34; being separated, divorced, or single,8, 9, 82 especially if cohabitating122; partner substance abuse; partner unemployed54; being a repeat visitor for any

UNDERSTANDING VICTIMS OF DOMESTIC VIOLENCE

Awareness of the mushrooming literature about victims of violence3, 55, 67, 119 allows a clinician to place a woman's answers to questions about violence in appropriate context. General understanding of intimate violence and its consequences derives mainly from in-depth studies of women using victim services. Victims identified by universal screening imperfectly mirror the service-seeking population.33 Screening can identify women who have experienced minimal violence, violence without feeling

VICTIMS' MENTAL HEALTH

Even educated and well-disposed emergency medicine clinicians can react negatively to victims, who often do not display the disarming postures of desirable patients. Depression18 and anxiety, ranging from scattered symptoms to diagnosable disorder,58 are the most common sequelae of abuse. Time pressures may limit caregivers' tolerance for the negativism, hopelessness, and helplessness of depressed or anxious patients. Abused women also can seem evasive, manipulative, or withdrawn.59 Even more

IMPLICATIONS FOR EMERGENCY INTERVENTION

Women who “screen positive” for domestic abuse, then, can have medical problems that are life threatening or trivial. They may be calm or agitated, overtly distressed or unusually withdrawn, alert or confused. They can be articulate or unable to communicate; rich or poor; white, black, Hispanic, or Asian; cooperative, or hostile and defensive. The victimization may have occurred prior to admission or months before. The history of abuse may be disclosed at any point between triage and discharge,

CONCLUSION

By conservative estimate, one in six women seeking emergency care for any reason describe abuse by someone they know within the past year. A substantial number of these women are battered wives or cohabitants. Medical caregivers in every setting have a moral obligation to address such victimization when they uncover it, to prevent further injury to the patient. Women remain in abusive relationships out of continuing attachment to their partners, economic dependency and other social forces, and

ACKNOWLEDGMENTS

Dr. Frank gratefully acknowledges the extensive bibliographic assistance provided by Irene Fuerst and Amy Schiffman (MSII).

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    Address reprint requests to Julia B. Frank, MD, Department of Psychiatry AN8411, 2150 Pennsylvania Avenue NW, Washington, DC 20037

    *

    This article uses female pronouns to characterize victims of domestic violence, although male subjects who have been assaulted also seek emergency treatment.

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