Domestic violence: How to detect abuse in psychiatric patients
Identifying domestic abuse and its concurrence with psychiatric disorders is critical to treatment—and to possibly saving the patient’s life.
Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.15
Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:
- “Do you live alone?”
- “Do you have a significant other?”
- “How is your relationship going?”
- “Is your partner supportive?”
- “What happens when you and your partner disagree?”
Table 2
Woman Abuse Screening Tool-Short version
| 1. In general, how would you describe your relationship? | ||
| □ a lot of tension | □ some tension | □ no tension |
| 2. Do you and your partner work out arguments with: | ||
| □ great difficulty | □ some difficulty | □ no difficulty |
| Answers are scored on a 1-to-3 scale, with 1 meaning “a lot of tension” or “great difficulty.” A score of 1 on either question indicates possible domestic abuse/violence. | ||
| Source: Reference 14 | ||
Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.
Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.16 In these states, clinicians should disclose their reporting obligation at the start of the patient interview.
Assess danger to any patient who reports being a victim of domestic abuse/violence. Consider danger imminent if the patient acknowledges any one of the following:
- Homicide or suicide threats from partner
- Weapons in the home
- Excessive substance use by partner or victim
- Escalating abuse or threats
- Physical/verbal abuse of children
- Harm to pets
- Fear of the partner
Source: Reference 17
Advise a patient who reports domestic abuse/violence to pack important belongings in case she needs to immediately leave an abusive partner.
The emergency bag should contain:
- Identification for self and children (birth certificates, driver’s license)
- Important documents (school and health records, insurance cards, car title, marriage license, mortgage or rental papers, protective orders, custody papers, divorce papers)
- Medications (for victim and children)
- Keys (auto, home, safe deposit box)
- Phone numbers
- Clothing (for victim and children)
- Comfort items, such as toys and blankets for children.
Source: Reference 17
WHEN A PATIENT CONFIRMS ABUSE
Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”
Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.
Assess the danger to the patient (Box 2).17
Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.
Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.
DEVELOPING A SAFETY PLAN
Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.
Start by asking the patient:
- “If you leave home, where will you go?
- Is there an alternative if you cannot stay where you planned?
- Do you have an emergency bag?” (Box 3) 17
Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.
Instruct the patient to:
- Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
- Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
- Learn the local domestic violence hotline number.17
