Feb. 07, 2020
Encountering a patient with an injury due to potential interpersonal violence can be a challenging experience for trauma professionals. Beyond addressing the physical injury, navigating a situation with a patient's safety in the balance as well as legal implications can be complex.
Though the term "interpersonal violence" is used in professional circles, often medical co-workers use the term "domestic abuse" when talking with each other, according to Amanda M. Graham, L.I.C.S.W., M.S.W., and Katlin E. Morse, L.G.S.W., M.S.W., both social workers at Mayo Clinic's campus in Rochester, Minnesota.
"Domestic abuse encompasses everything, because more often than not, it has emotional, psychological and sexual aspects that go along with the physical abuse of someone with whom you have an intimate or familial relationship," says Morse, who facilitates a men's domestic abuse treatment group for perpetrators.
Typically, providers learn about other aspects of abuse — the emotional and mental aspects — as they evaluate a patient with potential physical assault.
Incidence of domestic abuse
Domestic abuse is common, according to Morse and Graham. In the U.S., though statistics are elusive, the Centers for Disease Control and Prevention estimates 1 in 4 women and nearly 1 in 10 men are affected by sexual or physical violence, stalking by an intimate partner, or both.
Presentation of domestic abuse-related injuries has increased in hospitals. In Olmsted County, Minnesota, for instance, cases with an ICD-10 code indicating confirmed physical abuse occurred as follows: 55 cases in 2014, 91 in 2015 and 93 in 2016. Morse notes that in the same county, the women's shelter is often full.
Overall, however, seeking treatment for domestic abuse remains fairly rare, due to fear of reprisal, says Graham. "So often, it goes unreported. It's so hard for the victims to decide to report due to fear of not being believed, making things worse or nothing being done. It's challenging to show evidence, making it hard to prosecute."
Determinants of domestic abuse
Some key factors contributing to domestic abuse in the U.S., according to Morse, include the lack of training for children in interpersonal relationship skills and cultural normalization of controlling behaviors. She and Graham also believe the rise of cellphones and the internet have led to increased emotional, mental and psychological abuse due to easier access to victims in multiple ways.
While indicating that domestic abuse boils down to power and control, the Mayo Clinic social workers point to the following as particular domestic abuse risk factors:
- Adverse childhood events
- Chemical dependency
- Mental health issues
Signs of domestic abuse
Due to risk factors with leaving the relationship, survivors may mask abuse they are enduring, according to a National Domestic Violence Hotline survey report. Though domestic abuse does not discriminate — it can impact those of any socioeconomic status, race, ethnicity, culture or age — the abuse typically goes unreported among those with higher socioeconomic status because there is potentially more to lose, says Morse.
Key tipoffs for a domestic abuse situation include:
- Frequent emergency department visits
- Unexplained injuries or a story that seems inappropriate to the injury presented
- Injured patient acting timid
- Behavior change when a partner enters the room
- One partner in a relationship acting more overbearing
- Patient indicating that his or her partner doesn't allow the patient to have money or visits with family
"If one partner is more outspoken or demanding, that's not indicative of domestic abuse, but you can pick up on relationship dynamics," says Morse. "More often than not, though, who the abuser is, is completely disguised."
What trauma providers can do
If a patient's story about the mechanism of his or her injuries does not line up with what you are observing, it's important to listen to the patient and start from a place of nonjudgment and support. If available, Graham advises asking a social worker to join you in the patient interaction.
It potentially may be difficult for a survivor to speak up about the cause of the injuries with the abuser or family members present. However, providers can use naturally presented opportunities, such as a walk with the survivor to a CT scan, to inquire privately about the circumstances of an injury.
If abuse is acknowledged by the patient, it's important to inform the patient of his or her right to file a police report. Don't be surprised, however, if the patient doesn't want to take legal action or consider leaving the relationship.
"We have patients who come in with injuries and are not ready to leave their partners," says Graham, indicating this stance is supported by data from the National Domestic Violence Hotline survey report. "It could cause more nonreporting of domestic abuse-related injuries if we pressed the agenda to leave. Each assessment is different and depends on what the patient wants."
Morse and Graham also suggest trauma providers educate themselves about domestic abuse and available resources, such as:
If a survivor is not currently in therapy, help him or her find a therapist specializing in domestic abuse, if one is available in your area. Therapy can educate the survivor about appropriate interactions in a relationship and how to vocalize concerns if disrespected or harmed.
Courses are available in Minnesota communities on how to avoid repeating the cycle of abuse, as frequently this behavior is learned or modeled.
If a domestic abuse survivor wants to return to his or her partner, offer advice on how to stay safe and provide psychoeducation, if the survivor is interested.
Crisis phone numbers
Though survivors may be reluctant to take written phone numbers or other resources due to the risk of discovery by the abuser, you may suggest adding a domestic abuse hotline number in a location on his or her cellphone that the abuser won't find.
Women's shelters for survivors of domestic abuse are available throughout Minnesota. For male domestic abuse survivors, whether in a heterosexual or homosexual relationship, few men's shelters exist, though a men's shelter is available in the Twin Cities.
The rise of domestic abuse and the difficulties survivors face in acknowledging that their personal safety is endangered underline the importance of screening, say Morse and Graham.
"It's not hard for providers to miss domestic abuse," says Graham. "Thus, screening for safety concerns in every patient encounter is critical."
For more information
Preventing intimate partner violence: What is intimate partner violence? Centers for Disease Control and Prevention.
Logan TK, et al. Who will help me? Domestic violence survivors speak out about law enforcement responses. National Domestic Violence Hotline.