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Domestic Violence
Dr. Dawn-Elise Snipes, PhD, LMHC
~ Review the extent of the problem
~ Identify risk factors for violence
~ Review practice guidelines for working with survivors of DV
~ Identify primary, secondary and tertiary interventions
~ Explore components of an effective routine DV screening program

~ 2-4 million women battered each year
~ 20-30% lifetime risk for a woman to be battered
~ 1,500 women murdered/year by partners
~ 20-30% of women seen in medical setting may be abuse victims
~ 5-6% prevalence of elder mistreatment (1.8 million)
~ 1,100 childhood deaths from abuse each year
~ 140,000 childhood injuries from abuse each year
~ 1.7 million reports of child abuse each year
~ 250,000-450,000 cases of child sexual abuse/year
~ 16 percent of adult women report a history of sexual abuse by a family member
Economic Costs
Acute medical care for injuries or neglect, and their complications
~ medical complications from injuries with enduring effects
~ mental health and substance abuse care for victims, perpetrators and families
~ inappropriate medical care for unrecognized mental health problems (“distressed high utilizers”)
Criminal justice system
~ intervening, arrests, prosecution, incarceration, etc.
Legal system
~ separation, divorce, custody disputes, protection orders, etc.
Social welfare organizations
~ emergency shelters, housing, foster care, etc.
Impediments to work
~ absenteeism or poor productivity
Practice Guidelines
~ Implement routine, universal screening
~ in all health care settings
~ for all females 12 years of age and older
~ Skills to foster an environment that facilitates disclosure:
~ how to ask the question
~ how to respond
~ what to document
~ your legal obligations
~ Screening strategies and initial responses
~ respond to the needs of all women
~ take into account differences based on diversity
~ Use reflective practice to examine how your own beliefs, values, and experiences influence the practice of screening
Educational Guidelines
~ Mandatory educational programs in the workplace designed to increase:
~ knowledge and skills
~ foster awareness and sensitivity about abuse
~ Curricula incorporate content on abuse in a systematic manner
Organizational Recommendations
Develop policies and procedures
~ supporting routine universal screening & initial response
Work with the community at a systems level to improve collaboration and integration of services between sectors
Practice implementation requires:
~ adequate planning, resources, administrative support
~ appropriate facilitation
~ an assessment of organizational readiness and barriers
~ involvement of all members
~ dedication of a qualified single point of contact
~ ongoing opportunities for discussion and education
~ opportunities for reflection
~ Woman abuse is:
~ the intentional and systematic use of tactics to establish and maintain power and control over the thoughts, beliefs and conduct of a woman through the inducement of fear and/or dependency
~ The tactics include:
~ emotional, financial, physical and sexual abuse, as well as, intimidation, isolation, threats, using the children and using social status and privilege
Primary Prevention
~ Prevents disorders before they occur
~ May include such activities as:
~ educating patients about the domestic violence
~ teaching parents about appropriate discipline
~ educating children about respect and appropriate assertiveness
~ recognizing and referring patients at-risk for perpetrating abuse
~ assessing potentially over-stressed caregivers
~ advising middle-aged parents about the need to plan for future care needs of dependent, impaired adult children
~ making routine inquiries about:
~ any violence in the home
~ presence of stressors
~ availability of firearms
Other Prevention Types
~ Secondary prevention
~ involves such efforts as making patients aware of physician interest in hearing about abuse
~ screening for all forms of victimization, psychiatric disorders
~ making available information about community resources and safety planning
~ Tertiary prevention
~ providing care for injuries received by victims
~ identifying/referring for associated mental disorders
~ monitoring of an ongoing care plan for abuse; notifying child welfare, elder, or other reporting entities
Other Prevention Types cont…
~ Advocacy involves
~ Support and encouragement for individual patients
~ Efforts to achieve broader changes that will reduce the morbidity and mortality from family violence
~ Offering support for victim advocacy groups
~ Supporting efforts to reduce social factors which promote violence.

Characteristic symptoms seen in all traumatized people:
~ Hyper-vigilance (e.g., Easy startling, guardedness)
~ Re-experiencing aspects of the trauma (e.g., Unwanted images of the trauma, nightmares)
~ Emotional numbing

 Other characteristics
~ Self-neglect, malnutrition, dehydration, failure-to-thrive
~ Depression, anxiety, panic attacks, sleep disorders
~ Alcohol, drug abuse
~ Aggression towards self and others
~ Dissociative states, repeated self-injury
~ Somatizing disorders, eating disorders, chronic pain
~ Suicide attempts
~ Compulsive sexual behaviors, sexual dysfunction
~ Lying, stealing, truancy, running away (in children)
~ Poor adherence to medical recommendations

Clues cont…
~ The symptoms of traumatized individuals often represent attempts to master their trauma.
~ Children work toward resolving their trauma through:
~ Repetition of the struggle with authority figures
~ The use of play and behavioral reenactment
~ Adults, work toward resolution
~ In intimate relationships
~ In dealings with their own children
~ In therapy

Clues to Elder Abuse
~ Expressions of frustration (abuse or neglect) by family members who:
~ are overwhelmed with caretaking responsibilities
~ have unrealistic expectations of the elder
~ resent dependence on the elder
~ are angered by problematic behaviors of an impaired elder
~ Neglect of a frail or impaired elder by family members who are hostile, under-involved, or exploitive
~ Gross expressions of violence
~ Over-stressed caregivers with insufficient knowledge of or access to resources
Clues to Elder Abuse
~ Mental health indications:
~ Mood and anxiety disorders
~ Substance abuse
~ Somatoform disorders
Risk Factors for Child Abuse
~ Parental depression or other mental illness
~ Parental substance abuse
~ Parental chronic physical illness
~ Physical abuse of a parent by the parent’s partner
~ Poor adherence to medical recommendations for children or erratic office visits
~ Marked aggression among siblings
~ Extreme over-protectiveness by one parent
~ Parental over-investment in proving for a child who is physically ill
Problems in Adult Survivors
~ Chronic head, face, back or pelvic pain
~ Gastrointestinal distress
~ Musculoskeletal complaints
~ Asthma/respiratory ailments
~ Obesity, eating disorders
~ Insomnia
~ Pseudocyesis
~ Sexual dysfunction
~ Pseudo-neurologic symptoms (dizziness, paresthesias, etc.)

~ Universal screening refers to the characteristics of the group to be screened and occurs when nurses ask every woman over a specified age about her experience of abuse.
~ Routine screening refers to the frequency with which screening is carried out; performed on a regular basis regardless of whether or not signs of abuse are present.
~ Indicator-based screening refers to screening whereby nurses observe one or more indicators that suggest a woman may have been abused and subsequently question her about the indicator(s).
Initial Response
~ Initial Response: a series of responses by clinicians to a disclosure of abuse
~ Acknowledging the abuse
~ Validating the woman’s experience
~ Assessing immediate safety
~ Exploring options
~ Referring to violence against women services at the woman’s request
~ Documenting the interaction
Routine Universal Screening
~ Benefits:
~ Increasing opportunities for women to disclose abuse
~ Increasing opportunities for clinicians to identify abuse
~ Linking health consequences to abuse
~ Providing early intervention
~ Avoiding stigmatization by asking all women about abuse
~ Reducing the sense of isolation abused women experience
~ Affording opportunities to assist children of abused women
~ Giving a strong message that abuse is wrong
~ Informing women about violence against women services
~ Fostering healthy communities
Other Considerations
~ Screening questions are incorporated into routine health history/intake process
~ Clinicians consider the immediate safety of the women
~ Screening occurs when the woman’s condition is stable
~ Questions are asked face-to-face in private, never in the presence of their partner or other family
~ In cases where language is a barrier, only trained cultural interpreters are used
Asking the Question
~ Explain that all women are being asked about abuse because violence is so prevalent in society
~ Tailor your approach to the woman
~ Inform women that they can expect to be screened each time a health history is taken
~ Send a clear message that violence is unacceptable
When She Says Yes
~ Believe the woman
~ Name the abuse (identify what she is experiencing is abuse)
~ Assess immediate health needs
~ Assess immediate safety
~ Explore her immediate concerns/needs
~ Determine a plan of action
~ With the woman’s consent, refer to appropriate resources
~ Have a contact list of violence against women services available
When She Says No
~ If you suspect yes:
~ Discuss what you have observed and explain why you continue to be concerned about her health and safety
~ Offer educational information about the health effects and prevalence of abuse
~ Highlight referral services
~ Document her responses
~ Share general information/provide education about woman abuse
Multicultural Sensitivity
~ Culturally diverse women may be reluctant to answer questions about and/or disclose abuse due to:
~ Isolation from one’s community of support
~ General mistrust due to racism, sexism, classism
~ Religious factors
~ Language/communication barriers
~ Lack of culturally sensitive services (Geffner et al., 2001; Maher, Zillmer, Hadley, & Leudtke, 2002
~ The record needs to include:
~ A safety check
~ Direct quotations of what the woman describes
~ Direct observations made by the nurse
~ Referrals discussed and made and/or information given
~ Referral services include more detailed documentation
~ Relevant health history
~ History of abuse including the first, worst and most recent incident
~ Where and when the abuse took place
~ Name and relationship of abuser
~ Detailed description of injuries and photos (if taken)
~ All health care provided
~ Information and/or referrals to resources provided to the woman
Organizational Development
~ An assessment of organizational readiness and barriers to education
~ Involvement of all members who will contribute to the implementation process
~ Dedication of a qualified individual to provide the support needed for education and implementation
~ Ongoing opportunities for discussion and education to reinforce the importance of best practices
~ Opportunities for reflection on personal and organizational experience in implementing guidelines
~ Violence in the home not only impacts the direct victim, but all members of the family
~ Violence comes in many forms including physical, sexual, emotional and financial
~ Culturally responsive, routine screening of all women, children and elders is recommended
~ Agencies must have in place a protocol for documenting screenings and handling client responses.
Other Resources
~ Department of Health (DH) (2000). Domestic violence: A resource manual for healthcare professionals. Available:
~ Family Violence Prevention Fund (FVPF) (2004). National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. Available: