Intimate Partner Violence: Identification and Intervention in Primary Care

1. Intimate Partner Violence: Identification and Intervention in Primary Care Bruce Ambuel, PhD Family and Community Medicine Medical College of Wisconsin

2. Funding Partners • Healthier Wisconsin Partnership Program • CDC • Wisconsin Office of Justice Assistance—VAWA

3. Broad brush strokes

4. 5 Questions • What is intimate partner violence? • How common is IPV? • What are the health consequences? • Can physician’s identify IPV victims? • Can physician’s help IPV victims?

5. Question 1: What is IPV? • Violence is the threatened or actual use of physical force or power against another person, against oneself, or against a group or community which either results in, or has a high likelihood of resulting in injury, death or deprivation. CDC

6. Intimate Partner Violence Directed at a... • Spouse • Intimate partner • Ex-spouse • Ex-partner

7. Physical Battering Sexual Battering Pet Battering Property Destruction Psychological Terror Stalking Violence to others Typology of IPV

8. Psychological Terror Fear Isolation Ever-present possibility of violence

9. Ownership & rule making “I own you.” “I make all the rules.” “I choose when and how to enforce the rules.”Barbara Hart, Penn. Coalition Against Domestic Violence

10. Partner violence is functional Perpetratorsintend to cause… Physical pain Injury Intimidation Fear Violence used systematically over time Punish Dominate Control

11. IPV vs. stranger violence Perpetrator and victim often: • live in close proximity • share overlapping social networks • dependent or interdependent • strong emotional bonds

12. Questions #2: How common is partner violence?

13. Incidence in Primary Care • 12-25% of women report physical violence in past 30 days • 25% in past year • 15% report injury in past year • LK Hamberger, DG Saunders, & M Hovey (1992). Prevalence of Domestic Violence in Community Practice and Rate of Physician Inquiry, Family Medicine, 24(4) • MJ Johnson & BA Elliot (1997). Domestic violence among family practice patients in midsized and rural communities. J Fam Prac, 44(4):391-400 • NE Gin, L Rucker, S Frayne, R Cygan, A Hubbell (1991). Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics, J Gen Intern Med 6:317-322.

14. Prevalence in Primary Care • 30-50% of female patients report experiencing IPV in lifetime • 25% report injury in their lifetime • L. Kevin Hamberger, Daniel G. Saunders, & Margaret Hovey (1992). Prevalence of Domestic Violence in Community Practice and Rate of Physician Inquiry, Family Medicine, 24(4) • MJ Johnson & BA Elliot (1997). Domestic violence among family practice patients in midsized and rural communities. J Fam Prac, 44(4):391-400 • NE Gin, L Rucker, S Frayne, R Cygan, A Hubbell (1991). Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics, J Gen Intern Med 6:317-322.

15. Question #3: Does IPV Affect Health and Wellbeing?

16. Intimate Partner Violence • Preventablemorbidity&mortality: Women victims at increased risk • physicalinjury • disability • depression, suicide attempts, PTSD • physical complaints and disease • hospitalization for all causes • less preventive care • more episodic care • death

17. Question #4 • Can physicians and other health care professionals identify IPV victims?

18. Quiz #2 Write the sentence down that you use to ask a patient about IPV during a routine history. Write the exact words as you would say them to the patient!

19. Primary care clinics and EDs • Women IPV victims present to primary care clinics & EDs • Women patients want physicians to ask • Physicians can identify IPV victims • Patients benefit from IPV screening and referral • Many organizations recommend screening & intervention: AMA, ACEP, ACOG, AAFP, AAP

20. Predictive value of asking • KM Feldhaus, et al. (1997). Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 277(17):-1361 • Design: Random time block sampling of 322 women from urban and suburban EDs in Denver • Gold standard: 2 surveys validated in partner violence research

21. Partner Violence Screen 1. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is making you feel unsafe now?

22. Results for 3 questions • Sensitivity: 65-71% • Specificity: 80-84% • + Predictive value: 51-63% • - Predictive value: 88-89%

23. Other Screening Questions Does your current partner frighten you or hurt you? Does your current partner try to control your behavior, friendships or activities? Has your current partner ever pressured you to do something sexual that you did not want to do?

24. Characteristics of effective questions • Ask about specific behaviorsorpsychological states • Avoid general, emotionally charged terms: abuse, violence & assault • Ask about various types of violence:fear;hurt; injury;unwanted sexual contact;control • Ask about current problems from previous relationships

25. History of Current IPV • In my practice I’m concerned about prevention and safety. • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom? • Do you feel safe in your current relationship? • Is there a partner from a previous relationship who is making you feel unsafe now?

26. Question #5 • Can physicians and other health care professionals help IPV victims? New evidence of clinical benefit from asking and intervening

27. Safety Behaviors Counseling Lower Assaults Threats of abuse Danger risk of homicide Work harassment events Higher Safety behaviors Community Advocacy Lower Physical violence Difficulty obtaining community resources Higher Quality of life Social support Brief Interventions @ 24 mo.

28. Hide money Hide extra car keys Secret code w/ friends/family Remove weapons Ask neighbors to call police if violence begins Hide bag with extra clothing Have available: SS #s for self & children Rent & utility receipts Birth certificates ID or drivers license Bank account numbers Insurance policies & numbers Marriage license Important phone numbers Safety counseling topics

29. Tantalizing suggestions Interventions can • Reduce violence • Reduce risk of homicide • Reduce depression • Improve safety • Improve social support • Improve quality of life

30. “Is anyone you know frighteningyou or hurting you?” • “Yes” • What do you do and say?

31. Quiz #3 What do you say and do? You ask a patient “Is anyone you know frighteningyou or hurting you?” and they say “Yes.” How will you respond? Write 5 things to do when a patient says “Yes”.

32. S-O-S Doc Intervention • Support, belief, confidentiality • Safety: Help assess danger • Options: Safety planning & follow-up • Strengths to build upon • Document • Lucy Candib, MD, suggested the SOS format for intervention

33. Support, Belief, & Confidentiality • Make eye contact • Nobody deserves to be hit or hurt. • Talk privately-- Our discussion will remain confidential (describe limits). • You have a right to be safe and respected. • The abuse is not your fault. • I’m sorry you have been treated this way.

34. Safety: Assessing Danger & Lethality-- 1 • Patient self-assessment: Do you feel safe going home? • Patient assessment of children’s safety:Are your children safe?

35. Increasing frequency or severity Weapons used Drug and alcohol abuse Forced or threatened sexual acts Life transitions: pregnancy; separation; divorce History of past violence or suicide attempts Threats to kill Safety-- 2

36. Options: Local Resources • Local or regional woman's shelters • Legal advocacy • Police • 911

37. Emergency Plan

38. If a Patient Decides to Leave an Abusive Partner • Provide phone and privacy so the patient may contact the women’s shelter or another advocate • THIS IS NOT COMMON

39. Follow Up • Encourage and schedule follow-up appointments. • Assess barriers to follow-up • Will you have transportation for the next appointment? • Will your partner try to prevent you from returning?

40. Strengths • Identify and validate patient strengths • You are facing a very tough situation with a great deal of courage. • I can see that you care deeply about your children. • You have shown great strength in very tough circumstances.

41. DocumentationHistory • Describe what the patient said using direct quotes • Add other historical data • Avoid pejorative language • Use “Patient said ‘My husband hit me in the head with a pan.’” • DO NOT use “Patient claimed..” or “Patient alleged…”

42. Observations • Behavior • Injuries-- • location & quality • use drawings, body charts, or photographs • in photos use ruler for scale; victim’s face for identity

43. Assessment • Your assessment of potential partner violence: • “Injury inconsistent with reported mechanism of injury” • “Injury and history consistent with intentional injury” • Include name of perpetrator if reported by patient

44. Plan • Safety plan • Follow up plan

45. Trainingis not enough • Training MDs & RNs increases ↑ Knowledge ↑ Attitudes ↑ Clinical Skills • But, clinical practice does not change ~ Screening ~ Identification ~ Intervention ~ Prevention

46. The End • Questions & Discussion

47. Appendix— • Overview of McFarlane and Sullivan & Bybee studies

48. Increasing safety behaviors • Design: 2 group repeated measure • Particpants: 150 women presenting to DA’s DV unit for protection order • Systematic assignment on alternate weeks to treatment (75) or usual care (75) • Intervention: • 6 counseling telephone calls to discuss safety promoting behaviors • 48-72 hours, 1, 2, 3, 5, 8 weeks • Measures at baseline, 3, 6, 9, 12 and 18 months • Demographic data • Safety promoting behaviors checklist

49. Outcomes • 99% retention rate (1 subject committed suicide) • Safety promoting behaviors increased at 3, 6, 12 and 18 months • Effect size: Average of 2 new safety behaviors at 3 months, sustained at 18 months

50. Secondary Prevention of IPV • Design: Randomizes, 2-arm clinical trial • Participants: 360 abused women in urban primary care clinic who reported physical or sexual abuse in past 12 months. • Interventions: • Abuse assessment by nurse & wallet-sized safety plan and referral card; • Abuse assessment by nurse & 20 minute safety planning and counseling session. • JM McFarlane, JY Groff, JA O’Brien & K Watson. Secondary prevention of intimate partner violence: A randomized controlled trial. Nursing Research, 2006 55(1)52-61