Practical Guidelines on Handling Abuse Issues in Clinical Settings
It is understandable that physicians, like society in general, are uncomfortable talking about domestic violence. As in many other areas of behavioral inquiry, however, it is necessary, and guidelines have been developed with techniques for raising the subject and eliciting truthful responses.
The first step in approaching this problem is to educate all medical personnel and staff in a clinical practice about the reality of domestic violence, including why patients are reluctant to talk about it and why physicians are reluctant to ask about it (see Guidelines for Physicians). The next steps have been clearly outlined by well known prosecutor, advocate, educator, and survivor of domestic violence, Sarah Buel, who offers 10 recommendations for physicians related to their role in bringing about solutions to this problem.61 We have added comments to make these recommendations more relevant to abused women with disabilities.
1. Conduct universal screening.
Considerable research has been done on the most effective means of identifying women who are victims of domestic violence. Studies have shown that women are more likely to disclose such stigmatizing experiences if screening is done by a nurse instead of asking patients to complete a brief written assessment.63 Computer-based health-risk assessment has also been shown to encourage more disclosure and documentation of abuse when patients receive computer-generated health advice and physicians receive patient risk summaries.64 Researchers at the Center for Research on Women with Disabilities65 developed a tool for identifying women with disabilities who are in abusive situations, called the Abuse Assessment Screen - Disability, or AAS-D. It is concise and relatively simple to administer in a clinical setting.
2. Educate yourself and all staff about the dynamics of domestic violence.
Ample information is easily available now through the literature cited, websites of the medical organizations mentioned above, and local battered women's programs. These local programs often have staff that will come to a clinical site and conduct in-service training. Basic information on screening techniques, recognizing the signs and symptoms of abuse, follow up interviewing, appropriate referrals, local resources, and measures to ensure the physical and emotional safety of your staff should be included in this training. It is essential to request and receive information specifically about women with disabilities as part of this type of training, given the many unique situations of dependence, physical limitations in self-defense, limited available helping resources, and the general lack of awareness or sensitivity to the vulnerability they face. Maintain contact with the Center for Research on Women with Disabilities through the violence page on our website for materials and updates on current research and intervention programs. The American College of Physicians publication, Violence Against Women,66 contains a wealth of information on all of these topics, including violence against women with disabilities.51
3. Develop a protocol for addressing domestic violence with patients who are victims and abusers.
As required by the Joint Commission on Accreditation of Healthcare Organizations and as recommended by major medical organizations, every clinical setting should have a protocol for addressing domestic violence. At a minimum, this protocol should include a regular schedule of in-service training on the identification and management of cases where domestic violence is suspected, detailed screening and assessment procedures, staff assigned to conduct appropriate interviewing, information on local resources for reporting and referral, specific information about the accessibility and responsiveness of these resources for women with disabilities, and a plan for follow-up to discuss the abusive situation.
4. Document the victim's injuries, history of abuse, and identity of the batterer.
In the case study that opened this chapter, justice was never served for lack of documentation. What documentation did exist from the victim and her nurses was perceived as lacking credibility. Physicians are accustomed to preparing documentation for legal proceedings, and the credibility of their testimony is generally high. Therein lays the power of physicians to make a critical difference in the survival and well-being of abused women. With medical expertise combined with awareness of the dynamics of domestic violence, health professionals would be well equipped to disentangle the complexities of abuse in the context of disability. Specific information on recognizing the signs and symptoms of abuse in the medical history and medical examination can be found in Guidelines for Physicians. In documenting evidence of suspected abuse, descriptions, photographs (with the woman's permission), and observations should be included. If abuse is suspected, statements to that effect should be written in the patient's record, whether or not discussion of this concern or any follow up take place.
One important detail in eliciting authentic abuse histories is to speak to the victim apart from the person who accompanies her. That person may very well be the perpetrator. Classic perpetrator behaviors in such settings include insistence on being with the patient at all times, speaking for the patient (a common behavior of many people toward women with disabilities, especially those with speech impairments), excessive expressions of concern, gestures of affection, and offers to help. For women with disabilities, these intimidating behaviors can come not only from intimate partners, but also from family members and personal care assistants. For disabled women with speech impairments, as often seen in cerebral palsy and other neurological impairments, it is especially important to have someone take the time to communicate with them directly and privately.
5. Speak up with abuse victims and offenders.
It takes a certain amount of courage to address suspected abuse with patients. Examination of one's own feelings and experiences is essential for approaching others on this topic with confidence. By entering into such discussions with patients, healthcare professionals bear witness to the violence, and thereby have moral and legal obligations to take action while at the same time protecting their own physical and emotional well-being.67
Buel (p. S52)61 offers some useful language for talking with patients about suspected abuse. For victims, an effective way of beginning a discussion is, "I'm afraid for your safety," "It will only get worse," or "You don't deserve to be abused." If the victim has a disability, statements such as, "Yes, people with cerebral palsy often fall, but their bruises are not usually where yours are," or "Have you ever talked with family or friends who could help with your personal care needs if you felt unsafe?" will let them know that you are attuned to some of the issues they face. For batterers, you can say, "You can't keep doing this," "Most men are not violent with their partners and children," or "I wouldn't be doing you any favor to make excuses for the abuse; this is illegal and will likely land you in jail, possibly with a criminal record."
6. Provide safety planning and referrals.
Assess the degree of danger the patient may be experiencing by asking if she is fearful at the moment, if the batterer is in a violent phase or under the influence of drugs or alcohol now, or if he has a weapon with him there at the clinic. For situations of extreme danger, contact the police and Adult Protective Services for the safety of the victim, your staff and yourself, and the other patients in the clinic.
The effectiveness of safety planning has been well documented in the literature.68 Research has begun on adapting traditional approaches to safety planning to the situation of women with disabilities.69 The basic components of safety planning are identifying family, friends, or church members the woman could stay with if her safety were threatened; developing a code system with a trusted person to signal for help; and keeping cash, keys, and other important documents at a safe location. We have added to these the disability elements of preparing plans for emergency accessible transportation; alternative means of communication; keeping extra medications, medical supplies, and, if possible, extra assistive devices at a safe location; and arranging for emergency back up personal care assistance. Planning is also appropriate on safety measures in medical settings, such as having trusted persons accompany the patient and always keeping mobility devices within reach. Referral information should be on hand for the local police, Adult Protective Services, local battered women's programs, low cost or free legal defense resources, and disability-related service providers such as the local center for independent living or home health care agencies.
7. Avoid victim blaming in all contacts with victim and others.
The remnants of traditional beliefs about domestic violence are, unfortunately, still very much with us. As recently as the 1970's, battering and rape were thought to result from agitation or seduction by women, and even children were blamed for provoking child abuse, giving rise to the oxymoronic concept of non-injurious abuse. Healthcare professionals must examine their own beliefs very carefully and work to expunge any notion that victims are to blame for the violent actions of perpetrators. For the situation of women with disabilities, it is helpful to ask yourself whether, in any other context, such treatment would be acceptable. When persons with disabilities who cannot tend to their personal needs are left without food or water, left to sit in feces, or confined to restricted areas of the home, that is not neglect; that is abuse.
8. Acknowledge that healing occurs at varying rates and support the patient's method of coping.
Solutions to abusive situations are much more difficult to identify for women with disabilities, particularly when financial dependence and the need for personal assistance serve to perpetuate the abuse. Alternatives, such as exploration of eligibility for government-funded benefit programs and natural supports in the woman's environment (family, friends, neighbors, church members), may take time to cultivate. Communication with local rehabilitation resources, disability rights organizations, or developmental disabilities support systems may open new avenues for changes to a non-violent living arrangement.
Many women with disabilities survive intimidation, coercion, and violence by using denial. Although this is effective in the short term, it can lead to missed opportunities for intervention when intervention could be most effective. Pointing out the facts of a situation, the extent of injuries, the possible long term effects of such injuries, and the impact on a woman's physical and emotional functioning, can help her to understand her present and her future and encourage her to seek assistance.
9. Understand the liability implications for failure to intervene appropriately, including the duty to warn and reporting requirements.
Many states have legislated mandatory reporting by healthcare professionals related to abuse of persons with disabilities and older persons who cannot speak for themselves. It is essential that physicians become familiar with these requirements just as they would for legislation related to the handling of controlled substances. Careful consideration must be given, however, to the woman's ability to speak and take action for herself, as well as the possibility of retaliation by the batterer. Women should be informed, involved, and consulted at every step of this process.
10. Understand the correlation between substance abuse and domestic violence.
Research has shown a very strong correlation between substance abuse and domestic violence, mainly on the part of the perpetrator, but also occasionally by the victim. Screening for substance abuse risk factors and behaviors should be conducted along with screening for domestic violence in the health evaluation of all patients. Abuse of prescription medicines, alcohol, or illegal substances is no more tolerable among persons with disabilities than it is for anyone else. Disabled women who are victims of violence by substance abusing partners may have other avenues of relief in addiction rehabilitation service programs.
Based on excerpts from Nosek, M.A., Hughes, R.B., Taylor, H.B., Howland, C.A. (2004) Violence against women with disabilities: The role of physicians in filling the treatment gap. In: S.L. Welner and F. Haseltine (Eds.) Welner's Guide to Care of Women with Disabilities.(pp. 333-345) Lippincott, Williams & Wilkins, Philadelphia.
51. Nosek MA, Howland CA. Women with disabilities. In Liebschutz, J.M., Frayne, S.M., & Saxe, G.N. Violence against women: A physicians guide to identification and management. Philadelphia: American College of Physicians, 2003, 201-210.
61. Buel SM. Treatment guidelines for healthcare providers' interventions with domestic violence victims: experience from the USA. Int J Gynaecol Obstet 2002 Sep;78 Suppl 1:S39-44.
62. Varjavand N, Cohen DG, & Novack DH. (2002) An assessment of residents' abilities to detect and manage domestic violence. J Gen Intern Med, 2002 Jun; 17(6):465-8.
63. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: self-report versus nurse interview. Public Health Nurs 1991 Dec;8(4):245-50.
64. Rhodes KV, Lauderdale DS, He T, et al. "Between me and the computer": increased detection of intimate partner violence using a computer questionnaire. Ann Emerg Med.; 2002, 40:476-484.
65. McFarlane J, Hughes RB, Nosek MA, Groff JY, Swedlund N, Mullen PD. Abuse Assessment Screen-Disability (AAS-D): Measuring frequency, type, and perpetrator of abuse toward women with physical disabilities. Journal of Women's Health and Gender-Based Medicine, 2001,10, 861-866.
66. Liebschutz JM, Frayne SM, Saxe GN. Violence against women: A physicians guide to identification and management. Philadelphia: American College of Physicians, 2003.
67. Saxe GN, Liebschutz JM, Edwardson E, Frankel, R. Bearing witness: the effect of caring for survivors of violence and health care providers. In Liebschutz, J.M., Frayne, S.M., & Saxe, G.N. Violence against women: A physicians guide to identification and management. Philadelphia: American College of Physicians, 2003,157-166.
68. McFarlane J, Malecha A, Gist J, Watson K, Batten E, Hall I, & Smith S. An intervention to increase safety behaviors of abused women: results of a randomized clinical trial. Nurs Res, 2002 Nov-Dec;51(6):347-54.
69. Taylor HB, Hughes RB., Mastel-Smith B, Howland CA, Nosek MA. Developing and determining the feasibility of a safety planning intervention for women with disabilities, in preparation, 2002.