An Overview

30 MINUTE READ

from Luke’s Journal 2019 | Hot Topics #2 | Vol. 24 No. 1

Domestic violence is as old as the Fall,¹ as current as the latest news, and can be regarded as an intimate and familial outworking of the ancient desire for power and control over others.

Christian doctors and health professionals are well placed to  make a difference for our patients  by identifying and responding to domestic violence in our practices.  We can also support the work of others who provide resources to churches and other organisations which seek to respond to domestic violence with hope and justice for broken families and hurting individuals.

Domestic violence is a pattern of behaviour based on abuse of power and abuse of trust. Effective confrontation of domestic violence involves detecting and responding to the violence occurring in individual situations, as well as helping to change behaviour in our community through teaching and modelling healthy relationships. True Christian relationships are based on the pattern of our Lord who humbled himself and came to serve and who challenged those who “lord it over others’ (Matt 20.25-28, Philippians 2:6ff).

How widespread is the problem of domestic violence?

The stories shared by people who have lived with domestic violence (DV) help provide an understanding of DV’s persistence, secrecy and power to create trauma. (Domestic Violence resource centre Victoria: https://www.dvrcv.org.au/stories.) Australian Bureau of Statistics figures of 2012² indicate that 1 in 6 Australian women and 1 in 19 Australian men had experienced physical or sexual violence from a current or former partner. The term ‘intimate partner violence’ includes a partner whether or not they live in the home, and of either sex, and is inclusive of ex-partners. Violence within same-sex intimate relationships (whether male or female) appears to be equally as common as violence in heterosexual relationships, but the statistics are incomplete.³ Female-to-male intimate partner violence also occurs.

Of women who have ever been abused 1 in 2 were abused when pregnant and 1 in 5 for the first time when pregnant. Only 20% of persons experiencing domestic violence in Australia have ever reported to Police.⁴

Domestic violence includes abuse which is neither physical nor sexual. This includes psychological denigration, emotional intimidation and financial abuse. Controlling behaviours such as isolating a spouse from friends and family can make the person experiencing domestic violence easier to control, while simultaneously making it harder for her⁵ to seek help. Controlling behaviours may be falsely attributed to a needy and jealous ‘love’ such as stalking, or be presented as ‘supportive’ behaviours such as picking the person experiencing domestic violence up after work when the intention is actually to avoid her having time on her own. Persons experiencing domestic violence describe their chronic fear and how abusers can systematically reduce their confidence and strength so that the person experiencing domestic violence may begin to think that she is incapable or crazy or that no one will believe her if she reports her situation.

The Duluth Power and Control wheel (Below) can be a helpful tool in unpacking and understanding some of the interlinking aspects of abusive relationships.

Patterns of domestic violence vary. In some cases DV is angry and explosive. This violence may be intermittent and followed by remorse and excuses. In other cases violence can occur nightly. Alcohol and drug abuse or mental health issues may be a factor in the build up to explosive episodes of DV, but should not be regarded as the sole cause.

Diagram 2 (page 68) demonstrates a recognised cycle of violence. The periods of calm and enmeshment, presenting as closeness and repentance, can deceive persons experiencing domestic violence and health professionals, (and persons perpetrating domestic violence) into thinking that everything is now resolved and harmonious.

There are cases of domestic violence where the abuser displays no anger but instead remains calm, and any physical violence is calculated and planned.

There may be no violence but instead fear is created by spoken or implied threats. Reported threats of serious violence should be taken seriously by health workers. Family dislocation can increase the significance of a threat. Abusers may have codes for serious physical acts which only the victim understands. In some contexts threats to deprive the children, for example by ‘losing’ their pet, may be powerfully used by an individual to sexually control their ex-partner. There is an elevated risk of violence by a partner or ex-partner around the time of separation.⁶

Community responsibility for domestic violence

While DV can occur to anyone, however wealthy and accomplished, it is more common in situations of poverty and unemployment⁷ and among people previously exposed to childhood trauma or adult trauma including war or refugee experience.⁸ If change is to occur, an individual perpetrator must have a genuine desire to stop and to take responsibility for his or her own behaviour. From a society perspective we share a responsibility to create a more aware and respectful community with resources to help people bearing burdens of post-traumatic stress disorder and other adult stressors and to avoid social experiences of devaluation such as chronic unemployment.

“While domestic violence can occur to anyone… it is more common in situations of poverty and unemployment and among people previously exposed to childhood trauma or adult trauma including war or refugee experience.”

Domestic violence as a  health issue

The World Health Organisation (WHO) describes violence against women as a major public health issue affecting physical, mental and reproductive health. Any chronic illness is adversely affected by emotional or physical battery. The WHO highlights the following conditions as common presentations of the results of DV: post-traumatic stress and other anxiety disorders, sleep difficulties, eating disorders, suicide attempts, depression, problem drinking, headaches, back pain, abdominal pain, gastrointestinal disorders, limited mobility and poor overall health.

Recent research has revealed the extent of Acquired Brain Injury among women who experience physical violence as a result of blows to the head or strangulation.⁹ 

The victim experience

People experiencing DV often feel deeply ashamed about their situation and are likely to find it difficult to disclose domestic violence to a health professional or, indeed, to a friend
or church leader. However Australian research indicates that women who have been abused want to be asked about DV and are more likely to disclose if asked. It seems reasonable to the author to extrapolate this to the church situation provided the question is asked with sensitivity, empathy and adequate confidentiality.¹⁰

Common misunderstandings

• If a disclosure of DV is later withdrawn many people may think that the initial disclosure was false. This is usually not so. Retraction may result from fear of further violence or other fears such as losing the children, compounded by lack of family or community support.

• A second common error is to disbelieve the victim because she is showing signs of her life spinning deteriorating mental health. Police may arrive at a DV situation to find a weeping fragile woman who appears neurotic, and a calm, controlled, alleged perpetrator who states that it has all been a misunderstanding. Victims who are in pain or fear, or have had a recent anoxic event, may be disbelieved.

• There is a myth that the sensible victim would always leave immediately. However, victims may stay in a DV situation because of a complex mix of difficulties which may be coupled with low self-esteem and concerns for family stability and safety. Many victims become expert in protecting their children and hiding the abuse from wider family and others by managing the behaviours of a violent partner. Leaving is often dangerous and may precipitate homelessness and other losses. Many women will work and plan for a better future for their family over a long period so that they can leave at a safer time. Those, whose preferred option would have been an intact and flourishing family may retain a degree of hope for the violence to stop through a change in their partner’s behaviour.

• Domestic violence may be wrongly categorised as a ‘relationship problem’. Tension may have built up before the explosion of violence as a result of behaviour that either or both parties regret, but this is not the cause of the violent behaviour.

• Someone may state that the perpetrator could not control his behaviour. A useful thought experiment to challenge this statement is to ask if the perpetrator would have behaved in the same way if a police officer or his boss had been present. 

Domestic violence presenting as injuries in a health setting

Recognising that considerable physical violence can occur without causing visible injury, doctors need to be alert to opportunities to identify injuries caused by DV. Perpetrators will often direct the assault to parts of the body which are hidden and soft and hence less likely show bruising. Victims may hide visible injuries at work, or in the health setting such as the antenatal clinic, by wearing covering clothing such as long sleeves and scarves and by fabricating an explanation for the cause of symptoms. Patients suffering DV may appear unreliable or inconsiderate as they postpone appointments to hide injuries. Strangulation, suffocation and brain injury may result in vague or nil physical signs.

HOW TO ASK
about domestic violence

Privacy is essential and may require some creativity and effort to achieve in an Emergency Department. Avoid asking in front of children. The child may be later questioned by the perpetrator “What did Mummy say at the doctor, today?” 

Direct questions are needed. Some victims will not yet recognise that the pushing or punching they have experienced is domestic violence. I offer the following simple and direct approach: 

First normalise asking the question by giving some context or reason. Here are examples:

When I see a patient with an injury like this I always ask …
OR When I am taking a medical history for ‘headache’ I ask my patients about domestic violence…
OR Domestic violence is very common in Australia so I need to ask you…

Then ask:
Did anyone hurt you?
OR Did anything else happen? Has anyone hurt you?
OR Have you been hurt by your partner, now or in the past?

In a longer consultation there will be opportunity for more general preliminary questions such as “How are things at home?” and whether things get “out of hand”.¹¹

HOW TO RESPOND
if a patient discloses domestic violence

1. Validate the person who has disclosed the domestic violence to you.
It may have required considerable courage. Show you heard what they said and believe them:
“It is good that you told me”, or “I am very sorry to hear that”.

2. Say something that indicates that domestic violence is not acceptable and not the victim’s fault:
“That’s domestic violence. Domestic violence is never acceptable/OK” or “You are not to blame. No-one deserves to be treated like that”

3. Offer help.
For a chance conversation (on a bus for example) a phone number can be provided for a DV Support service (1800 RESPECT). This can make a significant difference. In medical practice there is usually the opportunity to offer a more comprehensive medical response to domestic violence.

The medical response to domestic violence

• Documentation of history and examination is good medicine. Document the allegation and take further history of the violence without pressuring the patient to talk. Documentation of injuries such as bruising may prove important years later, in a legal context such as when Police seek to protect the victim by taking any action to restrain the perpetrator, or there are family court proceedings. Ideally, injuries should be drawn on body diagrams¹² and documented by medical photography. Patients may be fearful to have this information visible to other staff members in the medical record of a group practice. If software settings are not available to protect the information, a supplementary paper file which is indexed to the computer-based health record may be a solution.

• Ask about pressure on the neck, choking or difficulty breathing. Patients often do not realise the seriousness of strangulation and may not report it. In 50% of cases there may be no visible external injuries to head and neck. It is possible to kill a person with the pressure from one hand. Pressure to the carotids with a forearm in a skilful choke-hold will render a person unconscious in 8 seconds. Unfortunately it is easy to acquire this skill from a YouTube tutorial. Acute or long term brain damage from strangulation or head injury is being increasingly recognised as a significant health issue.¹³

• Ask if children were present at the time of the assault, or are otherwise at risk, and consider whether a report to the child protection authorities, or any other referrals for the children’s health, are necessary. Consider frail elderly, the disabled and other vulnerable persons in the household. What you are permitted to do, or mandated to do, to protect vulnerable people varies in each State. Medico-legal insurers and local professional organisations should be able to provide detailed advice.

• Provide information and resources. Generally, the most helpful response to a patient revealing abuse is to listen supportively and offer information, resources and a commitment to follow-up. This non-directive response assists a victim with her own decision-making and to build on her own strengths.

This includes:
• A DV support and counselling service or social work service so a victim can work through and explore her options. They will know how best to find safe accommodation.

• Local police can provide information on protection, including how to apply for orders given by a magistrate to restrain the perpetrator from certain actions, such as restricting him from entering the street where the victim lives.

• Phone services available Australia-wide. Can you find a space in your practice for a patient to talk with a phone counsellor before she leaves?

“The most helpful response to a patient revealing abuse is to listen supportively and offer information, resources and a commitment to  follow-up.”

Useful numbers include:

1. 1800 RESPECT. This phone or web service offers advice, information and counselling to anyone impacted by domestic or sexual violence. This could include victims, worried family members, or you or your staff impacted by a harrowing experience with a patient experiencing DV.

2. Men’s Referral Service (NSW, Victoria and Tasmania) 1800 766 491. This includes a counselling service for men concerned about their own violent or abusive behaviour.

3. Men’s Line 1300 78 99 78. This is an Australia wide men’s counselling service and can provide an immediate counselling response and referrals and information to local programs.

4. Lifeline 13 1114, Headspace (for persons 14-24) and Kids Help Line 1800 55 1800.

5. Safety Assessments and Planning. There are practical resources to guide health workers in assisting victims to develop a safety plan. (Chapter 3 RACGP White Book https://www.racgp.org.au/yourpractice/guidelines/whitebook/chapter-3-safety-and-risk-assessment/).

In most cases DV is a chronic condition, but in some cases a victim may present in crisis when there is immediate serious risk and the victim has nowhere safe to go. This may be indicated by serious injury, escalating injuries and threats, isolation from help and the presence of weapons in the home, such as a gun or knife. A traumatised victim may be incapable of making a safe decision. If attempts to persuade a victim who is in imminent danger to immediately involve the police fail, then it may be necessary for the health worker to inform the police without victim consent.¹⁴ State laws vary. Medicolegal defence services can provide advice.

Family violence as a Chronic Condition

It is important to recognise that responding to DV can be a long process, and a particular interaction with a health worker may be a step on the way. It can be traumatic for health workers to know that their patients are returning to a dysfunctional and abusive situation. A non-judgemental and respectful stance in listening will leave the door open for victims to return for further discussion and practical help.

Uncounted women across the world endure long term violence because they live in counties with no laws or systems to protect their rights. In these cases, the choice to leave the marriage would likely involve permanent isolation from their children, or perhaps involve their children being put out with them to starve on the streets. Aid services that provide education and economic empowerment for women have been shown to improve the health of women and children and reduce the incidence of DV.

Warnings for health care workers

It can be tempting for a doctor to think it might be helpful to call in the perpetrator and tell him to stop. This is ineffective and dangerous: the perpetrator may go home and punish the victim.¹⁵

Couple counselling is contraindicated in domestic violence situations. The perpetrator can punish the victim at home for what she said during counselling.

When a victim discloses domestic violence it may be a natural reaction for the health worker to express their shock and strong criticism of the perpetrator. Expressing this to the victim tends to have the effect of making her feel more ashamed and disempowered, and may provoke her to come to his defence. Concentrate on condemning the unacceptable behaviours rather than condemning the perpetrator.

Other forms of family violence

In this article I have not addressed the important areas of child abuse and elder abuse. There are many other patterns of violence. I list here three that are common and not well recognised.

• Family violence by teenage children. An overwrought and worked up teenager may hit out at a parent, usually their mother. The teenager may have recognised anxiety or depression, or other mental illness, but there needs to be a clear message that violence is completely unacceptable and must stop. It can help for both the family and the doctor to clearly state to the teenager that a push can lead to a chain of events where the police are called and the teenager is charged. Anyone, including a neighbour or health worker, might call the police. Enquire about other patterns of abusive family behaviour.

• Violence from an adult child living at home. A case example would be a middle-aged woman who has an adult child with a serious mental health problem living with her, and the adult child becomes violent to her. The mother is worried that if she puts her adult child out of the home they may get deeper into a drug culture or become a victim of homelessness and violence. These are complex situations and the health worker may need to advocate to find a service that will respond with the detailed support and information needed.

• The exhausted carer. There are people without adequate support taking on enormous caring burdens, such as the care of a very troubled autistic child or an angry cognitively-impaired adult. A carer doing a heroic job may “snap” and push or thump. The carer may present very troubled and remorseful. These carers need relief and help.

The medical response to the perpetrator as a patient

There is hope when a patient admits that things “get out of control”, admits to perpetrating violence and asks for help to change their own behaviour. It is vital to reinforce that abuse is not acceptable. It is also helpful to non-judgmentally provide information about the health harms to victim and children. Reinforce that only the perpetrator can take the steps to change. Medical history will involve an assessment of risk for other family members and a history of suicidality, weapons availability, mental health and drug and alcohol issues. Evidence-based “Men’s behaviour change” programs and similar programs can be effective. These require long-term commitment. Men may be motivated by wanting to be good dads.16 It is not possible for the one practitioner to provide ongoing counselling to the victim and to the abuser separately as there will be a perceived breach of confidentiality and impartiality, even if none occurs. If it is necessary for a couple to separate, it is preferable for the perpetrator, rather than the victim, to leave the family home.

Special concerns for Christians

Christians affirm the nurture of healthy relationships, and that special care is needed for vulnerable persons in our communities. Conversely, bullying at home, church, school or work makes for a violence-prone society. Christian health workers could prepare information for their local church or community from the excellent resources freely available, such as 1800 Respect https://www.1800respect.org.au about domestic violence or http://www.joinonelove.org about identifying unhealthy relationships and building healthy relationships. Resources produced for Christian organisations include http://www.saferresource.org.au. The RACGP has an excellent publication titled, “Abuse and Violence: Working with our Patients in General Practice” at https://www.racgp.org.au/whitebook/ and this is suitable for all health professionals to develop their knowledge and skills.

Christians offering pastoral care to persons affected by domestic violence need to recognise that ‘worldly’ remorse and sorrow about violence are not the same as repentance (2 Cor 7:10). Repentance will be seen in long-term difficult and sacrificial actions, such as commitment to specialised behaviour-change programs, and the willingness to move out of the family home for a period of time, or perhaps forever. Church members can provide practical assistance such as transporting children to events, or providing a safe place to live. A marriage may end in divorce. It is vital for those providing pastoral care to recognise how hard it is to speak up about DV and to realise that when there are no reports of ongoing violence this does not mean that the situation is solved for that family. To conclude, each case of domestic violence impoverishes all within the community – not just the silent victims such as children and grandparents. 

In addition, we all bear some responsibility for the perpetration of violence: words of anger or impatience on anyone’s part may add to the burden a stressed perpetrator takes home or diminish the confidence of a victim of DV. We also collectively bear some responsibility for poverty and war which increase stress and violence.

I am grateful for those who have gone before, and campaigned for resources and laws to protect the weak and vulnerable, and for training for police, counsellors and other professionals. I am grateful for those who continue this work and those victims who have bravely spoken out.

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References

1. Genesis 4. Cain in anger murders his brother and in the same chapter Lamech, threatens his wives with how easily he could murder them.
2. Australian Bureau of Statistics’ (ABS) 2012 Personal Safety Survey ,
3. UK NICE Public Health guideline 2014. Domestic Violence rates experienced by males in a homosexual or bisexual relationship in the UK may be higher. https://www.nice.org.uk/guidance/ph50/chapter/3-context
4. Australian Bureau of Statistics’ (ABS) 2012 Personal Safety Survey ,
5. In this article I have used the  female pronoun for the person experiencing domestic violence  and  the male pronoun  for the  person perpetrating domestic violence for the purpose  economy of words. I acknowledge that while this is the most common pattern it  misrepresents many situations. In addition I have used the word ‘victim’ for simplicity. I acknowledge the the concern  rightly noted in the DV literature that this word can be overly passive and  does not recognise that ‘victims’  are often taking active steps to protect themselves and their family.
6. UK NICE Public Health guideline 2014
7. Worldwide, 1 in 3, or 35%, of women have experienced physical and/or sexual violence by an intimate partner or non-partner sexual violence.  http://www.bocsar.nsw.gov.au/Pages/bocsar_pages/Domestic-Violence.aspx
8. Understanding and Addressing Violence Against Women WHO 2012
9. http://www.dvnswsm.org.au/our-work/resources/projects-and-initiatives/dfvabi/
10. Hegarty, Hindmarsh and Gilles, MJA, 2000
11. Intimate Partner Violence, Identification and Response in General Practice   https://www.racgp.org.au/download/documents/AFP/2011/November/201111hegarty.pdf
12. https://www.rch.org.au/clinicalguide/guideline_index/Child_Abuse_Diagrams/
13. https://www.strangulationtraininginstitute.com/resources/
14. https://www.racgp.org.au/your-practice/guidelines/whitebook/chapter-3-safety-and-risk-assessment/
15. Abuse and Violence: Working with our Patients in General Practice RACGP
16. Several services are listed here: https://www.saferresource.org.au/perpetrator_interventions