Prevalence

Half of Canadian women have survived at least one incident of sexual or physical violence (Statistics Canada, “The Violence Against Women Survey”, 1993.)

Over a quarter (29%) of Canadian women have been assaulted by a spouse (Statistics Canada, “The Violence Against Women Survey”, 1993.)

35.6 percent of women in the U.S. are raped, assaulted or stalked by intimate partners at some point during their lives, and approximately six percent experience these events in a given year (CDC, 2012)

Men are also at risk: 28.5 percent report lifetime victimization and five percent report past year victimization. (CDC, 2012

Screening

Some advocate for screening if there are signs/symptoms suggesting IPV

• Routine screening in all patients for IPV is not recommended in the family practice setting (MacMillan, 2009; Kievens, 2012). 

Others advocate for routine screening

• Ask all patients about IPV, in the same way  that one might ask about smoking and drinking. Even if the answer is negative in the beginning, it helps the patient feel more comfortable about disclosing if warranted. 

Red Flags for IPV

Signs/symptoms that may suggest IPV includes, but are not limited to:

• Depression
• Anxiety disorders, including PTSD
• Eating disorders
• Sleep disorders
• Substance use
• Psychosomatic disorders
• Self-harm or self-injurious behaviours
• Substance abuse
• Chronic pain
• Vague complaints of chronic somatic complaints, e.g. chronic pain, rather than obvious physical trauma
• Multiple missed appointments

Risk Factors for Fatal Domestic Violence Cases

According to a review by the Ontario Coroner’s Committee (2013-2017), when there has been a fatal domestic violence case, the following risk factors are important. The greater the number of factors, the greater the risk.

• History of domestic violence (current or past)
• Actual or pending separation
• Perpetrator depressed
• Obsessive behaviour displayed
• Prior threats / attempts to commit suicide
• Victim had intuitive sense of fear
• Perpetrator displayed sexual jealousy
• Prior threats to kill victim
• Excessive alcohol or drug use
• Perpetrator unemployed
• History fo violence outside the family
• Prior attempts to isolate victim
• Actual or perceived new partner in victim’s life

Screening Tools

• Woman Abuse Screning Tool (WAST)

1. In general, how would you describe your relationship with your partner? A lot of tension, some tension, or no tension?
2. Do you and your partner work out arguments with great difficulty, some difficulty or no difficulty?

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History / Interviewing Strategies

Interview the patient alone in a safe environment with no one else present, ideally not even with children around

• Sample questions
  • Opening
    • Clinician: “Its important for me to ask about people’s close relationships.”
  • Normalizing statement for sensitive topics
    • Clinician: “Sometimes partners or ex-partners use physical force.”
  • Probing questions
    • Clinician: “Have you felt humiliated or emotionally harmed by your partner or ex-partner?”
    • Clinician: “Do you feel safe in your current or past relationships?”
    • Clinician: “Are you in a relationship with anyone who has hurt or threatened you?”
    • Clinician: “Have you ever been forced into having sex by your partner or past partners?”
    • Clinician: “Is your partner jealous and controlling?” “Does your partner keep you away from family and friends?” “Can you come and go as you please?”

Screen for co-morbid mental health conditions such as depression, anxiety and substance abuse.

• Clinician: “Any troubles with your mood?” “Any troubles feeling anxious?” “Do you find yourself drinking alcohol?” “How much?” “Do you feel your alcohol use is a problem?” “Are you using any street drugs?” “Is this causing any problems?”
• If IPV is suspected, but the patient denies
  • As with motivational interviewing, do not force or pressure the patient to disclose; rather, focus on simply maintaining a relationship with the patient, so that the patient returns, and over time, can build up trust with the provider
  • Acknowledge your concern and your willingness to discuss during future visits
  • Avoid blaming statements such as “Why don’t you just leave?”

Physical Exam

Suspect physical abuse if there are unexplained injuries.

Document any physical abuse.

Management and Treatment Plans

Do’s

If patient reports potential IPV, acknowledge the admission of abuse

• Clinician: “Thank you for telling me about what has happened to you. I’d like to ask you more about what happened…”

Validate that IPV happens

• Clinician: “Unfortunately, violence at home is a common problem that happens in our society."

State that violence is unacceptable

• Clinician: “Although violence is common however, everyone deserves to feel safe. You have a right to be free of abuse and violence. It is never acceptable."

Express your caring and concerns about the patient’s safety, especially if there are children.

• Clinician: “I am worried about your safety as well as your children. Violence in a relationship is unacceptable and is against the law. It affects the health and well-being of you, and your children.

Give hope

• Clinician: “The good news, is that there are services that can help."

Focus on the relationship rather than pressuring patient to seek help

• As with motivational interviewing, do not force or pressure the patient to seek help if the patient is not yet ready.
• Focus on maintaining a relationship so that you can build up the patient’s trust over time

Consider contacting child protective services (e.g. Children's Aid Society) due to the negative impact that IPV has on children

• If you are unsure of whether or not child protective services needs to be involved, err on the side of caution, and contact them for a ‘blind consult’ and provide generic, non-identifying details, to see if they recommend involvement

Consider police involvement if there are immediate safety issues

• Clinician: “Do you feel safe to return home today?” “Do you feel your life is in danger today?” “Does your partner have a weapon?"

Obtain permission for referrals to services

• Ask the patient if he or she would like to be connected to IPV services
  • Clinician: “Would you like some help?”
• Provide information and/or refer to services such as
  • Shelters
  • Counseling/treatment services
  • Social / legal services
  • Consider printing out a ‘personalized safety plan’ for the patient to fill out

Develop safety plan with patient

• Who are your neighbours that you can ask to call police, if there are suspicious noises coming from your home?
• Who can you go to, or where are the places you can go if you had to leave your home, or if you cannot return home?
• Who can you leave extra money, keys, clothes and documents with?
• Who can you turn to for emotional support? Or if you are feeling lonely and wanting to return to your abusive partner, who can you call for support to help keep you safe and strong?

Do assess the level of risk for serious harm.

Do arrange a follow-up appointment.

Don’ts

Do not confront the abusive partner, especially if the partner is also your patient. Rather, focus on ensuring that the victim is aware of appropriate services and supports, and assist with connecting to those services.

Is there Immediate Danger?

Is there an imminent risk of life threatening or serious harm?

• Contact police / woman’s shelter
• Ask patient about staying with a friend

Personalized Safety Plan

I can tell these people about the violence and ask them to call police if there are suspicious noises coming from my home.

1. ___________________________________

2. ___________________________________

3. ___________________________________

These are the places I can go to if I leave home:

1. ___________________________________

2. ___________________________________

3. ___________________________________

I can leave extra money, car keys, clothes and documents with

1. ___________________________________

Key things to bring if I leave

• Identification
• Driver’s license and registration
• Passports
• Birth certificates for me and my children
• Social Insurance Number (SIN) card
• Money
• Banking card
• Credit cards
• Keys
• House / Work
• Car
• Medications
• Divorce papers
• Lease/rental agreement, house deed
• Mortgage payment book, current unpaid bills
• Insurance papers
• Address book
• Pictures, jewelry, items of sentimental value
• School and medical records
• Change of clothes
• Children’s favorite toys and/or blankets

To keep myself safe and independent, I will

• Open my own bank account
• Practice my escape route with a trusted person

After a relationship is over:

I can

• Change the locks
• Install steel/metal doors
• Install a security system
• Ensure that there is lighting outside the home
• I will inform _________ and ______________ that my former partner no longer lives with me, and ask them to call the police if my former partner is seen near my home or children.
• I will tell people who take care of my children who has permission to pick them up. These people who have permission are:

1. ___________________________________

2. ___________________________________

3. ___________________________________

If I am feeling lonely, sad and wanting to return to my abusive ex-partner, these are the people I can call for support to help keep me safe and strong

1. ___________________________________

2. ___________________________________

3. ___________________________________

References

Liebschutz JM, Rothman EF: Intimate-Partner Violence — What Physicians Can Do. New England Journal of Medicine, 2012; 367 (22): 2071 -2073.

Available at http://www.nejm.org/doi/full/10.1056/NEJMp1204278. Accessed Nov 29, 2012.

Rhodes KV: Interventions for Intimate Partner Violence Against Women, Feb 5, 2003; 289(5):601-605. Available at http://jama.jamanetwork.com/article.aspx?articleid=195899#REF-JSR20021-16. Accessed July 7, 2013.

MacMillan HL, Wathen CN, Jamieson E, et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2009;302:493-501

Klevens J, Kee R, Trick W, et al. Effect of screening for partner violence on women’s quality of life: a randomized controlled trial. JAMA. 2012; 308:681-689.

Practice Guidelines and Position Papers

Stewart D, MacMillan H, Wathen N: Intimate Partner Violence. Position Paper of the Canadian Psychiatric Association. Can. J. Psychiatry, 2013; 58(6): Insert, pp1-5. Retrieved July 19, 2013 from http://publications.cpa-apc.org/media.php?mid=1524

American Academy of Family Physicians. Violence position paper: AAFP policy and advocacy statement. Retrieved July 7, 2013 from http://www.aafp.org/about/policies/all/violence.html

CME / CPD about Domestic Violence

“Recognizing Domestic Violence in the Workplace: Training for Health Care Professionals” is a module created for the College of Physicians and Surgeons of Ontario (CPSO) by Dr. Mason and colleagues in response to the tragic murder of Dr. Elana Fric.

http://vaw.dveducation.ca

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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