Case studies and scenario-based learning

Case studies
Scenario-based learning
IMPRODOVA Risk Assessment Integration Module

The learning materials are not tailored to the needs of every country; they include generic cases that need local adaptation.

Case studies

Case Study: Disclosure of domestic violence to the primary care physician

Sabrina is an accountant, 30 years of age, married for 8 years to a construction worker. She presents to her primary care physician with low energy and headaches that have affected her for over a year. The headaches have worsened in the past month (since her husband was laid off), affecting her mostly at the end of the day. She has trouble sleeping and reports pains all over. She has been to several medical practices in the past year, but has found nothing to be helpful. She has had blood tests, been prescribed painkillers, been advised to get more exercise and change her diet. She desperately needs something to be done for her today as her husband is getting impatient with the lack of results. She is concerned he will become very angry with her when she returns home today. Sabrina’s doctor asks, ‘what happens when your partner becomes angry?’ She has not previously been asked this question and Sabrina hesitates to answer. Her doctor says, ‘I would really like to hear what is going on at home’. Sabrina bursts into tears and slowly the story of her experience with partner violence unfolds. After the doctor assessed the risk according the procedures defined for such cases, the doctor ascertains that Sabrina currently is not in danger of escalating violence and Sabrina confirms she feels she can manage what is happening for now. Right now, she does not want to go to a shelter or contact the police, what the physician suggests no matter how high the risk is. He wants her to have all the information available to make a good choice. They make a follow-up appointment for ongoing support and the doctor shares with her the number of a helpline if anything should happen until their next appointment.

Case Study: Disclosure of domestic violence in medical practice

We are in a family practice and a 25-year-old patient comes to the consultation.

Physician: “Good morning Mrs Schmidt, what can I do for you today?”

Patient: “I feel totally overworked at the moment and wanted to ask if you could put me on sick leave for two weeks?”

Physician: “Is there any particular reason why you feel that way and has this happened before?”

Patient: “I have never been on sick leave because of overload before. I have just recently separated and everything just gets too much for me at the moment.”

Physician: “Of course I can put you on sick leave, but if you feel so overwhelmed by your situation, I would be happy to offer you further support. Perhaps you would like to talk to me about it?”

Patient: “Mmm, I actually feel very uncomfortable to talk about it. There were some problems in my previous relationship. My boyfriend was a control freak and constantly checked my cell phone. We were always fighting whenever I wanted to meet with my friends or family. As a result, I became more and more isolated and the only company when leaving the house was my boyfriend. Messages from my friends were read by him before I had a chance to read them. I finally broke up, but I don’t know if that was the right decision.”

Physician: “If your boyfriend controlled and bullied you so much, why do you think the breakup was a mistake?”

Patient: “He keeps calling me and sending me messages. He puts me under pressure by saying that he cannot live without me and will hurt himself if I don’t come back. All the time I see his car in the parking lot: while shopping, being at work or meeting with friends. I always have the feeling that he is around. Can that still be a coincidence? I have already met him twice because I felt so sorry for him and I was afraid that he would really hurt himself.”

Case Study: Domestic violence affects mental health

Mary is a professionally employed woman in her late 40s, who experienced significant intimate partner abuse during her (now-ended) 23-year marriage. Before leaving her abusive partner, the violence escalated and her physical safety was seriously threatened.

“A turning point for me out of my abusive marriage was gaining access to domestic violence literature. I remember sitting with a small publication in my hands and reading through a list of different types of abuse: emotional, psychological, social, financial, physical, and a corresponding list of common behaviours. I was in a state of shock, because I could tick most of the categories and behaviours on the list as ‘my life’. The book also discussed the ‘cycle of violence’ and I could identify closely with the patterns it described. I had always considered myself an intelligent, well educated person but the ‘cycle of violence’ occurring in my life had created so much confusion that I was unable to put it all together and understand that this was systematic cyclic abuse being used to control me and that living with the stress was making me increasingly physically sick.”.

Mary confiding in her my private care physician and friends and their ongoing support was pivotal in changing her internal dialogue, providing the reality check she needed to confront the pattern of violence and become more confident and decisive about changing her circumstances.

“It took a long, long time for me to give up the hope, the dream that things were going to change. I had adopted a strategy of forgetting abusive events as quickly as possible as a means of coping and surviving. It often came as an enormous shock when my pyhsician or friends reminded me of an event or how I had felt at the time, because I was trying desperately to dwell on the good things and kindnesses that always followed the abusive episodes that left me incredibly emotionally vulnerable and usually quite unwell physically.

I can’t even remember what the trigger was on that Saturday night, but he was very drunk, and he had just lost the job he had recently started. I sat frozen with fear on my bed for hours while he screamed at me that he wanted to kill us both. I could not get out of the house, but I managed to lock myself in a bedroom and waited till he left the house the next day before leaving the room. That day I went to see my mother to ask if I could stay with her for a while, but she was too frightened. I went home and locked myself in my room again overnight. On Monday I took the courage to go to my physician told him about the death threats and he advised me to contact the police to seek assistance. They helped me finding a secure place and I never went home again. I had nothing with me except my handbag and the clothes I was wearing.

In the first few weeks after leaving I was very ill, both physically and emotionally. The sense of loss and grief for the life I had known for the past 23 years was immense; my home, my garden, my pets and everything I had created was in that house. I could barely function, bursting into tears constantly night and day – I just couldn’t control it. I was extremely anxious. I couldn’t eat … I couldn’t sleep without drinking alcohol. I felt like there was an electric current vibrating through my whole body and I just wanted it all to stop. I found myself thinking that if I could get home again, this violent emotional upheaval and the painful physical symptoms would go away. This is not what I wanted, or how I wanted my life to go. It was the most awful, distressing time of my life. I felt like I would have accepted comfort from almost anywhere. I was incredibly vulnerable and frightened that my husband would follow through with his threats to suicide. I was terrified for my own personal safety and was very concerned that I was putting my mother’s safety at risk by staying with her. This time I did not go back even though I considered it many times … I knew I would not survive if I did and the many small steps I had made towards independence with the help of a number of people, including my physician, meant that I now had the strength, health and support to leave.”

Tasks

a) What has been done by the physician to help Mary?
b) Which agencies and professionals may have been involved in supporting and/or providing services to Mary?
c) Make a list of different professionals who make up the multidisciplinary team in your organisation and who could be involved in the provision of services for those who have experienced domestic violence (this will vary depending upon where you are based).
d) Do you think that everything is fine? If you would meet Mary 7 years later, what would you believe would be her situation? List various possible scenarios and the likelihood that they will occur.

What is the situation of Mary 7 years later?

“It is now 7 years since I left my abusive marriage. A couple of months after I left and had resettled into a new home, my husband broke into my house and attacked me. I honestly thought I was going to die that night. A friend arrived shortly after he had left and saw I was injured and badly shaken and insisted we call the police. I laid charges against my husband and arranged a restraining order. Even though I had some support from the police, I certainly did not feel safe as he had again threatened to kill us both. The following 6 months was the loneliest time in my life, being in that empty house alone and terrified he would come back again. Friends and family didn’t feel safe to visit me. I started to drink alcohol to cope and to numb my feelings. I drank too much for quite a long time.

Friends and family became aware that I was drinking too much too regularly and confronted me about it, and I did see a psychologist a few times. I was so desperately upset and anxious most of the time. I felt awful so I self-medicated with alcohol. I never drank when I went out or when I was with company. But once I was inside my front door, I would pour myself a glass of wine and often I couldn’t stop until I fell into bed after cleaning the house for hours almost obsessively.

I left my marriage and survived, but while the high-risk period just after leaving is far behind me, I have ongoing health and psychological problems to this day. Recurring traumatic nightmares have been a persistent problem for me. It is not unusual for me to wake up screaming and incredibly distressed two to three times a week. I am acutely sensitive to aggression even on TV. Just witnessing aggression will trigger a traumatic nightmare. I have had persistent sleep problems also. I frequently wake up at night and cannot get back to sleep. Work and financial pressures can trigger episodes of anxiety that I feel totally incapable of getting under control. These episodes can last for weeks at a time when I live with an internal tremor, a fluttering feeling in my chest and pounding in my temples and enormous tension despite being on antidepressant medication. During such episodes my blood pressure rises considerably, I feel very unwell, cannot sleep and my work and relationships suffer. I just start to hide and avoid anything that further exacerbates the tension and anxiety. I have had three serious episodes of ulcerative colitis over the past 7 years. The impact on my professional life has been considerable, due to my health and sleep problems. I have needed to take quite a lot of sick leave at times.

My private care physician helped me finally to understand that I suffer from Post-traumatic stress disorder (PTSD) that needs to be treated and managed with medication and therapy. It was a relief really to have someone identify it as PTSD and start to explore options for treatment with me. I am beginning to gain more of a sense of control, that things are not so hopeless, and that in time I will not feel so exhausted and overwhelmed. I have been somewhat immobilised by the tiredness. I felt I couldn’t plan for the future because I just didn’t have any energy. I really can’t say I have been happy or that I have enjoyed life for a very long time. All I have been able to manage is to keep putting one foot in front of the other to keep life together.

Looking back now, I realise what a pivotal role my physician had in all those years. Most helpful was his reminding me of why I had come to see him the last time and asking how things had gone over the following week or two. It forced me to remember and face the considerable distress and effect on my health being caused by my now Ex-husband and to relate it to the current situation and state of my mental and physical health.”

Tasks

a) What health problems is Mary experiencing still 7 years after leaving her abusive marriage?
b) Is this an unusual course of events?
c) What finally made the difference for Mary to feel better?
d) What did Mary find helpful when her physician spoke with her and why was this helpful?

Adapted from a case study from RACGP (2014): Abuse and Violence: Working with our patients in general practice

Case Study: Elder abuse

Winnie, aged 69 years, lives by herself in a small country town. She has been a patient of yours for a number of years. She has severe arthritis and requires more and more help with the activities of daily living. Even with regular visits from community services, she finds it difficult to cope, but she is adamant that she doesn’t want to go to the regional hospital.

Eventually she moves in with her daughter and husband and their young sons. The neighbours begin to complain about the noise. Since Winnie has moved in, there is not much space in the house and the children are fighting more often, shouting and more often playing outside. Winnie’s daughter receives no help from her other sisters and is expected to cope with the increased washing, cooking and other duties without complaint.

When you make house calls to Winnie you notice that she has marks and bruises on her arms and upper torso. These are explained away by her daughter, who says that she is becoming clumsier and keeps knocking into things, also Winnie is taking blood thinners. Winnie just shakes her head and says nothing, when you ask her if everything is ok at home, even when you speak to her in private. You are worried about pressing the issue since you do not want to upset anybody by raising a false alarm.

Adapted from a case study from RACGP (2014): Abuse and Violence: Working with our patients in general practice

Tasks

Discuss the case study.
a) What would you do when being Winnie´s physician in this situation?
b) What are the main risk factors that Winnie is at risk to suffer from domestic violence?

Primary care physicians need to be aware that abuse may be happening in this situation.

What could be done to help Winnie?

You may involve the home nursing service, home help, day centre, carer support groups or other local services to relieve the pressure on this family. Another alternative is to seek the help of an aged care assessment team if available.

Measures taken in Winnie´s case

Winnie remains living in her daughter’s house with some extra support – for example, a toilet raise and respite care – which allows her daughter time out of the house; and Winnie attends the day centre once a week.

It is unclear whether this will alleviate the situation, so it is important to maintain a close watch on Winnie with weekly house calls.

For more information on elder abuse:

https://mwiaviolencemanual.com/elder_abuse/

Case Study: Domestic violence has a negative impact on children

Gabby married her husband Nick after a long relationship and shortly thereafter moved to her husband’s family farm. The couple were happy at the farm and soon had their first child. During the pregnancy Nick’s behaviour began to change and by the time their daughter was born the relationship did not ‘feel’ as it had before. Nick seemed withdrawn and spent long periods of time by himself. He began to remind Gabby of Nick’s father who had always been a stern presence in his life.

Nick’s behaviour became threatening and controlling, especially in relation to money and social contact. He was increasingly aggressive in arguments and would often shout and throw objects around the room. Gabby thought that because he wasn’t physically hurting her, his behaviour did not constitute abuse. Nick did not show much interest in their daughter, Jane, except when in public, where he would appear to be a doting and loving father.

Jane was generally a well-behaved child, however, Gabby found that she was unable to leave her with anyone else. Jane would cry and become visibly distressed when Gabby handed her to someone else to be nursed. This was stressful for Gabby and also meant that her social activities were further limited.

Jane took a long time to crawl, walk and begin talking. Her sleeping patterns were interrupted, and Gabby did not often sleep through the night, even when Jane was over 12 months of age. When Jane did begin to talk, she developed a stutter, and this further impeded her speech development. Gabby worried about Jane a lot. Their family doctor told her that this was normal for some children and if the speech problems persisted, that she could always send Jane to a specialist at a later date.

After a number of years, Nick’s behaviour became unacceptable to Gabby. During arguments he had taken to holding the rifle that he had for farming purposes, and Gabby found this very threatening. On a number of occasions, items that Nick threw hit Gabby and she was increasingly afraid for their daughter. Gabby decided to leave and consulted the local women’s service, who assisted her to get an intervention order against Nick.

Once Gabby had taken Jane away from Nick her behaviour changed. Jane’s development seemed to speed up and Gabby couldn’t understand why. As part of her counselling at a local women’s service, she discussed this issue and her counsellor recognised the developmental delay, stutter, irritation and separation anxiety as effects of Jane’s having lived in an abusive situation.

This could be seen as a missed opportunity for identifying family violence. If the family doctor could have asked Gabby or Nick (who had presented with chronic back pain) about their relationship then what was happening to the family, and specifically to Jane, could have been identified much earlier.

Tasks

a) What could have been done better by those involved?
b) Take a moment to consider which agencies and professionals should have been involved in supporting and/or providing services to Gabby from the beginning.
c) Make a list of different professionals who make up the multidisciplinary team in your organisation and who could be involved in the provision of services for those who have experienced domestic violence (this will vary depending upon where you are based).

The wide range of professionals, provider services and specialist agencies who may be involved in supporting victim-survivors of domestic violence can include—but are not limited to—primary and secondary health care services, mental health services, sexual violence services, social care, criminal justice agencies, the police, probation, youth justice, substance misuse, specialist domestic violence agencies, children’s services, housing services and education.

Adapted from a case study from RACGP (2014): Abuse and Violence: Working with our patients in general practice


The Medical Women’s International Association’s Interactive Violence Manual offers further cases developed by healthcare experts across the world on the following topics:

The case studies can be downloaded in the form of a PDF file or as a presentation.


Scenario-based learning

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IMPRODOVA Risk Assessment Integration Module

You can follow the whole risk assessment procedure for a specific case by downloading the following presentation. You will be introduced to Nora and learn a lot about the different roles of frontline responders.

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