Module 3: Communication in cases of Domestic Violence

Learning objectives

This module presents the different ways of asking about domestic violence in situations where you suspect the presence of domestic violence. Furthermore, first steps after the disclosure of domestic violence are presented.


IMPRODOVA: How to respond to a disclosure


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.

The answers to thoses tasks can be found in the corresponding sections of this module.

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?

The answers to thoses tasks can be found in the corresponding sections of this module.

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


Framework conditions for a conversation on domestic violence

First of all: don’t be afraid to help, even if you don’t know exactly what to do in a specific situation.

The important thing is to communicate with the victim in the first place:

  • Listening
  • Confirmation that one believes the victim
  • Validation of the disclosure decision
  • Emphasis on the unacceptability of violence
  • Make it clear that the victim is not to blame
  • Do not ask questions that could cause stress and a feeling of powerlessness in the victim

Interviewing victims of domestic violence should always be combined with effective intervention, including a supportive response, appropriate care as needed and referral to, for example, the health system or other support services.

Talking about violence with your patient

Only ever raise the issue of domestic abuse with a patient when you are alone with them in private and, if not, ask the escort to wait elsewhere.

Even if a patient is accompanied by someone of the same gender, that person could be related to the abuser or could be the abuser.

Offering Information sheets

Written information on intimate partner violence and domestic violence should be on display in healthcare settings in the form of posters, and pamphlets or leaflets in private areas such as washrooms (with appropriate warnings about not taking them home if an abusive partner could find them). A QR code leading to a website with further information should be included on the information materials. The posters, pamphlets or leaflets should be directed to female and male victims of domestic violence and not use stereotypes. Naming specific contact persons on site and providing telephone numbers of counselling centres or websites offering (anonymous) counselling can support victims of domestic violence when seeking help.

How to ask your patient

Here are some statements you can make to raise the subject of violence before you ask direct questions:

  • “Many people experience problems with their husband or partner, or someone else they live with.”
  • “I have seen people with problems like yours who have been experiencing trouble at home.”

Here are some simple and direct questions that you can start with that show you want to hear about their problems. Depending on their answers, continue to ask questions and listen to their story. If they answer “yes” to any of these questions, offer them support:

  • “Are you ever afraid at home or in your relationship?”
  • “Has your partner or someone else at home ever threatened to hurt you or physically harm you in some way? If so, when has it happened?”
  • “Does your partner try to control you, for example not letting you have money or go out of the house?”
  • “Have you been pressured or made to do anything sexually that you did not want to?”
How to talk to a victim

Make time for the victim

  • Choose a calm and cosy place. Make sure you have the time to listen to the victim if she/he decides to disclose or tell the whole story.
  • It is important to raise a suspicion in a sphere of trust.  This should happen alone with the victim in a room without disturbance. It is useful, if the person who talks to the victim has the same sex. It is important to be careful and emphatic.

Start talking

  • Let the victim know that you are there to help. Offer a sympathetic ear, and make sure the victim understands you are concerned with her/his safety. Don’t rush the process.

Don’t be judgemental

  • Give the victim the full opportunity to speak up. You want to get a good picture of the situation, so you’d better not make comments on what the victim presents. If questions arise, they must be clarifying ones. Questions inducing some kind of criticism must be avoided.
  • Let the victims know this is a judgment-free conversation. Offer your support and provide ways to get help. Help them look into available resources. If they’re not ready to talk about it, don’t force it. It’s important to recognize the right time. Encouragement helps.
  • Always be open, honest, non-judgmental, empathetic and supportive.

Be aware of the warning signs

  • Many victims try to cover up the abuses. You need to be aware of the indicators that could be a possible hint for abuse.

Believe the victim

  • … even if the victim’s story seems built up and unreal.

Validate the victim’s feelings

  • Sometimes, victims express conflicting feelings about their partner and their situation (guilt vs. anger; hope vs. despair; love vs. fear). Let the victim know that having these conflicting feelings is common (normal). But, at the same time, you should stress that violence is not okay and it is not okay to live in constant fear of being attacked or hurt. Even if the victim presents reasons for her/his staying with the offender, when fear is present it means the relationship isn’t healthy.
  • Without judging, tell the victim that her/his situation is dangerous, and that you’re concerned for her/his safety.

How to talk to a victim

In general, it is useful to use “I-Messages” and other non-violent communication methods. It can be used specifically to solve ambivalences of a victim during the counselling or in case of less time for counselling.

Ask directly about the violence e.g. “Have you been slapped?”

You could start with:

  • “I know many women have problems facing violence by their partners or other family members. Could it be, that this is the same in your case?”
  • “I now it is difficult to talk about family problems, but I am worried about you.”

Offer support

Assure the victim she/he is not alone, and that you are not going to be judgemental. E.g.:

  • „I know this is difficult to discuss, but you can talk to me about anything.“
  • „You are not alone. I’m here for you, no matter what.“
  • „You are not responsible for what’s going on.“
  • „No matter what you did, you don’t deserve this.“

Express your concern for the victim’s safety

It is important to help the victim recognise the abuse while acknowledging the difficulty of her/his situation. So, don’t be afraid to let the victim know you are worried.

  • „I see what’s going on, and I want to help you.“
  • „You don’t deserve to be treated that way. Good partners/ family members don’t say – or do – those kinds of things.“
  • „I’m worried about your safety, and afraid you’ll get really hurt if there is a next time.“
  • „Please, know that if you need to talk, you can always come to me.“

Avoid confrontation

If the victim is not ready to talk about the situation, do not force it. Recognise the right time and let the victim know about it.

  • „I’m here to help, and I’m always available, even I understand that you don’t want to talk about it now.“
  • „Remember that you’re not alone. I’ll be here for you when you’re ready.“

Let the victim make his/her own decisions

Avoid making judgments about the victim’s ability to make decisions, thus preventing that she/he loses confidence in you. Encouragement and asking is the key.

  • „I want to help you. What can I do to support you?“
  • „How can I help to protect your safety?“

Provide ways to get help

Help the victim listing available resources (state agencies, NGOs, family members, friends, neighbours).

  • „Here is the number to your local domestic violence office. They can help with shelter and counselling.“
  • „Let’s develop a safety plan.“

What not to say or do to a domestic violence victim

Although there is no right or wrong way to help a domestic violence victim,

DON’T

  • Bash the abuser. Focus on the behaviour, not the personality;
  • Blame the victim. That is what the abuser usually does;
  • Underestimate the potential danger for the victim and yourself;
  • Promise any help that you can’t follow through with;
  • Give conditional support;
  • Do anything that might prorogue the abuser;
  • Pressure the victim;
  • Give up. If she/he is not willing to open up at first, be patient;
  • Do anything to make it more difficult for the victim.
Responding to a disclosure

Assessment of the needs and concerns of the victim

When listening to the victim’s story, special attention should be paid to what he or she says about his or her needs and concerns – and what is not said but hinted at with words or body language. You can inform the victim about physical, emotional or economic needs, about the security concerns or social support he or she needs. The following techniques can be used to help the victim express his or her needs and to make sure that you are understanding:

Questions should be formulated as invitations to speak.

“What would you like to talk about?”

Open questions should be asked to encourage the victim to talk instead of saying yes or no.

“What do you think?”

What the victim says should be repeated to check your own understanding.

“You mentioned that you feel very frustrated.”

The victim’s feelings should be reflected.

“It sounds as if you are angry about this…”

The victim should be helped to identify and express their needs and concerns.

“Is there something you need or are worried about?”

What the victim has expressed should be summarized.

“You seem to be saying that…”

There should be no suggestive questions like

“I imagine that upsets you, doesn’t it?”

No “why” questions should be asked, such as

“Why did you do that?”

It might sound reproachful.

The victim should understand that his or her feelings are normal, that it is safe to express them and that he or she has a right to live without violence and fear.

  • Believe victim’s experience, being the victim of violence is not the victim’s fault.
  • Help is available both for the victim and the person responsible for violence, offer information about supports available.
  • Be respectful and build trust.
  • Take the victim seriously.
  • Take attention and listen to the victim. Active listening for example means paraphrasing and active body language.
  • Be empathic. Appreciate the victim’s experiences. Signalize that there is no excuse for violent behaviour.
  • Lay off the pressure.
  • Be patient and take time.
  • Don’t advice like “You should definitely get divorced”.
  • Convicting or condemning statements such as “Why didn’t you leave your husband long ago?” or “Why are you …didn’t come earlier?”.
Use of an interpreter

If the victim’s language skills are an obstacle to discussing these issues, a qualified interpreter or representative of the local Domestic Violence Unit should be used. This person should be of the same sex as the victim and sign a confidentiality agreement. During the conversation, the victim should be looked at and talked to. The patient’s partner, other family members or children should not be used as interpreters. It could jeopardize the safety of the victim or they may feel uncomfortable talking about their situation.

Special case: if the victim is a child

Child abuse can occur in countless ways, and the effects vary from child to child. While some children may have bruises or injuries that raise suspicion, this is not always the case. However, the majority of children are less likely to suffer direct physical injury; much more problematic are the long-term effects of violence on the neurological, cognitive and emotional development and health of the child.

There are children who do not want to talk at all. Others disclose domestic violence indirectly by not telling the details unsolicited or in a roundabout way: “Sometimes my stepfather annoys my mother”. The child hopes that the hint they give will be taken up. Many children are insecure because the perpetrator is someone they love.

The child should not be “interrogated”. One should ask simple questions such as:

  • “Is there something you’re sad or worried about?”
  • “Some kids can get scared at home. What do you believe may scare them?

The child should be reassured. You could say this:

  • “I believe you.”
  • “I’m glad you came to me.”
  • “I’m sorry this happened.”
  • “It’s not your fault.”
  • “We’ll do something together to get help.”