This module presents what needs to be considered when assessing the risk of victims of domestic violence and what steps are necessary to improve the safety of victims.
IMPRODOVA: Domestic violence in times of disasters
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
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?
The answers to thoses tasks can be found in the corresponding sections of this module.
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:
Risk Assessment and Safety Enhancement
Many victims who have been subjected to violence have fears about their safety. Other victims may not think they need a safety plan because they do not expect that the violence will happen again. Explain that domestic violence is not likely to stop on its own: It tends to continue and may over time become worse and happen more often.
Assessing and planning for safety is an ongoing process – it is not just a one-time conversation. You can help them by discussing their particular needs and situation and exploring their options and resources each time you see them, as their situation changes. Discuss whether it is safe for them to return home.
The patient should be helped to assess his or her immediate and future safety and that of his or her children. Risk assessment according to good practice includes
- collecting relevant facts about the domestic situation
- asking about the victim’s perception of risk
- a professional judgement on current risk factors
The patient may need to be referred to a specialised service for domestic violence. The strongest indicator for future risks/violence is the perpetrator’s current and past behaviour. The patient may also be advised to go to the police to ensure even greater protection. However, since this is always accompanied by a report to the perpetrator and the victim is expected to reveal himself or herself to a wider circle of people, this advice must be weighed up very carefully!
It is important that the patient is involved in a conversation about his or her risk perception and security management in the past. All plans that have been made must be documented for future reference! Copies should be given to the victims, if possible. At the same time, they should be made aware that there is a risk that the perpetrator might find the document and that the violence will escalate.
Some victims will know when they are in immediate danger and are afraid to go home. If they are worried about their safety, take them seriously. This is your responsibility.
Other victims may need help thinking about their immediate risk. There are specific questions you can ask to see if it is safe for them to return to their home. It is important to find out if there is an immediate and likely risk of serious injury.
The internationally most frequently used risk assessment instruments can be found under Teaching Materials on the page risk assessment tools.
Communication with victims about safety measures and risk assessment
For an initial risk assessment this must be done at least: Talk to the victim in a private setting and to assess immediate concerns:
Questions to assess immediate risk of violence
- Has the physical violence happened more often or gotten worse over the past 6 months?
- Has he/she ever used a weapon or threatened you with a weapon?
- Has he/she ever tried to strangle you?
- Do you believe he/she would kill you?
- Has he/she ever beaten you when you were pregnant?
- Is he/she violently and constantly jealous of you?
Victims who answer “yes” to at least 3 of the following questions may be at especially high immediate risk of violence.
Making a safety plan
Even a victim who is not facing immediate serious risk could benefit from having a safety plan. If they have a plan, they will be better able to deal with the situation if violence suddenly occurs. The following elements are part of a safety plan and questions you can ask them to help them make a plan.
Safe place to go
“If you need to leave your home in a hurry, where could you go?”
Planning for children
“Would you go alone or take your children with you?”
“How will you get there?”
Items to take with you
“Do you need to take any documents, keys, money, clothes, or other things with you when you leave? What is essential?”
“Do you have access to money if you need to leave? Where is it kept? Can you get it in an emergency?”
Support of someone close by
“Is there a neighbour you can tell about the violence who can call the police or come with assistance for you if they hear sounds of violence coming from your home?”
Be careful in cases of honour-related violence.
Victims’ needs generally are beyond what you can provide in a hospital or private practice. You can help by discussing the victim’s needs with them, telling them about other sources of help, and assisting them to get help if they want it. It will usually not be possible to deal with all their concerns at the first meeting. Let them know that you are available to meet again to talk about other issues.
Do not expect them to make decisions immediately. It may seem frustrating if they do not seem to be taking steps to change their situation. However, they will need to take their time and do what they think is right for them. Always respect their wishes and decisions.
Immediate risk of suicide and self-injury
Some people fear that the question of suicide might provoke the victim to commit it. On the contrary, talking about suicide often reduces the victim’s fear of suicidal thoughts and helps him or her to feel understood.
If the victim:
- has current thoughts or plans to commit suicide or to harm himself or herself
- If there is a history of thoughts or plans for self-harm in the past month or a record of self-harm in the past year, and the patient now appears extremely agitated, violent, desperate or uncommunicative, then there is an imminent danger of self-harm or suicide and the patient should not be left alone.
The victim should then be immediately transferred to a psychiatric hospital. If the patient refuses to go there alone, he or she should be accompanied or an accompanying person should be contacted. If the patient runs away or does not report to the clinic at the agreed time of arrival, the fire brigade should be called in. Breaking confidentiality is not a legal problem in this case. On the contrary, one is even obliged to report an acute self-endangerment.
Information about the usage of risk assessment tools in Europe regarding the Health Sector
Risk Assessment procedures and response strategies in different European countries in the Health Sector
We do not have comprehensive information about a standardized risk assessment tool in Scotland, though NHS Health Scotland is promoting the use of the DASH RIC amongst Health Visitors. With regard to other groups of health workers in Scotland, training on the use of the DASH RIC varies across health board areas. Some have done training with mental health and sexual health staff, but this is not consistent across the country. In most of the participating countries, including France, Germany, Slovenia and Hungary are there are no formalized DV risk assessment processes in the health sector. A prevalent opinion within the medical professionals of these countries is that they do not see DV-related risk assessment as part of their job. According to their understanding the health sector’s responsibility is restricted to document the incident and the injuries. According to our understanding this attitude is not very beneficial, since health care is an entry point for many DV cases, which might remain in latency in case of an insufficient risk assessment.
In Austria, Child- and Victims Protection Groups are discretionally used as part of risk assessment in hospitals, developed by national authorities and professionals (based on Campbell’s Danger Assessment) and adapted during the initiative “Living FREE of violence”. The tool in this form is solely used by medical professionals, but includes indicators compatible with others based on the Danger Assessment (Campbell, 19xx). The assessment consists of questions seeking to reconstruct past incidents of violence in the relationship and a checklist to guide possible steps to increase the security of the victim. The medical sector further employs a standardized forensic documentation procedure in cases physical injury. This also includes indicators relevant to risk-assessments in cases of DV.
The tool is used by internal experts on DV within hospitals, but physicians and other medical professionals are trained by them to use the tool and to cooperate in the risk assessment procedure.
In Finland, some emergency units use PAKE Abuse and Body Map form, which is a tool used in assault and abuse cases (not just DV cases). Medical professionals, doctors and nurses are trained to use this tool. The purpose of the PAKE form is to improve the comprehensive treatment of the victim, including psychological condition and legal representation. It also intends to facilitate cooperation between health care, social work, the police and judicial authorities, and to advice the victim about available services. PAKE involves a detailed map of injuries. It covers the cause of the injury, the violent action, consequences of the action, further threats, pain, victims’ psychological condition, the involvement of children, and the follow-up treatment. PAKE is mandatory in those emergency rooms where it has been implemented. A doctor writes a medical report based on the PAKE form and sends it to the police if the victim gives his or her consent. However, health care professionals can only encourage the victim to report an offence to the police and can send information to the police only if the victim gives his or her consent.
In Portugal, there are two different sectors of the health system that face DV victims: hospitals and health centres. The first ones deal predominantly with emergencies, often quite close after a DV incident; the second ones deal with situations known within regular medical appointments (indoor approach) and during community medical work (outdoor approach). Both sectors mandatorily use standardized, locally invented risk assessment tools, owned by the Ministry of Health. An interdisciplinary team, including medical doctors, nurses, psychologists, social workers and even the police, if necessary, ensures that the risk assessment procedure is participatory and multidisciplinary. The tool includes a set of various steps to consider: (1) screening, (2) detecting/assessing, (3) diagnostic evaluation (hypothesis), (4) registering, (5) acting, and (6) signalling. Risk indicators cover different forms of threats, injuries; severity, intensity and frequency of violence; involvement of alcohol or other substances; and crime history. The risk assessment tool also contains items related with the risk perception of the victim. Imminent danger is diagnosed when there is the possibility of experiencing an imminent episode of violence, life-threatening for the victim (and/or her/his significant persons). It is based on information from the interview, the victim’s perception, a bio psychosocial assessment, and a physical exam.
In Austria, main shortcomings described are not related to the tools employed, but to the environment they are used in. Time constraints are mentioned and in some hospitals the lack of mandatory sensitivity trainings for medical stuff to gain expertise in using the tool. The Child- and Victims Protection Groups are not yet implemented in all hospitals in Austria, since roll out is going on. Implementation is seen predominantly in hospitals that were involved in the project “Gewaltfreileben” (Living Free of Violence) in Vienna. The risk assessment process and the groups are not regulated on a policy level. This seems to be an important gap in response to the high importance of hospitals for the identification and treatment of victims of DV.
In Finland a shortcoming mentioned in relation to the PAKE form is the paper form. In case of an electronic form it would be much easier to share information among the agencies. It might also vary how systematically PAKE is used in other areas in Finland.
In Portugal, two shortcomings are mentioned in relation to the risk assessment tool used at health care services. First, the time consuming nature of the procedure, second, that frontline responders were not involved in the design of the risk assessment policy, despite the fact that they have proper knowledge.
Interviewees of all countries that use DV risk assessment tools in health care emphasized the importance of continuous, mandatory training of the FLR’s for the use of the risk assessment tool, and the lack of sufficient trainings and properly trained staff as a problem.
Further information about risk assessment procedures in different European Countries can be found here:
IMPRODOVA Checklist for risk assessment of domestic violence
Within the framework of a sub-project of the EU project IMPRODOVA, the partners developed a checklist for risk assessment in the case of domestic violence (D 3.3), which can be downloaded and printed out. In this way you have – in short form – all information at a glance when you need it.
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.
You can check the Module online without using Powerpoint by clicking on this link:
If you want to use Powerpoint, please download the presentation by clicking this link: