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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Abused women and their physicians
The importance of relapse
Important Insights from Theory to Research and Clinical Practice
Can doctors always tell what stage someone is in?
Routine screening for intimate partner violence - an alternative perspective
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Baukje (Bo) Miedema, Canada Research Director, Dalhousie University Family Medicine Teaching Unit
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This article provides useful information for clinicians when confronted with a person who is the victim of Intimate Partner Violence (IPV). Physicians are “raised” in an action oriented environment; however, that is not always the best course of action when confronted with a patient who is the victim of IPV. Many abused women have little opportunity to leave the abusive environment but are often permitted to visit a physician. Consequently, it is important that physicians create a safe environment and preserve the trust placed in them. If a physician, to whom an abused woman has disclosed, inadvertently informs the abuser, this may lead to more abuse or even death. The most significant contribution of this paper is the message that physicians should be aware of the behavior patterns of women who are ready to disclose. When abused women disclose their abuse the most important role for the physicians is do listen; the physician does not always have to act. For example, several women in the Zink et al. study indicated that just telling their story and being believed was an important first step. Only the abused woman can decide what the next step in the process of leaving will be. Many abused women leave an abuser many times before they are finally able to leave the relationship permanently - if at all. One participant quote gives the reader a glimpse of the complexity and multifaceted relationship between the abused and the abuser. The research participant said: “I mean it’s almost gotten to the point where I just want to leave, but then, you know, I do love my husband and it’s hard to leave”. This sentiment is not always easy to understand. An article by Karen Landenburger illustrates the complexity of the emotional process between the abused and the abuser. Landenburger identifies a four-phase process of how a relationship turns into an abusive one and the long process of the termination of that relationship. The four phases are: binding, enduring, disengaging, and recovering. Some women never move through all of these stages and are never able to leave the abusive relationship. The support of a clinician at each step in this process is important. Zink at el. aptly conclude that the current clinical guidelines may focus too much on “seeking options to end the abuse” and do not focus enough on a supportive role. Landenburger, K. A process of entrapment in and recovery from an abusive relationship. Issues Ment Health Nurs. 1989;10(3-4):209-27. Competing interests: None declared |
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Peter F. Cronholm, Philadelphia, USA Family Physician
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The authors describe a study exploring a stage-matched model of intimate partner violence using the transtheoretical model of behavioral change for victims and providers. An issue that arises when trying to apply the transtheoretical model of change to patient behaviors is the common misperception that patients who are not actively addressing their behaviors have only experienced early stages change (precontemplation and contemplation). The transtheoretical model is best described as a cycle of behavioral changes that proceed through the five common stages cited by the authors (precontemplative, contemplative, preparation, action and maintenance) that more often than not revert to earlier stages via a stage described as relapse. It would be a mistake to categorize every smoker or overweight person encountered in a clinical setting as someone who has not struggled through innumerous periods of action and relapse. Relapse is a critical stage of behavioral change that can be utilized by both patient and clinician. Recognizing the role of relapse is an important consideration in the care of people struggling with issues of intimate partner violence. The importance of acknowledging the role of relapse lies in the clinician's ability to help patients utilize strategies that have resulted in relapse as teachable moments that, if modified or adapted, may lead to more sustained periods of maintenance and ultimately, determination. Clinicians must be aware of the shame and guilt that many patients experience with periods of relapse and self-perceived failure as they assist in reshaping conditions that have lead to relapse. Models of stages of change can be a valuable tool for clinicians to assist patients in modifying behaviors and promoting healthy lifestyles. A similar assessment involving perpetrators would be a valuable contribution to the identification and treatment of intimate partner violence. Competing interests: None declared |
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Barbara A. Elliott, Duluth, MN Professor, Dept of Family Medicine
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Therese Zink and her colleagues have written an important theoretical, methodological and clinical paper for us about medical response in settings of IPV. Methodologically, it is a well-done and well-reported qualitative study—which appropriately asks and answers a question that can best be answered by talking with surviving victims of IPV. In too many cases, our research does NOT test theory by talking with victims, but instead infers or deduces insights from quantitative findings. Truly learning/identifying what victims experienced is part of their stories and must be heard in that way. This project was well conceived and designed for exactly that purpose. This project also moves us ahead theoretically by confirming the validity of the theory and by further refining it. The clear use of participants’ quotations brings the stages of the transtheoretical model in settings of IPV to life. The insights of the theory’s stages are displayed through these women’s voices, and clarify that our existing clinical guidelines offer an approach to use “in the average situation” when working with patients living with IPV. Consistent with the theory, instead of using the average approach, there is the need to specify the approach to the phase of change being experienced by the victim. In addition, the specifics of this report indicate the nuanced distinctions within the stage transitions. The women’s voices also allow the authors to extend the theory’s implications to clinical care. These implications add both guidelines on WHAT TO DO as well as WHAT NOT TO DO in their specific circumstances. These observations have had immediate effect in my own work, where a physician approached me this week asking how to work effectively with a woman who the physician knows is in a violent relationship, but the patient is in the pre-contemplation phase of change. We discussed how to open the door to these issues without offending or pushing her away— consistent with the recommendations of this paper. Thank you Therese, Nancy, Jeff and Brenda for these efforts! Competing interests: None declared |
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Nancy J. Flanakin, Austin, TX Librarian, National Center on Domestic and Sexual Violence
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I think this is a thoughtful piece and that it used information from a good source, women who have emerged from abusive relationships telling what they think, in hindsight, their doctors should have done. I think that a doctor who carefully read this article could gain some useful tips and background. However, I also think that a doctor who is concerned about a patient who is being abused should proceed as forthrightly as possible using common sense and the knowledge he or she has, rather than being expected to know or find out whether a patient is in the "precontemplation", "early contemplation", or "late contemplation" stage. Competing interests: None declared |
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Felicity A Goodyear-Smith, Auckland. New Zealand Senior Lecturer & Family Physician, Department of General Practice, University of Auckland
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Zink et al note that that US professional organizations recommend routine screening of women for intimate partner violence (IPV) but ‘physicians are not screening’. They acknowledge that screening is controversial. Indeed a US Preventive Services Task Force review has found insufficient evidence to recommend for or against routine screening of women for IPV (grade I recommendation).1 Zinc et al identify fear of offending patients as a screening barrier. Previous studies have demonstrated that some women do object, especially if they are not in an abusive relationship. For example, Gielen et al reported that 59% of non- abused women and 46% of abused women objected to routine screening.2 Some researchers find a lower objection rate – for example 15% of 406 female patients in a cross-sectional study.3 The variability of these results will reflect the type of sample and the nature of the screening tool, as well as other factors. In Zink et al’s convenience sample of 32 identified victims of IPV, some participants reported that they had been offended when asked by their doctors, while others appreciated being asked. Similarly, a New Zealand study found 11/56 (19%) of women in victim support groups said they would not have liked their physician to ask about IPV.4 These data argue against physicians routinely asking women about IPV. Zink et al draw on Proshaska et al’s stages-of-change model to explain that some women may be in the pre-contemplative stage, not wanting to make any changes. An alternative option is routine screening of adult patients for lifestyle risk factors and mental health issues. When a generic question about violence and threats ‘Is there anyone in your life of whom you are afraid, who hurts you in any way or prevents you doing what you want?’ was embedded in a screening tool asking about smoking, alcohol, illicit drug use, gambling and other lifestyle risk factors, only 10 out of 2500 primary care patients (0.4%) objected to this question.5 As well as not causing offence, this question may detect at-risk patients who are not female victims of IPV. For example, about 20% of severe IPV victims are male, and both genders may be exposed to harmful behaviours from other people in their lives, for example in elder abuse or violence in the work place. References 1. U. S. Preventive Services Task Force. (2004) Screening for family and intimate partner violence: recommendation statement. Annals of Internal Medicine;140:382-386. 2. Gielen AC, O'Campo PJ, Campbell JC, Schollenberger J, Woods AB, Jones AS, Dienemann JA, Kub J, Wynne EC. (2000) Women's opinions about domestic violence screening and mandatory reporting. American Journal of Preventive Medicine;19:279-285. 3. Caralis PV, Musialowski R. (1997) Women's experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. Southern Medical Journal;90:1075-1080. 4. Hetrick S. Seeking help from the General Practitioner: experiences of women who have been abused [Master's thesis]. Auckland: University of Auckland; 1996. 5. Goodyear-Smith F, Arroll B, Sullivan S, Elley C, Docherty B, Janes R. (2004) Lifestyle screening: development of an effective and acceptable general practice tool. New Zealand Medical Journal;in press. Competing interests: None declared |
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