Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation

Participants

Thirty-two mothers who were victims of IPV and who were staying in local (urban and small-town) shelters or participating in community IPV-support groups in southwestern Ohio were invited to participate in the study through flyers distributed by agency staff during March 2000 and September 2001. Shelters and support group locations were chosen for their diverse pool of subjects with ethnic (African American or white), geographic (urban and small town), and socioeconomic variation.

Interview Protocol

Interviews were conducted privately without children present by the same female physician. Each interview lasted approximately 1 hour. After obtaining consent and collecting demographic information, the conversation was audiotaped and transcribed. Participants were asked to “describe the situation that brought you here,” which usually elicited the abuse story. They were then questioned about their experiences when seeking health care and their preferences about IPV screening in front of their children. Interviews were conducted until we had heard no new information about preferences for screening with the children present (not analyzed in this study). Interview questions are listed in Appendix 1, which is available online at: http://www.annfammed.org/cgi/content/full/2/3/231/DC1.

Initial Analysis

Using immersion-crystallization techniques,³³ a team of 4 researchers with qualitative experience (2 family physicians, 1 anthropologist, and 1 psychologist) read and coded the 32 transcripts. While performing these initial analyses about the mothers’ preferences about screening with the children present, we learned that deciding to come to a shelter or join a support group was a process and that participants had taken a number of steps and weighed a variety of factors, including considering whether their relationships were abusive, before taking action.³⁴

Given these findings, we reviewed the IPV literature and discovered several models of how victims come to terms with IPV.^35–,³⁸ One model was the stages of change (transtheoretical model),^39,40 which is familiar to many primary care physicians for helping patients make behavior changes. There are 5 stages of change: pre-contemplation, contemplation, preparation, action, and maintenance. In attempting to make a change, an person cycles through the stages, often moving back and forth between contemplation, action, and maintenance.³⁹

The stages-of-change model matches modifications in attitude and behavior with tools used by the individual altering his or her behavior.⁴¹ Prochaska et al^39,40 identified 10 tools that are cognitive-affective or behavioral activities. The cognitive-affective tools (consciousness-raising, dramatic relief, self-reevaluation) are used during precontemplation and contemplation. Behavioral tools are used in the action and maintenance stages. Using the right tool for each stage is important.

Several authors have examined the stages-of-change model applied to behavior change in IPV, both with the abuser^42,43 and the victim.^38,44,45 No study has examined the victim’s perceptions of physician management in light of the stages of change. Whereas many factors shape the victim’s process of managing the abuse, the victim clearly has some control over how he or she chooses to respond to the abuse, and it is, therefore, important that victims’ processes be carefully described and examined.

Subsequent Analysis of Stages-of-Change Model

To organize this analysis,³³ our team purposefully chose 4 of the 32 transcripts to create an initial codebook.⁴⁶ The 4 transcripts were chosen because of the participants’ rich descriptions of their experiences, as well as their diverse backgrounds (ethnicity, socioeconomic status, urban and small town, and shelter resident and living with abuser). The team read the 4 transcripts independently, and then met to discuss the initial code-book. The remaining 28 transcripts were then divided between the 4 team members, with the principal investigator (PI) reading all of the transcripts. The PI met with each researcher to discuss coding within the individual transcripts, and disagreements were resolved by consensus. After all 32 transcripts had been read and coded independently and cooperatively by at least 2 researchers, the entire team met again to discuss thematic development.^33,46,47 Segments of the transcripts were coded for the stage of change (precontemplation, contemplation, action, maintenance) represented by the victim’s thoughts or behaviors. Within each stage we identified the victims’ opinions about the care they received or wished they had received from physicians. Although all mothers had taken the action of seeking help (shelter or support group), some were mandated to do so by the court or child protective service. As a result, victims’ stories focused on their early processes of understanding that their relationships were abusive (precontemplation) and of weighing the pros and cons of how to manage the abusive relationship (contemplation). We therefore concentrated on these stages. Victims described a variety of factors that had or continued to affect their decisions. We categorized these into factors internal or external to the abusive family.

Finally, we reexamined our evolving model in light of the stages of change and IPV victims’ process literature. Drafts were presented to a convenience sample of 10 primary care physicians who were chosen because of their familiarity with the stages of change. As a result of these meetings, minor changes were made to improve clarity.

Demographics

The mean age of our sample (n = 32) was 32 years (range 18–45 years). The average length of the abusive relationship was 6.7 years, (range 1–8 years); 28% had an ongoing relationship with the abusive partner. Additional demographic information is displayed in Table 1⇓.

Stages of Change and Physician Management

We organized this section to present 3 insights related to the stages of precontemplation and contemplation: (1) the definition, (2) the tools the victim used to make changes during that stage, and (3) management actions by physicians that participants found helpful or thought would have been helpful during a particular stage. Finally we discuss insight about the internal and external factors that affected the victims’ management of their abusive relationships. Understanding these factors may give physicians some insight into “why she won’t just leave.”

Precontemplation

Victims in precontemplation do not recognize their partner’s behavior as abusive and see their relationships as normal.^38,44,45 By inquiring about IPV, the physician is raising awareness. When asked how she would respond to a physician screening for IPV, one participant responded:

P. I would probably wonder, like, what does this have to do with why I’m here? Like, with my stomach, the irritable bowel syndrome, because maybe that could work me up or something.… I would kind of wonder why they’re asking.

This participant’s comments suggest that she may not have made the connection between the abuse and her medical condition.

Because physicians generally cannot tell which patients are in abusive relationships unless there are warning signs or diagnoses (illnesses frequently found in patients with IPV) or an abusive interaction between the patient and her partner is observed, guidelines recommend routine screening for IPV.⁴⁹ Some participants told us that at times they were offended or did not understand why they were asked about abuse. Reflecting on precontemplation, other participants who were screened by physicians appreciated being asked, and if they had not been screened, they wished that they had been. One participant remarked, “It might have sped up my process.”

Participants also indicated that they wanted IPV pamphlets available in examination rooms and bathrooms. They suggested, however, that doing anything beyond asking the appropriate screening question (raising the issue) and having resources available might be unproductive. Participants wanted physicians to be nonjudgmental and to indicate that screening for IPV was common practice.

Contemplation

During contemplation the victim sees the abusive relationship as a problem and has an increasing awareness of the advantages and disadvantages of change. Contemplation can last for years.^38,44,45 In our sample, contemplation could be divided into 2 phases: nondisclosure and disclosure

Safety Assessment and Planning

When we checked our model with physicians knowledgeable about the stages of change, they asked where safety assessment and safety planning fit in. None of our participants described a physician doing either a safety assessment or reviewing a safety plan, and none volunteered that they wanted this done by physicians. We did not probe about safety issues, however. We did find that some participants did not expect physicians to know much about IPV, as reflected in one participant’s statement, “…a lot of times people [including physicians] do not know how to handle it.”

Factors Affecting the Victim’s Process of Changing

Unlike for other behavior changes, such as quitting smoking, which may be seen as predominantly an individual struggle to change, a variety of internal and external factors had affected participants’ processes with IPV. Although the IPV victim cannot change the abuser’s behavior, she has some control over her response. Participants described the following factors internal to the abusive family that affected their choices: (1) the victim’s realities (ie, finances, education), (2) the abuser and the victim’s attachment vs perceived threat or degree of harm, and (3) the children. These factors appeared to have either helped or hindered participants’ efforts to create safety. We will present examples of each.

Current IPV Guidelines

Guidelines for managing victims of IPV grew out of the emergency medicine literature^50,51 For the most part, these guidelines recommend screening and identification, safety planning, and referral.⁵¹ These physician interventions are generally targeted to victims who have disclosed the abuse and are seeking options to end the abuse. Based on our data, we are concerned that these guidelines^19–21,51 might not adequately outline the management skills physicians need in earlier stages.

During precontemplation and contemplation, victims might not be ready to take such steps as calling a hotline or joining a support group. Instead, in earlier stages victims use cognitive and affective tools: consciousness-raising, dramatic relief, and self-reevaluation.³⁸ Table 2⇓ displays examples from our data. Consciousness-raising occurs, for example, when physicians screen for IPV. Giving feedback on an abuser’s observed behavior also raises the victim’s awareness about IPV. Dramatic relief happens when a physician verbally recognizes an emotional state or helps the victim express an emotion. These emotions can often be picked up from hints given by the patient. Levinson has called these direct or indirect comments that patients make about the personal aspects of their lives clues. When physicians picked up on clues during a patient encounter, they actually saved time and arrived at a more accurate patient assessment.⁵² Self-reevaluation occurs when the patient has enough information to examine her situation and its consequences. Physicians can assist by having resources available and educating about how abuse affects health (her own or her child’s).

Other Stage-Matched Models

The interventions suggested by our participants are sometimes at odds with other proposed stage-matched models. For example, Fraiser et al⁴⁵ lists “urge patient to think seriously about the situation” and “develop a safety plan” as interventions during precontemplation. Because our data showed that women have not yet seen the abuse as a problem, “urging the patient to think seriously about the situation” might be seen as too pushy or pejorative toward the abuser. Having pamphlets about safety planning is appropriate, but a discussion may alienate the victim during early stages of change.

Table 3⇓ displays physician interventions generated from our data in light of the current IPV guidelines.

Guidelines recommend that physicians do both a safety assessment and help the victim formulate a safety plan when they become aware that a patient is in an abusive relationship,^19–23,53 but based on our data, we think that these guidelines are focused on victims in the action stage. A safety assessment includes assessing the victim for concerns of suicide or homicide and determining whether the abuser owns a gun, has made threats about harming the victim, uses alcohol or drugs, or has hurt the children or family pets.⁵⁴

During precontemplation or contemplation, the physician can use the safety assessment as an opportunity to raise consciousness and convey to the victim concern about her situation if safety risks are present. If abuse of the children or serious threat of harm is uncovered, then a physician should follow state mandatory reporting statutes and urge the victim to take steps toward assuring her safety. When undertaking these actions, the physician walks the fine line of potentially alienating the patient and preserving her safety.

Safety planning includes helping the victim prepare to leave.⁵⁴ Although our participants did not ask for safety planning, in a study that surveyed 115 IPV victims who had sought help from IPV agencies, 25% reported safety planning done by a physician and considered it a desirable behavior.⁵⁵ Physicians might consider doing safety planning with victims who are seeking options to the abuse in the stage of contemplation. Safety plan information should be available in the examination room, but if reviewed too early, such planning may alienate the patient.

Limitations

Our participants had already taken the action step of going to a shelter or joining a support group, so their perspectives might not accurately portray the situation of women currently in abusive relationships who have not sought help. Nevertheless, this study is grounded in the experience of women who have experienced all the stages of change up to action, and our findings provide an important window into how victims want physicians to help them. Participants were interviewed for 2 different issues: (1) desires related to screening and management with their children present, and (2) experience in the health care setting related to their abuse. Data saturation was obtained for the first issue but might not have been reached for the second issue. We believed we had good data for the precontemplation and contemplation stages.

In summary, given physicians’ lack of screening and frustration with managing IPV,^3,27–,³¹ we wondered whether tailoring the physician intervention to match the victim’s stage might help to simplify management. Although a review of the literature on stages of change and patient care found no studies documenting evidence of increased efficiency or patient satisfaction when physicians use stage-matched techniques to help patients manage behavior changes, our discussions with colleagues and other anecdotal evidence suggested that stage-matched interventions might make office visits more efficient and increase physicians and patients’ satisfaction. Given the complexity of the processes of change related to IPV, we hypothesize that stage-matched interventions will streamline these processes for both the physician and the patient.