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

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

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

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