A recent study of San Francisco Bay Area physicians reports on successful intervention techniques for victims of domestic violence. The UCSF study provides insight into how physicians can intervene to help victims of domestic violence through validation of the patient's worth as a human being and by establishing a culture of caring so patients can share their concerns.
Physicians in the study used a team approach to interview victims of domestic violence, and engaged the help of nurses, rape crisis counselors, social workers, behavioral mine counselors and psychologists. The physicians prioritized domestic violence by taking the time to intervene once abuse had been identified, dealing with the abuse even if it meant dropping the medical procedure scheduled for the patient. Staff members were also educated in continuing education classes about rape, domestic violence, and child and elder abuse so that the physician's office could provide a culture of caring for the victims of domestic abuse. With this proactive environment, the physicians found that a powerful message was sent to the patient that battering is not a private, shameful issue, but a health care issue of great concern. The physicians reported that the victims of domestic violence felt comfortable in a culture of caring so they could share their concerns with the health care providers.
The study was based on six focus groups with a total of 45 physicians from primary care (family practice and general internal medicine), obstetrics and gynecology, and emergency medicine. The physician participants identified an average of 28 patients per year as having been physically abused by an intimate partner, and thought they had helped approximately 60 percent of the patients. The study is published in the October issue of the Journal of Family Practice. Lead investigator is Barbara Gerbert, PhD, UCSF professor and chair of the division of behavioral sciences in the School of Dentistry's department of preventive and restorative dental sciences
"The most common intervention was validation, indicating the victim's worth as a human being and that abuse was undeserved," Gerbert said. Physicians also reported that, within the context of a trusting relationship, they tried to break through the denial presented about the seriousness of the victims' experiences. "Another tactic was to listen to the victim nonjudgmentally," explained Gerbert. The physicians emphasized the need to maintain a healing attitude by banishing criticism, blame and judgment. Achieving a supportive environment was difficult and required relinquishing the desire to "fix it" by treating the women as competent adults, the physicians reported.
"A recent survey of battered women rated validating statements and compassion from the physicians as among the most desirable interventions and equal to safety planning and offering referrals," Gerbert said. Survivors of domestic violence described how validation from a health care professional not only provided relief and comfort, but triggered a realization of how serious the situation was.
"The physicians also used medical charting and took photographs of any injuries with Polaroid cameras, then referred the patient to information services such as resources and shelters while discussing a plan for safety," Gerbert said.
Through role-playing, some physicians were able to tell patients about others who were in the same type of situation and who had found a safe place to heal. As part of a plan for safety, the physicians suggested that patients keep a suitcase packed, have 24-hour hot line numbers for safe places readily available, and learn what circumstances should cause them to call the police.
The study physicians were careful to consider safety from the battered woman's point of view and to take preventive measures to protect the victims. These tactics were acknowledged by physicians and survivors as planting the seeds for change in this area of health care.
Gerbert and her colleagues offer a model for health care professionals in the field of domestic violence, using the acronym AVDR: Health care providers should:
- Ask patients about abuse
- Provide Validating messages that battering is wrong and the patient is a worthy individual
- Document presenting signs, symptoms and disclosures in writing and photographs and
- Refer victims to specialists in domestic violence.
Specialists from the community then can assess patient safety and make appropriate safety plans.
There was a wide range of personal rewards for the physicians in the study. Some physicians reported seeing patients change their lives; others reported shifts in the way a woman viewed herself and the relationship with the abuser.
One physician said, "And the rewarding piece for me comes when at some point, she looks up and notices, and you can see this change of realizing she's cared about, and then what that must mean to her: that she's worth something... then later on [there are] those little steps that you see people make when they feel like they're worth something. That's the most ongoing and rewarding thing."
Physicians participating in the study had an average age of 43 years; 53 percent were women and 21 percent were men. Primary care was the major medical specialty for 47 percent of the physicians, and more than 51 percent practiced in a group setting.
Co-authors of the study are Nona Caspers, MFA, UCSF senior editor; Nancy Milliken, MD, UCSF associate professor, obstetrics and gynecology; Michelle Berlin, MD, MPH, assistant professor, obstetrics and gynecology and epidemiology, Center for Clinical Epidemiology and Biostatistics, Hospital of the University of Pennsylvania, Philadelphia; Amy Bronstone, PhD, UCSF staff research associate, preventive and restorative dental sciences; and James Moe, PhD, UCSF staff research associate II, preventive and restorative dental sciences. Lead author Gerbert is also Director of the Center for Health Improvement and Prevention Studies. The study was funded by a grant from the National Institute of Mental Health.