The clinician's role in the face of domestic violence

Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.

Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.

Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.

What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.

Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.

Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.

For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.

In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.

The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.

Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.

Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.

Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.

Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.

Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.

What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.

Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.

Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.

For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.

In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.

The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.

Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.

Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.

Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.

Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.

Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.

What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.

Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.

Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.

For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.

In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.

The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.

Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.

Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.