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Clinical guidelines

Abuse and violenceWorking with our patients in general practice

Chapter 4. Intimate partner abuse: responding and counselling strategies

Key messages

  • Intimate partner abuse is strongly associated with mental health issues, which should be treated by health practitioners with a good understanding of violence against women3
  • Women and their children are at increased risk at the time of separation. This process needs to be carefully planned to maintain safety65
  • Intimate partner abuse is an issue for the whole community. Health practitioners have a role to play3 and need to see themselves as part of the wider intervention – domestic violence services, legal, police, housing – that needs to occur to support survivors

Recommendations

  • A range of counselling approaches, including motivational interviewing strategies, provide support and are effective in assisting women to discuss safety and reduce depressive symptoms in general practice2 Level II B
  • Health practitioners should offer to refer women who have post-traumatic stress disorder (PTSD) and who are no longer experiencing violence for trauma-informed cognitive behavioural therapy (CBT)3 Level I B
  • Pregnant women who disclose intimate partner abuse should be offered empowerment counselling and advocacy support by trained health practitioners3 Level I B
  • Health practitioners should offer children who have been exposed to intimate partner abuse a referral for psychotherapeutic counselling or small group therapy3 Level I B

Introduction

Once we have overcome the many barriers to identification (Chapter 2), there is a role for ongoing follow-up, support and referral. GPs working in the Northern Territory need to be aware of the mandatory reporting requirements for domestic and family violence (visit www.1800respect.org.au/ workers/fact-sheets/mandatory-reporting -requirements).

Key ingredients to effective engagement, counselling and support include:

  • continuity of care
  • a sensitive, non-judgemental approach to enquiry
  • a good understanding of available community resources and barriers that these women face
  • ongoing support (refer to Chapter 2).

In a consultation with a victim of intimate partner abuse, you should:

  • demonstrate that you believe the patient
  • provide a strong statement that violence is never okay
  • make an assessment of their risk and safety (including any children) (refer to Chapter 3)
  • provide information about possible referral and support services
  • make an offer of ongoing support.

There are a number of challenges for GPs responding to intimate partner abuse, including feeling overwhelmed and managing personal experiences of abuse (refer to Chapter 14).

A range of responding and counselling strategies may assist patients experiencing intimate partner abuse. GPs interested in mental health may undertake this work themselves – while other GPs will prefer to refer patients to domestic violence services, social workers, psychologists, women’s services, and other community workers. GPs need to decide on their own skill and comfort level in this area and seek further training and resources.

GPs working in rural areas, with fewer services, might offer their patients phone counselling through the national telephone service 1800RESPECT (www.1800respect.org.au). They could consider offering access to this at their practice if the patient had no other opportunity to make a call or would be at risk if they tried to do this from home. This service can also offer help and information about services to the GP and practice.

This chapter outlines how we can respond to, follow-up and counsel our patients in a time-efficient manner. It also includes how to work appropriately with other services and refer to other practitioners to enable pathways to safety and healing.

The counselling strategies we use need to be:

  • effective
  • appropriate and possible in a GP setting
  • acceptable to patients and GPs
  • cognisant of the issues of disclosure and engagement.

Counselling approaches

In addition to safety assessment and planning (Chapter 3), effective counselling strategies that can assist survivors include CBT, motivational interviewing66–69 and an understanding of the behaviour change process.70–79

Motivational interviewing

Motivational interviewing (MI) is a patient-centred clinical intervention intended to assist in strengthening motivation and readiness for action.67 With intimate partner abuse, a woman’s ability to change her situation may be very limited. It is important that MI is done with safety as the foremost concern for women and their children.

One goal of MI is to elicit and reinforce ‘change talk’ from the patient.67,69,80 In MI, the focus is on reflections and questions on topics that relate to ambivalence and action – what might promote action and what makes it difficult or inhibits it. The skillful MI counsellor is attuned to change-relevant content in the patient’s behaviour and communication. Their thoughtful reflective listening statements help to facilitate action. At the same time, adopting the spirit of MI helps to affirm explicitly the client’s autonomy and choice with respect to what, whether, and how to change.

A core component of the MI approach is the MI spirit – a mix of skilful counselling style blended with a clear patient-centred approach. Key elements of the MI spirit include:69

  • A collaborative, rather than authoritarian, approach – the GP actively fosters and encourages power sharing in the interaction in such a way that the patient’s ideas substantially influence the direction and outcome of the interview. Gaining a better understanding of the patient’s ideas, concerns, expectations and preferences through using the MI approach increases shared decision making. Information is actively shared and the patient is supported to consider options and to achieve informed preferences.
  • Evocation – the focus is on the patient’s own motivation rather than trying to instil it. The GP works proactively to evoke the patient’s own reasons for action and ideas about how change should happen. All patients have goals, values and aspirations. Part of the MI approach is to connect health-related behaviour with the things that patients care about.
  • Honouring and respecting the patient’s autonomy – the MI process actively supports autonomy by building good relationships, respecting both individual expertise and competence and interdependence on others. Patients can and do make choices and it is ultimately their right to choose what they wish to do – patient self-determination is respected. Specifically, patients have the right to follow their own preferences and make their own decisions even if these are regarded as problematic by others.

MI is different to the transtheoretical model of behaviour change. The latter is intended to provide a comprehensive conceptual model of how and why changes occur, whereas MI is a specific clinical method to enhance personal motivation for change.81

The transtheoretical model of behaviour change (TTM) is commonly referred to as the ‘stages of change’ model and has been used in many clinical settings to determine patient readiness for action, including intimate partner abuse and other types of abuse and violence.2,82–84 While the stages of change model can be useful, transition through the model is not usually linear. External factors, for example, social isolation or a lack of finances, may inhibit a woman being able to make any changes to her situation. More importantly, there is limited rigorous evidence of the effectiveness of the stages of change approach as the preferred counselling approach for women who are victims of intimate partner abuse.2,83,85 It is preferable to maintain a degree of flexibility rather than adopting a rigid approach when choosing intervention strategies.86

The stages of change, as applied to intimate partner abuse, can be categorised into five components outlined below. It is important to keep in mind the limitations outlined above.

  • Pre-contemplative – the woman is not aware that she has a problem or holds a strong belief that it is her fault. Awareness is a key issue that you will wish to work on with your patient.
    • Suggest the possibility of a connection between symptoms and feelings of fear using the woman’s terms.
  • Contemplation – she has identified a problem but remains ambivalent about whether or not she wants to or, more importantly, is able to make changes. If the perpetrator is also a patient of the GP, this may generate ambivalence in the GP.
    • Encourage possibilities for change should she decide she needs them. Point out that you are available to help and support her on the journey.
  • Preparation/decision – the catalyst for change has arisen, whether it is concern for children or a realisation her partner won’t change. Change talk is more apparent.
    • Explore resources. Respect her decision about what she wants to do – for example, talk to family/friends/counsellor, leave the relationship, obtain a restraining order.
  • Action – a plan devised in the previous stage is put into action.
    • Offer support to carry out the plan and ensure safety planning is in place.
  • Maintenance – the woman’s commitment to the above actions is firm.
    • Praise whatever she has managed to do and support her decision.
  • Returning/relapsing – the woman may feel compelled to reverse action. Reasons include finding life too stressful, having limited or no access to children or resources.
    • Support her even if she returns to the relationship, doesn’t see a counsellor or fails to report abuse. Reassure her that this pattern of behaviour is common for women.

Getting started – raising the issue

Raising the issue can be challenging (refer to Chapter 2). Women are not likely to disclose abuse unless directly asked87 and many GPs don’t ask.88 Understanding the factors that contribute to disclosure and engagement in discussion is the first step in the process. It is also important to have an index of suspicion, especially with some typical presentations. For example, it may be a patient you have seen for years for depression, persistent headaches or vague somatic complaints. Begin to explore the possibility that they are experiencing violence or have experienced violence in the past with general and then specific questions (refer to Chapter 3).

It may be important that you simply suggest the possibility of a connection between what may be happening at home or in the past and their presenting symptoms.

Often people who have these types of health problems are experiencing difficulties at home. Is this happening to you?

Sometimes these symptoms can be associated with having been hurt in the past. Did that ever happen to you?

It is useful at this, and any, time to signal your support and acknowledgement that any violence is not acceptable. It is ineffective at this point to suggest leaving the relationship, but any message of support and identifying that alternatives exist, may be a trigger for action.2,72,85,87 Remember that women are at greatest risk of being a victim of homicide around the time of leaving. Therefore, planning when, and how, to leave needs to be done carefully to maintain safety.

There are a number of barriers (refer to Chapter 2) to disclosure, particularly in small or rural communities – for example, not wanting the GP to think badly of the perpetrator, particularly if there is a family doctor who also sees other family members. There is often also a fear of repercussions and consequences, particularly in small, interconnected and isolated communities where anonymity cannot be maintained. Women in rural and remote areas may also find it more difficult to seek help or end a violent relationship. A range of factors may compound the isolation that survivors already experience as part of the abuse, such as:

  • access to services
  • concerns about maintaining confidentiality and anonymity
  • the stigma attached to the (public) disclosure of violence
  • lack of transport and telecommunications.89,90

Table 8 outlines some of the contributors to both disclosure and engagement.

Table 8. Strategies to increase disclosure, engagement and readiness for action in women who experience intimate partner abuse
IssueWhat is neededDescription and commentsReferences
Healthcare worker characteristics Clinician attitudes, judgements and behaviours
  • Clinicians need to be non-judgemental, empathetic, active listeners, respectful, and compassionate. There must be development of trust
  • Importance of recognising/supporting patient autonomy
43,91
Raising the issue Setting the agenda communication and counselling skills Open questions, reflection and active listening, sensitivity non-judgemental enquiry, expressing empathy 2,43,92
Enquiry Ask about emotions and safety
  • Ask about the woman’s fears and concerns – anxiety, shame, self-blame, loneliness, humiliation and embarrassment are commonly associated with a reluctance to disclose
  • Assessment of safety (victim and any children) is important – What does she need in order to feel safe? How safe does she feel? Has the violence been escalating?
43,91
Reluctance to disclose Linkage to the presenting complaint Increasing awareness of how intimate partner abuse is a contributor to the woman’s presenting complaint – have a suspicion of intimate partner abuse when women present with anxiety, depression, substance abuse and chronic pain 2,95
Complexity Insight Women want GPs to have a deeper understanding of the complexities of their situation and circumstances. GPs need to gain an understanding of how the woman views intimate partner abuse and what are their identified supports 43,71,96
Validation Legitimisation of experiences Affirmation of experiences – address misconceptions eg it’s my fault, I deserve it
GP: You do not deserve this and it is not your fault
43
Vulnerability Asking about and acknowledging vulnerability
  • Cognitive behavioural strategies and motivational interviewing techniques
  • Promotion of patient autonomy, empowerment
2,68,93,97,98
92,93,99
Time Sufficient time to discuss Even brief interventions are valued, allowing the woman to progress at her own pace 43,91
Decision making Collaborative approach Shared decision making, identifying turning points:
  • protecting others from the abuse/abuser
  • increased severity or humiliation with abuse
  • increased awareness of options/access to support and resources
  • fatigue/recognition that the abuser is not going to change
  • partner betrayal or infidelity
78,85,100
Ambivalence Exploration of the value of changing and eliciting change talk
  • Enquiring about ambivalence and motivation to do something
  • Change talk includes:
    • desire to change (I wish ... I would like to …)
    • ability (I could, I can, I might ...)
    • reasons (specific arguments for change), need (statements about the need to change)
    • commitment (I will, I am going to …)
    • taking steps (this week I started …)
69
Privacy and confidentiality Secure environment Reassurance of privacy and confidentiality, ensuring continuity of care 43,71,100

Exploring ambivalence

Many women who are abused express ambivalence about taking action, even if they have identified a concern (or perhaps even a problem).

Yes, I know my husband beats me occasionally, but in between he’s okay. He’s not nasty to the children and he treats me well.

Yes, my father was very hard on us … but we were really a happy family.

‘Yes, but’ is the classic phrase associated with ambivalence. Part of the person wants to acknowledge the abuse and another part does not.

It is useful to encourage patients to look at possibilities should they decide to do something. Just pointing out that there are options, that violence in any form is wrong and that they do not have to put up with it, will help to establish trust, build self-esteem and identify you as a supportive agent.100

Whatever you decide to do about the situation, if you think I can help, please let me know. I am happy to discuss this with you and we can explore the options together.

To gain some understanding of how a relationship is perceived by your patient, you could get her to fill out a healthy relationship tool and motivational interviewing tool. Ask her to rate how the relationship is going, on a scale from 1 to 10. If she rates it as only 1 or 2, ask what she would need to happen to change this to a 4 or 5. This should provide some insight into what the woman thinks might contribute to a turning point.

Similarly, if she rates it as a 7 or more out of 10, try to get a more complete picture of her situation by asking her why the rating was a 7 and not a 2 or 3. This should give you a sense of why this relationship is important to the patient. Asking what would make it a 9 or 10 may also shed light on what else needs to happen. A decision-balance matrix is also a constructive tool to explore a patient’s ambivalence about her partner and the relationship.80 Emphasise that the reasons entered in the boxes should be her own reasons, not what someone else has told her.

The GP needs to consider both dimensions of exploring a ‘decision balance’ – the emotional as well as the cognitive. On an intellectual level the woman may have a clear understanding of her circumstances and may acknowledge that she should leave. However, the fear associated with leaving the relationship and coping alone may be incredibly strong, and she may feel emotionally ill equipped for the enormous physical and emotional effort involved in making the changes.

Fear and the sense of powerlessness engendered by intimate partner abuse can be a prevailing deterrent for survivors trying to move forward and away from abusive partners. Often regaining confidence and emotional strength can be a gradual process, so that even small advances are initially viewed as real hurdles. GPs need to be aware that moving out of an abusive relationship may take quite some time; sometimes years. The GP can be an important source of ongoing support and strength if they are non-judgemental of the rate of change and supportive of the decisions and choices the survivor makes along the way.

Useful interventions include:

  • affirming the abuse is occurring – that is, believing the patient
  • assessing the risk to safety of the patient and any children
  • assessing the level and quality of social support available
  • documenting the abuse
  • educating the patient about abuse and the cycle of violence and how it affects health
  • exploring options
  • discussing a safety plan
  • knowing resources for domestic violence support agencies
  • making appropriate referrals.

What finally prompts women to take legal action, leave or change?

Most victims have to begin to reject their own reasons for staying in the relationship. The abused woman needs to stop believing that violence is normal. This may be a greater problem with women whose own parents have been violent. In order to be able to leave or take legal action a woman needs to:

  • stop excusing her partner of being sick, mentally ill, alcoholic, unemployed or under great stress
  • stop blaming herself, and stop believing she is bad, provocative or responsible for the violence
  • stop believing and hoping that if she is good her partner will not abuse her
  • stop pretending that nothing is wrong, and hiding or minimising her injuries
  • stop believing her children would be disadvantaged if she and they were to leave
  • stop believing that her partner will change
  • start believing that there are other options.

Turning points

Often something happens to tip the scales in favour of taking action. This may be triggered by a specific event or just an accumulation of experiences.

Common reasons given for reaching a turning point include:85

  • protecting others (eg children) from the abuse and the abuser. It may be that the perpetrator has started to hit the children. Many women in abusive home situations tolerate the violence ‘for the sake of the children’, but when they too are subjected to it, this can be the catalyst for change
  • increased severity or humiliation with abuse. The abuse may have escalated to a ‘new’ level. It may be that the first incidence of physical abuse has occurred or a more serious episode of physical abuse has occurred causing injury, or a serious threat has been made which leads to a change in the woman’s sense of her and her family’s personal safety if she does nothing
  • increased awareness of options and access to support and resources
  • fatigue or recognition that the abuser is not going to change
  • partner betrayal or infidelity.

Common ‘change talk’ statements when a women has reached a turning point may relate to desire to change (I would like to …), ability (I can ..., I might be able to ...), reasons (I would probably feel better if I ..., I’ve had enough), need (I ought to, I really should …) commitment (I am going to, something has got to change) and taking steps (this week I started to …).

It is important that the GP is aware of local and other resources the patient may have within their own social network and family. It is good to clarify:

  • What is it that the patient wants to do? Is this realistic and possible? The patient may need to explore alternative options.
  • How does she intend to go about it? Assess current level of risk and discuss a safety plan.
  • What role does she want you to play? Consider the legal issues – for example, documenting injury and impact and referrals to intimate partner abuse counselling and services).

The GP has a role when the patient has decided to act and taken some initial steps. Non-directive problem-solving techniques can help at this time (refer to Tool 5. Non-directive problem-solving/goal-setting tool).

Understanding and discussing her plan is helpful. Actions may include:

  • talking to family and friends
  • changing the locks on the house
  • going to see a counsellor
  • talking to someone at a refuge or shelter
  • leaving the relationship
  • taking out an intervention order
  • reporting the abuse to the police.

Maintaining change is often extremely difficult. Most of the time it does not become apparent what change actually means until it has been achieved. For example, if a woman leaves and finds it emotionally more difficult to be on her own than to deal with violence, she is likely to return. If through leaving she has been denied access to her children, she may also feel compelled to return.

Providing ongoing support and assistance is vital.

There are many reasons why people return to violent situations, but enjoyment of the violence is not one of them. It may be that several attempts to leave are made before long-term success is achieved. While it may seem that the patient is making an unwise choice, it is more productive to get a better understanding of why the patient chooses to stay. There may be very compelling reasons why the victim believes they cannot leave. Making judgements about the merit of the decision is rarely useful and may alienate the victim. It is useful for GPs to understand the circumstances why this has occurred and what the woman wants.

What happens to women after they leave?

Some women receive help from family and friends. Women’s shelters or refuges are available, although this support may be limited depending on location and whether a bed is available. In the situation of a patient leaving her partner, it may be at this point that you lose contact with the patient. The patient may move to safety at a friend or relative’s home, a refuge or out of the area, and there may be extremely good reasons why a survivor needs to sever links with her GP.

Problems experienced by women once they leave an abusive partnership include:

  • risk of further abuse
  • financial – many women experience a dramatic fall in living standard – for example, they have to claim the Supporting Parent’s Benefit
  • loneliness – the need for companionship and a sense of belonging is important to most women
  • the need to rebuild their lives and those of their children.
Many women re-partner, but the longer a woman stays in an abusive relationship, the harder it becomes to leave and re-establish a normal life. Some women carry the scars of physical, sexual and emotional abuse into the future. Anecdotally, around 50% of women who leave a relationship will return to that relationship at some point. Some may enter another abusive relationship. Few will recover totally from the experience.

Warm referrals

Many women do not follow through with GP referrals. There are some things you can do to make it more likely that a woman seeks the help you have recommended. If she accepts a referral, here are some things you can do to make it easier for her:

  • Offer to call to make an appointment for her if this would be of help – for example, if she doesn’t have a phone or a safe place to make a call.
  • Provide her with the written information she needs – time, location, how to get there, name of the person she will see.
  • Tell her about the service and what she can expect from it.

If she expresses problems with going to a referral for any reason, help her to make a decision using non-directive problem-solving techniques. Barriers may include childcare, transport, fear that the partner may find out. Always check to see if she has questions or concerns, and to be sure she has understood.

Conclusion

If GPs want to undertake supportive counselling, there are specific techniques that are helpful, including MI and non-directive problem solving. Not all GPs will feel comfortable providing this. Active listening is a simple supportive intervention in itself. Warm referrals to other professionals can also assist women on a pathway to safety, healing and recovery.

Case study: Mary

Mary is a professionally employed woman in her late 40s who experienced significant intimate partner abuse during her (now-ended) 23-year marriage. Before leaving her abusive partner, the violence escalated and she reached a crisis where her physical safety was seriously threatened. She identified a turning point when she recognised her domestic situation was abusive.

A turning point for me in my journey out of my abusive marriage was gaining access to domestic violence literature. I remember sitting with a small publication in my hands and reading through a list of different types of abuse: emotional, psychological, social, financial, physical, and a list of common behaviours in these categories. I was in a state of shock because I could tick most of the categories and behaviours on the list as ‘my life’. The book also discussed the ‘cycle of violence’ and I could identify closely with the patterns it described. I had always considered myself an intelligent, well educated person but the ‘cycle of violence’ occurring in my life had created so much confusion that I was unable to put it all together and understand that this was systematic cyclic abuse being used to control me and that living with the stress was making me increasingly physically sick. I could not deny it to myself any longer.

Mary confiding in her GP and friends and their ongoing support was pivotal in changing her internal dialogue, providing the reality check she needed to confront the pattern of violence and become more confident and decisive about changing her circumstances.

It took a long, long time for me to give up the hope, the dream that things were going to change. I had adopted a strategy of forgetting abusive events as quickly as possible as a means of coping and surviving. It often came as an enormous shock when my GP or friends reminded me of an event or how I had felt at the time because I was editing my consciousness, trying desperately to dwell on the good things and kindnesses that always followed the abusive episodes that left me incredibly emotionally vulnerable and usually quite unwell physically.

During a particularly bad period in my marriage, my GP suggested that I see a psychiatrist. This was helpful because he affirmed that it was my domestic situation that was making me ill and that it was my husband who needed therapy. This was very empowering for me to hear. The medication [given to me by the psychiatrist] helped to stabilise my mood, and my personal strength and ability to think more clearly began to grow. My husband had repeatedly refused to seek any counselling or therapy during the 23 years we were together.

Later on, I confided in one of my university lecturers that my home situation was affecting me very badly and I was having problems coping with my course. She suggested I speak to a professional and referred me to a therapist she knew. The therapist worked intensively with me with a focus on the future. She helped me to explore ways that I could make changes and gain some control over my life. She helped me to set goals and identify tasks that needed to be done. She recommended a change in medication and encouraged me to open my own bank account and make extra keys and arrange somewhere I could go in an emergency. I suppose this is when I finally decided I would leave because I now believed I had the strength and support to do it.

Following the first incident of serious physical violence I saw my GP who documented my injuries and counselled me at length. She, better than anyone, knew my history and she was as frightened for me as I was for myself and told me that I must leave him now – she had never articulated her fears for me so strongly before. We discussed my options and explored my available supports and I left the appointment feeling completely numb and paralysed. However, I was now determined to leave and my thoughts were preoccupied with putting as much in place as possible in the 2 months leading up to the night the death threats occurred.

I can’t even remember what the trigger was on that Saturday night but he was very drunk and he had just lost the job he had recently started. I sat frozen with fear on my bed for hours while he screamed at me that he wanted to kill us both. I could not get out of the house but I managed to lock myself in a bedroom and waited till he left the house the next day before leaving the room. That day I went to see my mother to see if I could stay with her for a while but she was frightened. I went home and locked myself in my room again overnight. On Monday I went to work and spoke to a friend who is a GP and academic and he listened and counselled me at length. He advised me to contact the police to seek assistance, however, I was told there was nothing they could do while I was living in my home with my husband. I never went home again. I had nothing with me except my handbag and the clothes I was wearing.

In the first few weeks after leaving I was very ill, both physically and emotionally. The sense of loss and grief for the life I had known for the past 23 years was immense; my home, my garden, my pets and everything I had created was in that house. I could barely function, bursting into tears constantly night and day – I just couldn’t control it. I was extremely anxious. I couldn’t eat … I couldn’t sleep without drinking alcohol. I felt like there was an electric current vibrating through my whole body and I just wanted it all to stop. I found myself thinking that if I could get home again, this violent emotional upheaval and the painful physical symptoms would go away. This is not what I wanted, or how I wanted my life to go. It was the most awful, distressing time of my life. I felt like I would have accepted comfort from almost anywhere. I was incredibly vulnerable and frightened that my husband would follow through with his threats to suicide. I was terrified for my own personal safety and was very concerned that I was putting my mother’s safety at risk by staying with her.

This time I did not go back even though I considered it many times … I knew I would not survive if I did and the many small steps I had made towards independence with the help of a number of people, including my GP, meant that I now had the strength, health and support to leave.

Mary’s story: 7 years on

It is now 7 years since I left my abusive marriage. A couple of months after I left and had resettled into a new home, my husband broke into my house and attacked me. I honestly thought I was going to die that night. A friend arrived shortly after he had left and saw I was injured and badly shaken and insisted we call the police. They arrived quickly and this time they responded very differently because we were no longer living together. I laid charges against my husband and arranged a restraining order. While I had some sense of support from the police, I certainly did not feel safe as he had again threatened to kill us both. The following 6 months was the loneliest time in my life, being in that empty house alone and terrified he would come back again. Friends and family didn’t feel safe to visit me. I started to drink alcohol to cope and to numb my feelings. I drank too much for quite a long time.

Friends and family became aware that I was drinking too much too regularly and confronted me about it and I did see a psychologist a few times. I just didn’t care that much about myself at the time to take health warnings seriously. I was so desperately upset and anxious most of the time. I felt awful so I self-medicated with alcohol. It was really my secret life. I never drank when I went out or when I was with company. But once I was inside my front door I would pour myself a glass of wine and often I couldn’t stop until I fell into bed after cleaning the house for hours almost obsessively.

I left my marriage and survived, but while the high risk period just after leaving is far behind me, I have ongoing health and psychological problems to this day. Recurring traumatic nightmares have been a persistent problem for me. It is not unusual for me to wake up screaming and incredibly distressed two to three times a week. I am acutely sensitive to aggression even on TV. Just witnessing aggression will trigger a traumatic nightmare. I have had persistent sleep problems also. I frequently wake up at night and cannot get back to sleep. Work and financial pressures can trigger episodes of anxiety that I feel totally incapable of getting under control. These episodes can last for weeks at a time when I live with an internal tremor, a fluttering feeling in my chest and pounding in my temples and enormous tension despite being on antidepressant medication. During such episodes my blood pressure rises considerably, I feel very very unwell, cannot sleep and my work and relationships suffer. I just start to hide and avoid anything that further exacerbates the tension and anxiety. I have had three serious episodes of ulcerative colitis over the past 7 years.

The impact on my professional life has been considerable, due to my health and sleep problems. I have needed to take quite a lot of sick leave at times.

Unfortunately my GP stopped practising a couple of years after my marriage ended, so for a long time I did not have a GP at all and did not see a doctor. I couldn’t face the prospect of starting over with a new GP and having to tell my story and make someone else understand the background to my health problems. I think it would have made a huge difference if I had had the ongoing support and care of my GP over the past 7 years.

I have recently found a new GP who has helped me to understand that I have a type of PTSD that needs to be treated and managed with medication and therapy. It was a relief really to have someone identify it as PTSD and start to explore options for treatment with me. I am beginning to gain more of a sense of control, that things are not so hopeless, and that in time I will not feel so exhausted and overwhelmed. I have been somewhat immobilised by the tiredness. I felt I couldn’t plan for the future because I just didn’t have any energy. I really can’t say I have been happy or that I have enjoyed life for a very long time. All I have been able to manage is to keep putting one foot in front of the other to keep life together.

My advice to anyone going through post separation after living in an abusive domestic environment is to maintain those precious relationships that will be your lifeline – including your GP. Keep regular contact with your doctor so you get the support you need to manage the inevitable health issues you will more than likely experience. I feel incredibly fortunate to have had the support of my mother and a wonderful group of female friends and some special work colleagues who have stood by me but looking back, I should have sought out more professional help along the way. It could possibly have reduced the health impacts of intimate partner abuse a great deal for me.

Looking back now I realise what a pivotal role my GP had in my journey out of my abusive marriage. One of the most powerful techniques she used with me was reminding me of why I had come to see her the last time and asking how things had gone over the following week or two. It forced me to remember and face the considerable distress and effect on my health being caused by my husband and to relate it to the current situation and state of my mental and physical health.

I also think that is it was really helpful to imagine that someone else, someone I love, was experiencing the same treatment that I was and to be asked how I would feel about that. I seemed to have a far greater ability to put behaviour into acceptable versus non acceptable categories when it was associated with someone else. Perhaps my GP’s greatest gift to me apart from managing my health problems was helping me to achieve coherence with regard to my current situation and a possible alternative future. I know she was instrumental in saving my life and I cannot emphasise enough the importance of the role she played.

Resources

Please refer to Tool 7 for resources nationally and in your area.

Further information

References

  1. Taft A, O’Doherty L, Hegarty K, et al. Screening women for intimate partner violence in healthcare settings. Cochrane Review. The Cochrane Library, 2013.
  2. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
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