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White Book

‘Domestic’ or intimate partner abuse/violence - Chapter 4

Intimate partner abuse and violence: Ongoing support and counselling

‘Look at what I have been through, instead of what you think is wrong with me, don't pathologise me when it’s not helpful to me, and remember that medicine doesn't have all the answers’
Cina, victim/survivor, The WEAVERs Group

Key messages

  • Intimate partner abuse/violence (IPAV) is strongly associated with mental health issues for victims/survivors, which requires a therapeutic response.1
  • Health practitioners have a role in addressing IPAV2 and need to see themselves as part of the wider intervention – including domestic violence, legal, police and housing services – required to support victims/survivors.
Depending on individual needs, offer psychological therapies, including motivational interviewing, trauma-informed and mindfulness-based cognitive therapies, as these have been shown to provide support and improve women’s mental health in the short term (less than six months).
(Strong recommendation: Moderate certainty of evidence)
Offer to refer women who have post-traumatic stress disorder (PTSD) and who are no longer experiencing violence for trauma-informed therapy.
(Practice point: Consensus of experts)

After identification and providing a first-line response of LIVES (Listen, Inquire, Validate, Ensure safety, Support) as outlined in Chapter 2: Intimate partner abuse and violence: Identification and initial response and Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment, there is a role for ongoing follow-up, support and referral. This should follow trauma-informed care principles and practice.

This chapter outlines some general approaches (based on the woman’s expectations) that practitioners can take for women who have experienced IPAV, followed by specific counselling techniques using motivational interviewing. This chapter outlines how we can respond to, follow up and counsel our patients in a time-efficient manner. It also addresses how to work appropriately with other services and refer to other practitioners to enable pathways to safety and healing. Finally, we outline a whole-of-practice approach needed to support health practitioners to be ready to address the issue of abuse and violence in their patients.

What women want from their GP

‘Please seek to understand my own personal circumstances ... I am not a number ... and a pill isn’t always the answer!’
Sharon, victim/survivor, The WEAVERs Project

When disclosure occurs, victims/survivors want connection through kindness and care. A 2020 meta-synthesis3 of women’s expectations after they disclose IPAV to a healthcare provider found that women consistently want a compassionate, non-judgemental response and active support from their doctor, during and after questioning about abuse. Key themes are shown in Table 4.1.

This can also be summarised as the CARE model (refer to Figure 4.1):3

  • Choice and control
  • Action and advocacy
  • Recognition and understanding
  • Emotional connection.

When providing this support to women, it is important to:

  • not pressure women to disclose, and be aware that they may prefer to disclose at a different time
  • build a trusting doctor–patient relationship to maintain support for the victim/survivor
  • ensure that the environment is private and confidential, and provide sufficient time for consultations
  • endeavour to understand the woman’s situation and acknowledge the complexity of the issues
  • respect a woman’s choices and decisions and empower them to have control of their own life and circumstances (refer to Chapter 2: Intimate partner abuse and violence: Identification and initial response).
Table 4.1. What women want from their health professionals3
Theme Health professional actions
Connection through kindness and care
  • Demonstrate kindness, caring, empathy and respect to build trust
  • Sustain personal engagement to maintain support
See the evil, hear the evil, speak the evil
  • When listening to women, strive to understand the dynamics and context of their situation
  • Name the abuse and validate experiences
Do more than just listen
  • Ensure action and advocacy are guided by women’s needs
  • Connect women with services in the community for health safety and wellbeing
Planting the right seed
  • Tailor responses to women’s individual circumstances
  • Facilitate women’s empowerment, choice and control

Adapted with permission from BMJ Publishing Group Ltd: Tarzia L, Bohren M, Cameron J, et al. Women’s experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis. BMJ Open 2020;10:e041339.

Figure 4.1. The CARE model<sup>3 </sup>

Figure 4.1. The CARE model3

In addition to the above, a range of responding and counselling strategies may assist people experiencing IPAV. GPs who are 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 or 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 or telehealth services with mental health.

Counselling approaches

‘Please don’t forget I am more than just a 10 min timeslot … Please look at me and remember I am a person with a story.’
Emily, victim/survivor, The WEAVERs Project

In addition to safety assessment and planning, effective counselling strategies that may assist victims/survivors include cognitive behavioural therapy (CBT),1 motivational interviewing4–7 and an understanding of the behaviour-change process.8–17 For longer-term healing after IPAV, victims/survivors need access to appropriate therapeutic counselling and peer support if available, which may include trauma-focused and non-trauma-focused CBT.18

A systematic review1 of motivational interviewing, humanistic, CBT, third-wave CBT and other psychological-oriented interventions from middle- to high-income countries showed that therapies work to some extent in the context of IPAV. Psychological therapies ranged from two to 50 sessions and were delivered by a variety of staff (eg social workers, nurses, psychologists, community health workers, family doctors and researchers). The therapies showed a probable reduction in depression (moderate‐certainty evidence) and anxiety (low‐certainty evidence), but did not increase self-efficacy or safety planning, or reduce PTSD or IPAV.

Motivational interviewing

Motivational interviewing (MI) is a patient-centred clinical intervention intended to strengthen motivation and readiness for action.5 With IPAV, a woman’s ability to change her situation may be very limited. It is important that the foremost concern with MI is the safety of women and their children.

One goal of MI is to elicit and reinforce ‘change talk’ from the patient.5,7,19 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 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 skillful counselling style blended with a clear patient-centred approach. Key elements of the MI spirit include:7

  • 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 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 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.

The transtheoretical model of behaviour change that MI uses is commonly referred to as the ‘stages of change’ model. It has been used in many clinical settings to determine patient’s readiness for action, including IPAV and other types of abuse and violence.20–23

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/survivors of IPAV.2,22,23 It is preferable to maintain a degree of flexibility rather than adopting a rigid approach when choosing intervention strategies.24

The stages of change, as applied to IPAV, can be categorised into six components (refer to Box 4.1). It is important to keep in mind the limitations outlined above and also the ways of engaging women that are needed for this type of counselling (refer to Table 4.2).

Box 4.1. Working with the stages of change model in IPAV

Pre-contemplative – the woman is not aware that she has a problem, or she holds a strong belief that it is her fault. Awareness is a key issue that GPs will wish to work on with their patient.

  • Suggest the possibility of a connection between symptoms and feelings of fear, using the woman’s terms.

Contemplation – the woman 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 the woman 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 the woman’s decision about what she wants to do – for example, if she wants to talk to family, friends or a counsellor; leave the relationship; or 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 and having limited or no access to children or resources.

  • Support the woman, 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.

Table 4.2. Strategies to increase disclosure, engagement in women who experience IPAV (Practice point)

Target area

What is required

Strategies

References

Strengths and vulnerability

Asking about and acknowledging vulnerability

  • Cognitive behavioural strategies and motivational interviewing techniques
  • Promotion of patient autonomy, empowerment

6, 20, 25–27

26, 28, 29

Time

Sufficient time to discuss

  • Even brief interventions are valued, allowing the woman to progress at her own pace

30, 31

Decision making

Collaborative approach

  • • Shared decision making, identifying turning points:
    • protecting others from the abuse/abuser

9, 32, 33

Ambivalence

Exploration of the value of changing and eliciting change talk

  • Inquiring about ambivalence and motivation to do something
  • Change talk includes:
    • desire to change (‘I wish …’, ‘I would like to …’)

7

Privacy and confidentiality

Secure environment

  • Reassurance of privacy and confidentiality, ensuring continuity of care

16, 31, 33


Engaging women in care

There are key activities to keeping women engaged in ongoing support, they include exploring ambivalence, paying attention to turning points, action planning and facilitating referrals.

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.33

‘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 (refer to Tool 4.1) and motivational interviewing tool (refer to Tool 4.2). 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.

Tool 4.1. Healthy relationships tool

The health of an adult relationship encompasses a spectrum ranging from positive to negative.
Positive relationship health involves mutual trust, support, investment, commitment and honesty. It involves the exchange of words and actions in which there is shared power and open communication.
Negative relationship health involves unhealthy and abusive interactions with varying exchanges of emotional, physical and sexual violence. It involves words and actions that misuse power and authority, hurt people, and cause pain, fear or harm.

How healthy is your relationship with your current/ex partner?

Place an X on the point on the line that most closely reflects how you feel. (The X can slide along the scale)
 
Negative abuse
Positive healthy
  Unhealthy  
   

Tool 4.2. Motivational interviewing tool

Women may be anywhere along a spectrum of how they feel about their partner or ex-partner. Some may have left the relationship, with or without recognising that their partner’s behaviour was abusive. Other women may continue in relationships that are unhealthy or abusive. It is most likely that fear of their partner will have affected their emotional health, although some will not see that connection.


Example of written tool for motivational interviewing

This is a tool you can use with your patient.

GP: Taking action is often challenging for people. Below is a set of steps for examining your current situation to decide on what action you might like to take and then how motivated and confident you feel at the moment about carrying out that action.
 
Step 1 What do you like about your relationship or current situation?
Step 2 What are the things you don’t like about your relationship or current situation?
Step 3 [Summarise – GPs understanding of the woman’s pros and cons]
Step 4 Where does this leave you now?

For women who are ready to change to some extent:
 
Step 5  

For Steps 1 and 2, you may like to ask your patient to use the box below to write down her responses.
 
 
Like

Dislike
Relationship    
Action (Specify)    

For step 5, women may choose a whole range of actions and we have listed some likely options below:
  • Feel better about themselves eg do more exercise, take up yoga
  • Manage finances better
  • Become less isolated eg go to social group activity
  • Have better parenting strategies with their children
  • Improve their physical health eg. cut down on alcohol
  • Leave their partner
  • Get more understanding/affection from their partner
  • Get their partner to go to anger management classes
  • Get their partner to stop drinking/get a job/stop gambling.

These last three are obviously out of the woman’s control as it involves influencing their partner’s behaviour. Acknowledging this difficulty is important.
Next, you may ask your patient how motivated they are to carry out the actions they have suggested and what they feel they need in order to carry them out.
How motivated do you feel to carry out …………..?

You can ask your patient to place an X on the point on the line that most closely reflects how you feel. 

 
Not at all motivated
100% motivated


What would have to happen for your motivation score to increase?
How confident do you feel that you would succeed in carrying out…?

Place an X on the point on the line that most closely reflects how you feel. 

 
Not at all confident
100% confident


How can I help to increase your confidence?


A decision–balance matrix is also a constructive tool to explore a patient’s ambivalence about her partner and the relationship.19 Emphasise that the reasons entered in the boxes should be her own reasons, not what someone else has told her.

Consider both the emotional and cognitive dimensions when exploring a ‘decision balance’. 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 IPAV can be prevailing deterrents for victims/survivors trying to move forward and away from abusive partners. Regaining confidence and emotional strength is often a gradual process, so that even small advances are initially viewed as real hurdles. Be aware that moving out of an abusive relationship may take quite some time, sometimes years. A woman’s GP or other healthcare professionals can be important sources of ongoing support and strength, if they are non-judgemental of the rate of change and supportive of the decisions and choices the victim/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, 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 move from precontemplation to action (eg take legal action, leave or change)?

Most victims/survivors 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.

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:32

  • 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 the children 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 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 …’).

Action planning

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 (eg documenting injury and impact and referrals to IPAV 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 4.3).

Tool 4.3. Non-directive problem-solving/goal-setting tool

Non-directive problem solving assists individuals to use their own skills and resources to function better. For women who have decided that the abuse is damaging to their health and wellbeing, but whose intentions are not translated into action due to perceived external barriers, then problem-solving techniques may be helpful.

Remembering of course that as GPs we should not problem-solve for the patient.

Goal setting occurs in the following stages:

  • clarification and definition of problems
  • choice of achievable goals
  • generation of solutions
  • implementation of preferred solutions
  • evaluation.

When used by GPs, this technique engages the patient as an active partner in their care. It creates a framework for individuals to re-focus on practical approaches to perceived problems and learn new cognitive skills.

Whether the solution chosen by the patient is successful is not as important as what the patient learns during the process to apply in other situations. A written example of how a structured approach to problem solving can be applied with an individual is detailed on the next page.

Example of written plan for goal setting

Non-directive problem solving aims to help you:

  • recognise the difficulties that contribute to you feeling overwhelmed
  • become aware of the support you have, your personal strengths and how you coped with similar problems in the past
  • learn an approach to deal with current difficulties and feel more in control
  • deal more effectively with problems in the future.

ou are asked to follow six steps:

Step 1

Identify the issues/problems that are worrying or distressing you.

Step 2

Work out what options are available to deal with the problem.

Step 3

List the advantages and disadvantages of each option, taking into account the resources available to you. 

 

Problem

Options

Advantages

Disadvantages
 

 
   
       
 

Step 4

Identify the best option(s) to deal with the problem.

Step 5

List the steps required for this option(s) to be carried out.

Step 6

Carry out the best option and check its effectiveness.
Best option = ----------------------------------------------------
What steps are required to do this?
1.-------------------------------------------------------------------
2.-------------------------------------------------------------------
3.-------------------------------------------------------------------
 

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/survivor believes they cannot leave. Making judgements about the merit of the decision is rarely useful and may alienate the victim/survivor. It is useful for GPs to understand the circumstances that have led to the decision 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 victim/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 (eg 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.

Beyond first-line and ongoing patient-centred support, advocacy by healthcare providers29 with additional training or by specialist family violence services appears to be beneficial for some women. Advocacy involves providing women with information and psychological support to help them further access community resources, including justice response (eg linking victims/survivors with legal, police, housing and financial services). Trials of advocacy34 or support interventions for women who have sought help from shelters report some reduction in violence and possible improvement in mental health outcomes.35

Facilitating 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 (eg if she doesn’t have a phone or a safe place to make a call).
  • Provide her with the written information she needs (eg 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 decide using non-directive problem-solving techniques. Barriers may include childcare, transport and fear that the partner may find out. Always check to see if she has questions or concerns, and to be sure she has understood.

Whole-of-practice system support

The World Health Organization has outlined what factors need to be in place to support practitioners in their clinical work.36 In addition to women- or patient-centred care, a whole-of-system response37 involves promoting at the healthcare provider level:

  • a culture of gender equitable attitudes
  • trauma-informed principles (respect, privacy, confidentiality, safety)
  • a context of sufficient time allowed in consultations
  • a supportive environment, with leaflets and posters
  • an awareness about protocols and referrals.

At the practice level there needs to be: 

  • coordination of internal and external referrals
  • protocols
  • workforce support and mentoring
  • appointment of champions
  • advocacy for finances allocated to services for family violence
  • leadership and governance, demonstrated by policies
  • appropriate design of spaces to ensure privacy
  • data information systems for evaluation.

The importance of workplace support is highlighted by a systematic review of 47 qualitative studies of how health practitioners are enabled to address IPAV.38 Practitioners who collaborated within a team and worked within a health organisational system that was supportive were more likely to want to participate in identifying and responding to IPAV.38 Two other elements that were important were that they had tried a patient-centred approach and received positive feedback from patients, resulting in them trusting that the healthcare setting was a place to address IPAV.

Finally, the review showed increased engagement among providers who have a personal commitment to addressing IPAV, either because of their personal experience or because of their human or child rights or feminist lens, areas which are not often addressed in training. Many healthcare professionals will have experienced IPAV, and support should include training for the leadership team in the primary care setting. While professionals often erroneously are not considered to be traumatised themselves, and while they benefit from this in appearing well-adjusted, it also denies an important part of their experience that can enhance their practice if used carefully.39,40 A 2019 study showed that providers with a personal experience of IPAV are more likely to attend training and provide more effective care for victims/survivors.41

Supervision and reflective practice are useful when doing this challenging work; questions that providers may wish to consider as part of regular reflective practice and to enhance trauma-informed approaches to IPAV (refer to Tool 4.1).42

Tool 4.4. Practitioner reflective questions42

‘What kinds of power and privilege do I have? How do these shape my life and world view?’

‘Have I considered how experiencing trauma and violence may have contributed to the development of the presenting complaint or reason for referral?’

‘How do his coercive and controlling behaviours constrict her and her children’s lives and her ability to do what she wants to do, including ability to engage in any mental healthcare plans?’

‘What do I know about what safety strategies she previously tried, how these worked, if services were helpful, her partner’s reactions, and what, if any, access she has to financial, family, social and cultural supports?’

‘Are she and her family experiencing systemic barriers (eg lack of stable housing, limited access to money and transport, poverty, language barriers and dismissive racist responses from services)? How is this impacting her, her children and family’s safety and wellbeing?’

‘Who is working with her partner? What strategies are in place to support him and address his use of violence?’

‘Comprehending all of this, what actions can I take as a ‘safety ally’, as part of my treatment plan?’

‘How and with whom will I review whether what we are doing is supporting safety for her, the children and her family?’

Adapted from: Short J, Cram F, Roguski M, et al. Thinking differently: Re-framing family violence responsiveness in the mental health and addictions health care context. Int J Mental Health Nurs 2019;28:1209–19.

 

Please refer to Resources for state and national information.

  1. Hameed M, O'Doherty L, Gilchrist G, et al. Psychological therapies for women who experience intimate partner violence. Cochrane Database Syst Rev 2020:CD013017.
  2. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
  3. Tarzia L, Bohren M, Cameron J, et al. Women’s experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis. BMJ Open 2020;10:e041339.
  4. Neighbors C, Walker D, Roffman R, et al. Self-determination theory and motivational interviewing: Complementary models to elicit voluntary engagement by partner-abusive men. Am J Fam Ther 2008;38:126–36.
  5. Rollnick S, Miller W, Butler C. Motivational interviewing in health care. New York: Guilford Press, 2008.
  6. Arkowitz H, Westra H. Introduction to the special series on motivational interviewing and psychotherapy. J Clin Psychol 2009;65:1149–55.
  7. Miller W, Rose G. Towards a theory of motivational interviewing. Am Psychol 2009;64:527–37.
  8. Zalmanowitz SJ, Babins-Wagner R, Rodger S, et al. The association of readiness to change and motivational interviewing with treatment outcomes in males involved in domestic violence group therapy. J Interpers Violence 2013;28:956–74.
  9. Sheehan KA, Thakor S, Stewart DE. Turning points for perpetrators of intimate partner violence. Trauma Violence Abuse 2012;13:30–40.
  10. Schrager JD, Smith LS, Heron SL, et al. Does stage of change predict improved intimate partner violence outcomes following an emergency department intervention? Acad Emerg Med 2013;20:169–77.
  11. Kistenmacher BR, Weiss RL. Motivational interviewing as a mechanism for change in men who batter: A randomized controlled trial. Violence Vict 2008;23:558–70.
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