Intimate partner abuse and violence: Ongoing support and counselling

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

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).

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 model³

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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

In addition to safety assessment and planning, effective counselling strategies that may assist victims/survivors include cognitive behavioural therapy (CBT),¹ motivational interviewing^4–7 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).

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, 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

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.

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).

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

Please refer to Resources for state and national information.

• Acquired brain injury and family violence – a resource from Brain Injury Australia, Vic
• When she talks to you about the violence – a toolkit for GPs on domestic violence, Women’s Legal Service NSW.
• Supporting patients experiencing family violence – a resource from the Australian Medical Association (AMA), 2015.
• When she talks to you about the violence – a video resource developed by AMA NSW, 2014.