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.
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)
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.
||What do you like about your relationship or current situation?
||What are the things you don’t like about your relationship or current situation?
||[Summarise – GPs understanding of the woman’s pros and cons]
||Where does this leave you now?
For women who are ready to change to some extent:
For Steps 1 and 2, you may like to ask your patient to use the box below to write down her responses.
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.
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.
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 …’).
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
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:
Identify the issues/problems that are worrying or distressing you.
Work out what options are available to deal with the problem.
List the advantages and disadvantages of each option, taking into account the resources available to you.
Identify the best option(s) to deal with the problem.
List the steps required for this option(s) to be carried out.
Carry out the best option and check its effectiveness.
Best option = ----------------------------------------------------
What steps are required to do this?
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
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
- 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.