First-line response to intimate partner abuse and violence: Safety and risk assessment

This chapter outlines how to assess the safety of a woman who is a victim/survivor of intimate partner abuse/violence (IPAV) and any children who might be exposed to that abuse. Assessing safety is a key step in responding to and managing a disclosure, and should take place in some form in every consultation. The chapter also outlines safety planning.

Health professionals need to understand that there is great complexity in relationships that are abusive, and there are many barriers to women leaving.1 It is important to realise that a woman’s leaving does not necessarily stop the abuse and may escalate it. For some women, leaving may not be what they want, and it should not be positioned as the only or primary goal.2 The chronic nature of domestic violence means that becoming safe is an ongoing process, and health professionals need to understand that it can take time for women to navigate a pathway to safety and healing.³

Note that the brief safety assessment and planning process outlined here does not preclude the need for input from specialist services such as police and domestic violence services. Referral to domestic violence services should take place wherever possible, in response to the needs of the women. It is acknowledged that some women may not take up a referral to specialist services.³

Why don’t women just leave?

It is easy to look at the cycle of violence that sometimes happens in relationships and wonder why a woman doesn’t leave an abusive relationship. However, it is a myth that abused women can ‘just leave’. There are multiple, complex reasons why women often stay in abusive relationships.

• The most dangerous time for a woman in an abusive relationship is when she leaves, and many victims/survivors live in fear of reprisals if they were to leave. Approximately 40–50% of women killed by their spouse are separated or in the process of separating.⁴
• Having dependent children is a barrier. If a woman were to leave, she may not have housing appropriate for her and her children. This may be in part because she may also be isolated from friends and family if she were to leave. It is common for abused women to have no-one to turn to and to be unaware of services available.
• To leave may substantially reduce a woman’s standard of living. Women often do not have the equivalent earning capacity of men, and where financial abuse is taking place, a woman may not have access to money.
• After years of abuse, many victims/survivors have low self-esteem and doubt their ability to cope on their own. They also may have committed emotionally to the relationship and may be hoping that their partner will change. In some relationships after each cycle of violence comes an apology and a promise it will never happen again and often victims/survivors will cling to that promise even when the next cycle of violence occurs. Some partners even make threats of suicide if the woman were to leave, leaving her fearful that she will be the cause of his death.
• Some migrant and refugee women may experience significant family pressure to stay in the relationship or pressure over their visa status.

Overall, a woman should never be told to ‘just leave’, or asked, ‘Why don’t you just leave?’ This implies that she has some responsibility for the violence that has been perpetrated towards her. Chapter 4: Intimate partner abuse and violence: Ongoing support and counselling outlines how to use motivational interviewing techniques to help women weigh up their relationships and choose options in a non-judgemental way.

The World Health Organization (WHO) LIVES response (see Chapter 2: Intimate partner abuse and violence: Identification and initial response ) involves listening, inquiring about needs, validating, enhancing safety and supporting a victim/survivor of IPAV.

Enhancing safety within general practice and primary care involves a brief risk assessment and safety planning with women who have been subjected to abuse. A professional judgement needs to be made around a woman’s safety needs, based on three domains:

1. The woman’s own judgement of her safety
2. The presence of evidence-based risk factors (refer to Tool 3.1)
3. Information-sharing with other health professionals or services, as appropriate (eg police, domestic violence case workers). This might involve seeking information from other services or discussing the case with other workers.

Tool 3.1. Evidence-based risk factors

Source: State Government of Victoria.⁵
 

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Conducting an assessment

It is important to understand that women are experts in their own safety, as they have a lived experience with their abuser.  A key question to ask when assessing safety is, ‘Do you feel safe to go home today?’ Many doctors feel very concerned for a woman’s wellbeing; however, the woman is often the best judge about whether it is safe to go home.

If there are children involved, consider whether or not the situation falls under mandatory reporting laws. The safety of children should be assessed along with the woman’s safety, by asking her ‘Are you concerned about any safety issues for your children or other family members?’

A number of evidence-based risk factors put a woman at increased risk of serious harm or death, which should be explored with a woman when assessing her safety. Factors that pose particularly high risk are:⁶

• previous violence against the victim/survivor by the perpetrator
• leaving the relationship – this is one of the riskiest times for victims/survivors of IPAV, and women should be informed of that
• planning to leave or having recently separated is a dangerous time
• a history of strangulation or choking7
• previous intimate partner sexual violence
• obsessive, jealous or controlling behaviour, including stalking
• threats to kill
• access to weapons, or previous use of weapons by the perpetrator
• being physically assaulted while pregnant
• increasing frequency and severity of abuse.

Other risk factors from the perpetrator perspective for IPAV include:⁶

• perpetrator history of violent behaviour outside the household, as well as within, including violence towards animals
• self-harm, suicide attempts or threats of suicide by the perpetrator
• perpetrator history of witnessing or being the victim of family violence as a child
• evidence of mental health problems (eg personality disorders, drug and alcohol misuse) in perpetrator
• perpetrator attitudes that support violence towards women
• perpetrator unemployment.

A risk assessment tool may be used to help assess risk. The Victorian Government’s Family Violence Multi-Agency Risk Assessment and Management Framework provides several guides and tools for risk identification, screening and assessment.

Some questions to ask when assessing a women’s safety are shown in Box 3.1.

The Royal Australian College of General Practitioners (RACGP) Professional Development Program on Family Violence provides further information about IPAV. To see a GP do a safety assessment, see Module 2 (from 17.46–20.26 minutes).

A brief risk assessment (10 minutes) is also illustrated in this video.

Traumatic brain injury and strangulation

Traumatic brain injury (TBI) can be described as changes in brain function or detecting any brain pathology due to an external force, with head trauma and neck strangulations by perpetrators common as an injury mechanism for TBI. Thus, it is important to ask victims/survivors who have experienced physical violence if they remember times that they have reduced or lost consciousness, or had difficulty breathing, speaking or pre-syncopal symptoms from choking. The patient may also have gaps in memory and be unable to describe a clear sequence of events, with lack of awareness of their own loss of consciousness.

You could ask the following questions:

• ‘Have you ever been choked or strangled?’
• ‘Have you ever been hit in the head or face?’
• ‘Have you ever been pushed or shoved and banged your head against something?’
• ‘Have you ever lost consciousness?’

IPAV victims/survivors who experience anxiety, depression, dizziness and headaches show symptoms that are consistent with a post-concussive syndrome or lingering mild TBI.¹⁰ After any head injury, the victim/survivor may experience focal neurological symptoms and signs, altered consciousness and subtle cognitive deficits. After strangulation the survivor may experience the above as well as respiratory difficulties, a hoarse or husky voice, pain or difficulty on swallowing, and possibly bruising or petechiae above the pressure on the neck. TBI can also occur from recurrent mild injuries or concussions, or major injuries where they lose consciousness. Hypoxia puts the survivor at risk of an acquired brain injury, particularly with recurrent strangulations in the context of ongoing violence from the perpetrator.

Strangulation causes compression and potential occlusion of the great vessels or airway¹¹ and loss of consciousness typically occurs within 5–10 seconds and death can occur within minutes.¹² Strangulation is an important indicator of increased homicide risk, with survivors having a 7.48 times increased risk of being killed by that partner.^7,13 Around half of patients with strangulation will have no external sign of injury, but internal injuries (including subtle fractures to the larynx, carotid or vertebral artery dissection) should be considered if the history suggests a more serious strangulation. Red flag features suggesting the need for immediate referral to the emergency department after recent strangulation include any new or evolving neurological deficits, neck bruising especially if located over the carotid arteries, carotid bruits, history of loss of consciousness (particularly if associated with incontinence), and ongoing difficulty swallowing or breathing.¹⁴ Patients without red flag physical symptoms may be managed in the general practice setting after clinical assessment including neurological examination and examination of the head and neck.

Each victim/survivor should also be advised of risks of future harm if in an ongoing relationship with the perpetrator. It is important to ask about and document reported mechanisms of injury, physical observations, and any previous head injuries, strangulations, patterns of increasing frequency of strangulation, concussions or other extreme violence.⁷

After the assessment

Suggested pathways for how to respond following a risk assessment are shown in Figure 3.1.

Most women will feel safe to go home on the day of the consultation. A woman who does not feel safe to go home should be referred to domestic violence services for urgent crisis accommodation (refer to Resources). This should ideally take place with a ‘warm referral’, whereby the doctor assists the woman in making the referral; if the woman is not keen on this or is unable to go, phone numbers or brochures should be provided so that she can refer herself in her own time. Care must be taken to ensure that these materials are not discovered by her partner, and safety planning should be undertaken (refer to Figure 3.1).

Figure 3.1. Responding to a risk assessment¹⁵

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In the event that a woman is deemed to be at imminent risk of violence (if multiple recent risk factors are present – refer to earlier in this chapter), but she does not want to be referred to or go to a shelter or refuge, consent should be sought to refer her to the police.

If she does not consent, it may be necessary to seek legal advice from a medical defence organisation. Common sense should apply, and if the woman is at very high risk of being physically harmed, a referral to police should be made to safeguard her immediate wellbeing. Difficult situations such as these may require advice and input from colleagues, especially specialist domestic violence services.

If a woman is being repeatedly assaulted but is not willing to call the police, it is important to still provide her with appropriate information such as contacts for domestic violence or sexual assault services.

Information sharing

GPs are able to share information about a patient under certain permissions, such as in accordance with Australian Government privacy laws,¹⁶ which allow the disclosure of information with consent, or without consent in other circumstances such as to lessen or prevent a serious threat to the life, health, safety or welfare of a person. These permissions can be used to facilitate referrals, provide information to other services assisting the patient or notify appropriate services about information that is pertinent to preventing serious risk.

The Victorian Government has enacted a legal framework for information sharing in cases of domestic violence, to allow domestic violence services, police and child services to share information about cases to adequately manage the risk of violence. It is known as the Family Violence Multi-Agency Risk Assessment and Management Framework.

Safety planning

Safety planning involves developing a plan for a woman to follow should the violence escalate. The purpose of a safety plan is to outline escape and help-seeking strategies.⁶ It is essential to plan for the safety of both women and children.

Safety plans should be developed for every victim/survivor and should be specific to each woman’s circumstances. Working to keep victims/survivors safe has been shown to be the best way to keep children safe.¹⁷

A checklist for safety planning is shown in Box 3.2.

Safety planning needs to continue and evolve, as a woman’s circumstances may change, even after leaving her abuser. Mothers may have ongoing contact with their abuser through acts of the court or through a belief that continuing contact with the father is in the best interests of the children. It is therefore very common for women to have continued exposure to her abuser post-separation.¹⁸ As discussed, leaving or having recently left a partner is the most dangerous time for a victim/survivor of IPAV.

Documenting intimate partner abuse and violence

GPs should document a patient’s history and examination findings, including every injury – as they would for any assault.

• Describe every injury, including its location, size and age. This is important not only in case you later need to write a police report about the injuries, but also as a reminder of what has happened or to alert another health professional in the clinic about the woman’s history.
• Statements from the woman about the abuse should be documented word for word, using quotation marks.
• Any behaviour that you witness should be recorded, such as ‘The patient cried when she said that …’
• Document the management plan and any referrals that have been made.

Good documentation, provided confidentiality can be assured, is important for any legal processes that may occur. It is not always possible to predict which patients may be involved in legal processes in the future. Practices that cannot maintain confidentiality should take measures to ensure they can.

Some women may be concerned about confidentiality and may request that you do not keep notes. In addition, there may be occasions where confidentiality cannot be assured (eg if you know that a perpetrator is capable of hacking into private websites). In both these cases, avoid documenting the management plan any referrals, safety planning or other interventions, to reduce the risk of harm.

Some practices use codes in their electronic record, in the ‘reason for visit’ or other locations, to indicate an IPAV case without overtly saying so in the notes. Practices using paper records could use a coloured sticker.

Safety of children and mandatory reporting

Children who are exposed to domestic violence are at risk of behavioural, emotional, social, cognitive and physical issues.^19,20 Exposure to domestic violence tends to mean seeing and/or hearing the violence but can be witnessed in other ways, such as the aftermath of violence (eg seeing their injured mother).

In some states of Australia, where a child is a witness to violence and abuse but is not deemed to have experienced violence themselves and is not at immediate risk, the child can be referred to support services such as a vulnerable children’s organisation. It is important to reassure children that the violence is not their fault and to safety plan with them, if age-appropriate, for the next episode of violence.²¹ A child’s mother should be involved in the safety planning process and outside sources of support should be considered.¹⁸

There is considerable evidence that child abuse and IPAV co-occur.^22,23 Health professionals who see families in which IPAV occurs should be aware of and ask about child abuse. For more information, refer to Chapter 9: Child abuse and neglect.

It is important for health professionals to be aware of mandatory reporting laws in relation to child abuse.

The Northern Territory requires any adult to report to police if they believe on reasonable grounds that a child has been, is, or is likely to be at risk of a sexual offence or to experience harm or exploitation. In all states and territories, medical practitioners are required to report any assault perpetrated against people under the age of 18 years (under 16 years in New South Wales and 17 years in Victoria).

Each Australian state and territory has different legislation regarding what must be reported by whom (refer to Table 9.3 in Chapter 9). When in doubt, it is always best to check with your medical defence organisation or with the reporting agency, initially without mentioning the child’s name.

For more information visit the Australian Government Australian Institute of Family Studies.

Dealing with men who use intimate partner abuse and violence

GPs often see the whole family and may also manage cases of men who are violent towards women. This raises issues of safety and confidentiality. It is not recommended that one GP provides care for both a woman who is experiencing IPAV and her partner. This is discussed further in Chapter 5: Working with men who use intimate partner abuse and violence.

GPs often have to hold risk and support safety at times for families over a period of time, similar to how they often need to in areas such as suicide, mental health and cancer. This does not mean that they do not need to get support for themselves and their patients from specialists in the area. The next chapter outlines some techniques for an ongoing response when working with patients over time.