White Book

‘Domestic’ or intimate partner abuse/violence - Chapter 5

Working with men who use intimate partner abuse and violence

‘Men’s use of IPAV is a serious health issue for the entire family. It impacts the woman, any children in the family, and the man himself.’

Key messages

  • Both men and women may experience or use abuse in adult intimate relationships; however, men use abuse more frequently and severely.
  • Men who use intimate partner abuse/violence (IPAV) are not a homogenous group; they come from all socioeconomic, cultural and social groups.
  • It is not recommended for one health practitioner to counsel both a woman who is experiencing abuse and her male partner who uses abuse.
Consider asking men who are experiencing substance misuse and mental health concerns about possible use of IPAV.
(Practice Point: Consensus of Experts)
Men’s behavioural change programs are the referral options of choice for men who use IPAV.
(Conditional Recommendation: Low Certainty of Evidence)
Any psychological therapies should be delivered by people who are experienced IPAV, and should have a trauma-informed focus.
(Practice point: Consensus of Experts)

This chapter discusses working with men who use IPAV, including identification, safety and management. See other chapters for information about identification and initial response, safety and risk assessment, and ongoing support and management for women who experience IPAV.

Note that this chapter focuses on men’s use of IPAV in heterosexual adult intimate relationships. For details about IPAV in same-sex relationships, see the chapter on LGBTIQA+ family abuse and violence.

Prevalence

Self-report questionnaires used to identify men who use IPAV1 often lead to issues of under-reporting. The most consistent figures for prevalence come from reports by women who experience IPAV. These figures place prevalence rates of use of IPAV in Australia at 20–25% of the general population.2,3

While both men and women use IPAV in relationships, men use IPAV more frequently and severely, so that women who experience IPAV are more likely to fear for their lives.4

Men’s use of IPAV is a serious health issue for the entire family. It impacts the woman,2 any children in the family,5 and the man himself.6

Which men use intimate partner abuse?

There are no distinguishing characteristics of a man who uses or is likely to use IPAV: men who use IPAV come from all socioeconomic, cultural and religious backgrounds.

GPs need to be aware that individuals who use IPAV tend to minimise responsibility for their use of IPAV, blame their partner or other issues, and greatly under-report their use of IPAV. They generally have developed ways of convincing themselves and others that they aren’t responsible for their use of IPAV and often invite GPs and other practitioners to collude with those attitudes and beliefs.

Nevertheless, GPs have a unique opportunity to identify their male patients who use or are at risk of using IPAV and provide appropriate support and care.7,8

Why do men use intimate partner abuse?

To understand why particular men use IPAV, it is important to understand that there are larger community and societal issues – norms and expectations – that create a complex framework in which men operate. Men may use physical, sexual, emotional, social, financial and other forms of violence to maintain their power and control in adult intimate relationships. This is often based on societal acceptance of male dominance, stereotyping of gender roles, linking masculinity to dominance and acceptance of violence to resolve conflict. These are all attitudes that are associated with IPAV.9

While gender-based power and control is an underlying factor in men’s use of IPAV, other factors are involved. Men who use IPAV are more likely to come from families where their father used IPAV, where they experienced child abuse or where they had an absent or rejecting father. However, some men who use IPAV report well-adjusted childhoods and peaceful family-of-origin environments.5

Other factors that have been linked to IPAV are psychiatric disorders and substance abuse10–12 and these have also been correlated with more significant risk of injury to women partners experiencing IPAV.13,14 Poverty, unemployment and associating with delinquent peers in the community are also risk factors for use of IPAV. Individual, relationship, community and societal factors all play a part in shaping men’s use of IPAV,15 so it is important for GPs to view a clinical intervention as only one tool in a wider response. Legislation, policing, social sanctions and community attitudes are also critical to ending the man’s violence.16,17

It is extremely important to qualify that while some of the factors outlined above and in Box 5.1 may be risk factors for IPAV, they are not causal. The majority of men who use IPAV are neither mentally ill nor substance abusers. Profiling the characteristics of men who use IPAV is an emerging field of research.

Box 5.1. Risk factors associated with use of IPAV (these are not causal)

  • Attitude that supports violence towards women
  • Mental health problems
  • Drugs or alcohol misuse
  • Stressful events
  • Recent separation
  • History of abusive and violent behaviours
  • Adverse childhood experiences (eg child abuse and neglect)

The role of GPs

GPs, unlike other healthcare providers, focus on the care of all family members. Therefore, GPs may come into contact with:

  • individuals who experience IPAV
  • individuals who use IPAV
  • children who witness and/or experience abuse and violence
  • young people who use violence in the home.

Research shows that men who use IPAV present to general practice for healthcare needs more often than men who do not use IPAV.18 This can be for a range of issues including injuries, anxiety or depression.

Although men who use IPAV are often reluctant to seek help or disclose their behaviours, it is still necessary for GPs to ask about any potentially abusive behaviour.19 Indeed, GPs were viewed as the next most likely source of support for men who use IPAV, after friends and family. Men viewed GPs as a trustworthy source of help due to the reassurance that any disclosed information would remain confidential.19 A caveat to this confidentiality is if there is a risk to the safety of the (ex) partner and/or children. If there is a risk of safety to the (ex) partner, the man’s confidentiality can be breached if the GP believes this will increase the safety of the (ex) partner; with children this is covered by mandatory reporting. The known facilitators of help-seeking include a trusting patient–doctor relationship, the appropriate timing of questions about use of IPAV, and a non-judgemental attitude by the GP.20

It is not recommended for one GP to provide care to both the woman partner who experiences IPAV and the male partner who uses it.17 This can be managed by referral to another GP within the practice or by referral to another agency. Doctors in rural areas may find this particularly difficult and may need to refer patients to services in neighbouring towns.

Separate GPs are recommended to protect the woman’s safety and confidentiality. It is possible that a GP might inadvertently reveal information provided by a woman experiencing IPAV to her partner. Many men who use IPAV are extremely alert and attuned to what they think their partner is telling other people. If the GP ‘lets something slip’, even subtly, about the partner who is experiencing IPAV, the man may ‘punish’ the woman – assault her – for daring to discuss this with someone.

Identification

Although men who use IPAV need help to address their use of it, these men are often reluctant or unwilling to disclose.8

Use of IPAV is linked with increased rates of alcohol and substance misuse, mental health concerns and use of health services.11,18 While not all men with these factors will use IPAV, GPs need to be aware of the possibility of IPAV use among men who present with these concerns.

Again, although use of IPAV is linked with mental illness and substance misuse, it is important to not over-pathologise men who use IPAV. Abandoning generalisations and negative attitudes, along with being open to providing non-judgmental support to men who use IPAV, is important in providing successful treatment.20

Broaching the subject of IPAV with men may be difficult for several reasons, including:

  • trouble viewing the patient as someone who uses violence or abuse
  • concern about damaging the patient–doctor relationship for ongoing care
  • the practitioner feeling at risk from the man if they raise the topic
  • concerns that broaching the subject will add extra stress to the relationship
  • not wishing to invade the man’s privacy
  • the need to manage confidentiality and privacy issues when managing an entire 21,22

Remember, addressing the issue may help reduce the risk for other family members, but it may also increase the risk, so great care is needed when raising this subject.17 Broaching the subject of IPAV with men is possible with the use of funnelling questions (refer to Figure 5.1).17 This requires starting with a broad subject and becoming more specific. The efficacy of these queries is increased if you ask the questions in a caring, rather than accusatory, tone. Initial questions may include:23

  • How are things at home?
  • Have you or your partner ever been injured?

Then, after you have established some trust, you may wish to move onto more specific questions, such as:

  • When you feel angry, what do you do?
  • Do you think she is ever scared or frightened of you?
  • Do you do things that you later regret?
  • How do your children react when you get angry?
  • If there was a fly on the wall in your home, when you feel angry, what would that fly be seeing about your behaviour?

Figure 5.1. Funnelling questions to identify men who may use abuse and violence in intimate relationships<sup>17 </sup>

Figure 5.1. Funnelling questions to identify men who may use abuse and violence in intimate relationships17

Reproduced with permission from: Hegarty K, Forsdike-Young K, Tarzia L, Schweitzer R, Vlais R. Identifying and responding to men who use violence in their intimate relationships. Aust Fam Physician 2016;45(4):176–81.

Management

Immediate safety of the partner and any children who may have experienced and/or witnessed IPAV is the first priority when a man is identified to have used IPAV. Management objectives also include:

  • taking a history – especially suicidality, substance misuse, mental health and access to weapons
  • reinforcing that abuse and violence are not okay – condemn the actions, not the person
  • encouraging ownership of the behaviour – help the man who uses IPAV to take responsibility for his behaviour
  • encouraging active change.

Emotional regulations

Men do not use IPAV only when they are angry. They might be feeling a range of emotions when they use IPAV. Many men use IPAV when they are calm – controlling tactics used to restrict the woman’s life and to instil fear. Most men who use IPAV choose not to use IPAV in other settings even if they feel anger, such as in the workplace, in a major shopping centre or if the police are present. Many men will try to direct the conversation back to blaming their partner:

‘You don’t live with her; she keeps screaming at me and is hopeless with the finances …’

It is important not to allow the man who uses IPAV to rehearse his violence-supporting narratives like this for too long, and to assertively yet calmly bring the attention back to him. Some simple questions to ask the man regarding this include:

‘How would your reaction have been different if the police had been present?’ ‘If you were about to yell at her, how would your response change if the doorbell rang?’

Treatment and support

In Australia, Men’s Behaviour Change Programs (MBCPs), rather than anger-management programs, are the preferred referral option for men who use IPAV.24  MBCPs have been shown to have positive effects,25,26 helping some, but not all men, to stop using IPAV.

For some men, these programs work well to reduce or even stop their use of IPAV. For others, the programs produce mixed results, such as benefits that do not sustain over time, or a man stops using some forms of IPAV but not others. For other individuals, these programs produce little discernible benefit.24,27

In healthcare settings, interventions to target IPAV use (including cognitive behavioural therapy and motivational interviewing-based interventions) that are combined with alcohol treatment show some promise.28

Referral should be to an MBCP delivered by an accredited agency, which may have a drug/alcohol rehabilitation program and/or a mental health specialist. Such agencies will also contact and provide support for the woman (refer to Resources).

MBCPs are the referral option of choice even for men with substance misuse or mental health concerns. MBCPs include a thorough assessment and can work with, or refer men to, accompanying substance misuse or mental health services. If the substance misuse or mental health concerns are urgent, or if the man is not ready to accept a referral to an MBCP, then a referral to a drug/alcohol rehabilitation or mental health service is certainly better than no referral at all.

Telephone services

Most states have a telephone information, referral and counselling service for men who use IPAV.

Men who do not appear ready to attend an MBCP might be more comfortable taking the initial step of calling such a service. The service will then attempt to motivate them to attend a program.

GPs can also phone any of these services for information about local MBCP referral options.

Providing ongoing support

Referring men who use IPAV to an MBCP is not the end of the GP’s involvement. Supporting the man’s change and monitoring the safety of the family is an important and ongoing task. It is also very important to do the best possible to ensure that the woman receives counselling and support from a specialist family violence service, remembering that the same GP should not be the GP for both partners. Indeed, this should be the first priority – that the woman is receiving specialist family violence services. Permission should be asked from the man to allow the sharing of this information.

The importance of this ongoing care is underscored by the fact that MBCPs have a low success rate.

Couples or family counselling

Referral for couple or family counselling is not appropriate until the man has ceased using violent and abusive behaviours.29 Couple therapy requires people to open up and disclose important thoughts. If the woman does this while her partner is still being abusive, it may put her at increased risk. Alternatively, she may be forced to lie to protect her safety.

Gabby is a young woman who presents to you with symptoms of depression. As you explore Gabby’s symptoms, she tells you of how her husband, Nick’s behaviour changed since the birth of their first child, Jane, a couple of years ago. Gabby says that during the pregnancy, Nick became more withdrawn and solitary. Since Jane’s birth, Nick’s behaviour has become more aggressive, and she feels less at ease with their relationship. Nick is reminding her of his father, who had always been a stern presence in his life. Gabby states she does not feel at risk, and does not feel Jane is at risk.

At this stage Gabby is happy to not take things further. She is hopeful that she will be able to sort things out with Nick, and requests no further intervention. However, you make a note of the possibility of IPAV in her patient record.

Several months later, Gabby brings Jane into your practice due to concerns about some developmental difficulties – Jane isn’t sleeping well, was late to begin walking and talking, and when she did start talking, she developed a stutter.

You remember your earlier consultation with Gabby, and raise the possibility of IPAV with Gabby. You ask her whether Nick’s behaviour could be affecting Jane, and how Jane seems to feel in Nick’s presence. Does Jane like going to her father, or does she keep away?

Gabby says that Nick’s behaviour could certainly be having a negative effect on Jane. Jane is often upset in Nick’s presence and does not like going to him. At times she has even cowered away.

You ask Gabby whether it would be okay for Nick to be contacted about the impact his behaviour is having on her and Jane. Gabby agrees, and when asked, says she has no concerns about her safety regarding sharing what she has said about Nick’s behaviour with Nick. She says she has herself spoken to Nick about his behaviour and expressed her concerns to him. Gabby says she will explain to Nick about the forthcoming phone call and possible appointment. You explain to Gabby that it would be best if your colleague met with Nick.

Your colleague calls Nick and invites him in for a consultation. Nick agrees and comes in some days later.

After some general questions about how things are at home, Nick is asked: ‘Do you think Gabby is ever scared or frightened of you?’

After some thought Nick admits that Gabby may in fact be scared of him, and says that he has never thought of this before. Nick is then asked: ‘What do you think of Gabby being scared of you? Is this the sort of husband you want to be?’ After some thought, Nick looks upset, and admits that he is not happy with Gabby being scared of him, this is not the sort of husband he wants to be. He is shocked and distressed. He says that this has certainly never been his intention, and no, he doesn’t like behaving this way. When asked to reflect on the effect his behaviour may be having, he starts realising the negative effects his behaviour will have on his relationship with Gabby and Jane. He says that he absolutely wants a different relationship with Gabby to that which his father had with his mother, and a different relationship with Jane to that which his father had with him.

Nick is offered a referral to a local MBCP, and is given the organisation’s counselling number. He says he will think about it and leaves the consultation. After much thought and discussion with Gabby he agrees to attend – a huge step for Nick.

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