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.
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 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.
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.
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.
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.