White Book

Appendix 1

Nine steps to intervention – the 9 Rs

All GPs need to understand the nine steps to intervention:

  • Role with patients who are experiencing abuse and violence
  • Readiness to be open to
  • Recognise symptoms of abuse and violence, ask directly and sensitively and
  • Respond to disclosures of violence with empathic listening and explore
  • Risk and safety issues
  • Review the patient for follow-up and support
  • Refer appropriately and also
  • Reflect on our own attitudes and management of abuse and violence
  • Respect for our patients, our colleagues and ourselves is an overarching principle of this sensitive work.

Abuse and violence, as defined in the manual, is very common in our communities, affecting all age groups and socioeconomic strata. It occurs more commonly against women and children than men. Abuse and violence has major mental and physical health effects on our patients. As a result they use health services more frequently, although GPs often fail to identify the underlying abuse and violence. GPs are likely to be the first professional contact for survivors of any abuse and violence, as outlined in the manual. Unless this role is recognised and embraced, we will fail to address this major public health problem.3

The practice can be enhanced if all members of the clinic and clinic protocols are appropriately prepared with safety, confidentiality, choice, collaboration and empowerment as priority principles.329

Readiness to work in this area may be enhanced by undertaking training for doctors and all staff in recognition and management of patients experiencing abuse and violence, including the management of all family members. Placing posters and leaflets in clinic waiting areas offering support and referral to patients may allow patients to self-refer or realise that we are interested in this sensitive area.

GPs need to pay attention to confidentiality in our quality assurance and accreditation processes – including ensuring that the patient file is confidential and not accessible to other family members.

Practice protocols need to address the needs of these patients and the safety of staff.4

You need to ask patients who present with typical symptoms of abuse and violence and those with symptoms of abusive behaviour about violence and safety (case-finding). 

WHO recommends the following for all GPs:

  • non-judgemental support and validation including expressing the unacceptability of any abusive behaviour but not of the patient
  • practical care and support that responds to concerns but does not intrude
  • asking about history of violence, listening carefully, but not pressuring the patient to talk
  • provide information about resources, including legal and other services that the patient might think helpful
  • assisting the patient to increase safety for themselves and their children, where needed
  • providing or mobilising social support
  • providers should ensure that the consultation is conducted in private and emphasise confidentiality within limits of harm to herself/himself or others.

GPs need to assess the patient’s safety, risk of harm to themselves and others and discuss a basic safety plan with ongoing monitoring of the woman, her partner and children for safety and progress. You also need to assess the risk to children of abuse and violence and children’s and adult perception of the impact on children. It is important to document comprehensively and carefully, and to offer to report the incident to the appropriate authorities if the patient wants this. However, you need to report children at risk as well as women according to mandatory laws in the Northern Territory. When seeing couples, consider referring one partner to another colleague. Use a clinic protocol for monitoring danger to the patient and other family members in your practice.4

Responses during later interactions need to be informed by an understanding of the chronicity of the abuse and violence problem and to provide follow-up and continued support, which respects patient’s wishes. This will include an assessment of the patient’s and family’s level of social support and consider children’s access to significant supportive others. Do not offer couple counselling where there is abuse and violence in the couple’s relationship.

Offer options for referrals for women and children to safety, advocacy and therapeutic support services. Offer men who abuse referral to accredited behaviour change programs when available. We need to involve ourselves in inter-agency collaboration for the benefit of our patients.

Monitor personal and professional attitudes about abuse and violence for management bias and set up processes and policies that support the doctor and other staff in managing what can be complex issues.4 Ensure that you take time to reflect and take care of your own health and wellbeing.

Respect is an overarching principle when dealing with issues of abuse and violence. This involves respecting patient’s wishes, respecting our own limits and abilities to undertake abuse and violence work and, finally, modelling respectful relationships with our colleagues and in the community.