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Chapter 5

Dealing with perpetrators in clinical practice

Key messages

  • Mainly perpetrators are men and victims are women, although men may be victims as well 101
  • Perpetrators are not a homogenous group; they come from all socioeconomic, cultural and social groups 102
  • It is not recommended for one health practitioner to counsel both the victim and the perpetrator 4
Table 1

Table 1

Coding scheme used for levels of evidence and grades of recommendation 

Recommendation 
Health practitioners need to have an index of suspicion of the possibility of men using violence when they are also experiencing substance abuse issues

Recommendation 
Men’s behaviour change programs are the referral options of choice for men who perpetrate domestic violence

While it is important to focus on the survivors of abuse and violence, it is equally important to acknowledge the entire family when considering care. General practice, unlike other health services, may come into contact with the victim, the perpetrator and/or the children. Intimate partner abuse affects all members of the family. Most perpetrators of intimate partner abuse will be men, but it is also possible for a woman to be the abuser.3

Perpetrators of intimate partner abuse come from all social, cultural and religious backgrounds. One of the main problems in acknowledging the extent of abuse and violence is the fact that there is no distinguishing characteristic of a man who will be violent towards his partner.

We need to be aware that perpetrators of intimate partner abuse tend to minimise responsibility for their use of violence, blame the victim or other issues and greatly under-report their use of violence. They generally have developed ways of convincing themselves and others that they aren’t responsible for their violence, and can invite GPs and other practitioners to collude with those attitudes and beliefs that minimise responsibility.

In research conducted with perpetrators, self-reporting mechanisms are often used. This has led to fundamental issues of under-reporting,104 with the most consistent evidence coming from reports by survivors. These figures place prevalence rates of perpetration of violence at 20–25% of the general population.9

In order to understand why particular men become perpetrators, it is important to understand that there are larger community and societal issues – norms, expectations – that create a complex framework in which perpetrators operate. Perpetrators use physical, sexual, emotional, social, financial and other forms of violence to maintain their power and control in the relationship. This is often based on societal acceptance of male dominance, stereotyping of gender roles, linking masculinity to dominance and acceptance of violence as a way to resolve conflict. These are all attitudes that are associated with intimate partner abuse.105

While gender-based power and control is an underlying factor in men’s perpetration of intimate partner abuse, other factors are involved. Perpetrators are more likely to come from families where intimate partner abuse occurred, where they experienced child abuse or an absent or rejecting father. However, some perpetrators report well-adjusted childhoods and peaceful family-of-origin environments. Other factors that have been linked to intimate partner abuse are mental disorders15 and substance abuse106,107 and these have also been correlated with more significant risk of injury to the victim.108,109 Poverty, unemployment and associating with delinquent peers in the community are also risk factors for perpetration of intimate partner abuse. However, perpetration occurs across the socioeconomic spectrum.

Personal, situational and sociocultural factors all play a part in shaping perpetrators, 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 violence.110

It is extremely important to qualify here that while some of the factors outlined above may be risk factors for intimate partner abuse, they are not causal. It cannot be assumed that perpetrators are mentally ill and/or substance abusers. Profiling the characteristics of perpetrators is a new field of research.

Research shows that perpetrators present to general practice for healthcare needs and may be presenting more often than non-abusive men. This can include a range of issues from injuries to anxiety and depression. They can also have low self-esteem as an outcome of the abuse and violence.111

It is not recommended for one GP to counsel both the victim and the perpetrator.4 This may be managed by referral within the practice of one of the partners or by referral to another agency. Doctors in rural areas may find this particularly difficult. Doctors in small rural towns may need to refer patients to services in neighbouring towns where available. This can help to protect your patient’s safety and/or confidentiality.

Separate GPs are recommended because:

  • it is not possible for one person, however skilled, to counsel both parties in this sort of conflict
  • of the danger of a GP inadvertently revealing some of the information provided by the victim to the perpetrator. Many perpetrators are very alert and extremely sensitive to what they think the victim might be telling others, and can feel threatened or ‘less in control’ if they believe that the victim is disclosing about the violence. If the GP ‘lets something slip’, even subtly, about what the victim has disclosed to the perpetrator, in some situations this can lead to the perpetrator retaliating against the victim
  • perpetrators can appear very persuasive in minimising, denying, excusing and justifying their use of violence. They can appear quite convincing in blaming their partner, pathologising their partner – ‘she is so hysterical, you know what women are like …’ – or blaming their use of violence on the relationship or communication problems. Many perpetrators have quite intricate violence-supporting narratives and other methods that they use to absolve themselves of responsibility for their use of violence
  • many perpetrators try to directly or indirectly invite professionals and others to collude with these responsibility minimising narratives. It is therefore important for a different GP to hear the victim’s stories, so as not to be influenced by the perpetrator’s violence-supporting narratives.

GPs need to be aware that any patient may be a perpetrator. However, many of these patients are reluctant, unwilling or unable to identify themselves as being perpetrators of intimate partner abuse.112

While not all those who have mental health issues or substance abuse problems will display abusive tendencies, we need an index of suspicion of the possibility of abuse among this cohort. While there are links with mental illness and substance abuse, it is important for us to not over pathologise the perpetrator. Abandoning generalisations and negative attitudes, along with being open to providing support to perpetrators, is important in providing successful treatment.113

Management

Immediate safety of abuse survivors – the partner and any children – should be the predominant concern when a perpetrator is identified. Management objectives also include:

  • taking a history – especially suicidality, substance abuse, mental health and weapon ownership
  • reinforcing that abuse and violence are not okay – condemn the actions, not the person
  • encouraging ownership – help the perpetrator take responsibility and encourage active change.

Broaching the subject of violence with perpetrators may be difficult for a number of reasons including:

  • trouble viewing the patient as violent
  • damaging the patient–doctor relationship for ongoing care
  • being at risk from added stress114
  • invading the patient’s privacy
  • managing confidentiality and privacy issues when managing the entire family.

Remember, addressing the issue may help reduce risk for other members of the family. Broaching the subject of abuse with perpetrators is possible with the use of funnelling questions.112,115 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:112

  • 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?
  • 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?

Anger

Perpetrators do not use violence only when they are angry. The perpetrator might be feeling a range of emotions when they use violence. Furthermore, many perpetrators use forms of violence when they are fairly calm – controlling tactics used to restrict their partner’s life and to instill fear. Most perpetrators choose not to use violence in other settings when they feel anger, such as in the workplace. Many perpetrators 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 perpetrator to rehearse his violence-supporting narratives like this for too long, and to assertively yet calmly bring the attention back to him. For these reasons, anger management programs are not recommended for perpetrators of intimate partner abuse.

Men’s behaviour change programs are not anger management programs, though they might include components of anger management. Community-based intimate partner abuse perpetrator programs by and large come from a gender-based perspective that conceptualise men’s use of intimate partner abuse as a choice based on gender-based power and privilege, entitlement and sexist attitudes towards women, intentional choices towards coercively controlling women and restricting their lives for men’s benefit. The types of violence are seen as an intentional interlocking of tactics to control women’s lives. The programs often are based on a combination of this power model and approaches such as CBT or narrative. A CBT approach involves pointing out the pros and cons of violence, social skill training, and anger management techniques to promote alternatives to violence.116 In a systematic review that focused on CBT for men who use physical violence against their partners, there were very few evaluation studies.117

Keep in mind the stages of change model (refer to Chapter 4 ) and try to identify the most appropriate time to refer to an adequate program. This may be a specific behaviour change program for perpetrators run by an accredited agency (also providing support for the victim), drug/alcohol rehabilitation or a mental health specialist. Men’s behaviour change programs are the referral option of choice, even with men who have substance abuse or mental health issues. Men’s behaviour change programs include a thorough assessment and can work with, or refer men to, accompanying substance abuse or mental health services. If the substance abuse or mental health issues are urgent, or if the man is not ready to accept a referral to a men’s behaviour change program, then a referral to a drug/alcohol rehabilitation or mental health service is certainly better than no referral at all.

In most states (refer to Resources) there is a statewide telephone information, referral and counselling service for men who perpetrate family violence. These can assist you to locate men’s behaviour change program options. Men who do not appear ready to attend a men’s behaviour change program might be more comfortable taking the initial step of calling such a service. The service will then attempt to motivate them to attend a men’s behaviour change program. As the GP, you can also phone any of these services to find out information about local men’s behaviour change referral options, or you can encourage the perpetrator to phone this service direct. Check your local area for counselling and accredited groups available to perpetrators.

Note that providing the perpetrator with a referral is not the end of our involvement. Supporting the perpetrator’s change and monitoring the safety of the family is an important and ongoing task. If you are seeing the victim and the perpetrator for medical care (not counselling), it is important to check with the victim as to how they perceive the perpetrator is progressing. It is also very important to do the best possible to ensure that the victim is receiving counselling and support from a specialist family violence service. Indeed, this should be the first priority – that the victim is receiving specialist services.

The importance of this ongoing care is underscored by the fact that men’s behaviour change programs are not successful with all perpetrators. For some perpetrators, these programs work to drastically reduce or even stop their use of violence. For some others, the programs produce mixed results, such as benefits that do not sustain over time, the man stopping some forms or tactics of violence and not others. For other men, these programs produce little discernable benefit, or they drop out after the first few sessions.118

Finally, as a note of caution, many experts suggest that couple or family counselling is not appropriate until the abusive behaviour has ceased112 as it is not possible to provide couple or family counselling where there is such a power imbalance.

A resource for GPs managing these issues, Management of the whole family when intimate partner violence is present.

This chapter has provided an overview of the prevalence, identification and management of perpetrators in general practice. There is a lack of research in this area and GPs need to keep the safety of women and children at the forefront of their minds when discussing issues with perpetrators.

Case study: Gabby

Gabby married her husband Nick after a long relationship and shortly thereafter moved to her husband’s family farm. The couple were happy at the farm and soon had their first child. During the pregnancy Nick’s behaviour began to change and by the time their daughter was born the relationship did not ‘feel’ as it had before. Nick seemed withdrawn and spent long periods of time by himself. He began to remind Gabby of Nick’s father who had always been a stern presence in his life.

Nick’s behaviour became threatening and controlling, especially in relation to money and social contact. He was increasingly aggressive in arguments and would often shout and throw objects around the room. Gabby thought that because he wasn’t physically hurting her, his behaviour did not constitute abuse. Nick did not show much interest in their daughter, Jane, except when in public, where he would appear to be a doting and loving father.

Jane was generally a well-behaved child, however, Gabby found that she was unable to leave her with anyone else. Jane would cry and become visibly distressed when Gabby handed her to someone else to be nursed. This was stressful for Gabby and also meant that her social activities were further limited.

Jane took a long time to crawl, walk and begin talking. Her sleeping patterns were interrupted and Gabby did not often sleep through the night, even when Jane was over 12 months of age. When Jane did begin to talk, she developed a stutter and this further impeded her speech development. Gabby worried about Jane a lot. Their family doctor told her that this was normal for some children and if the speech problems persisted, that she could always send Jane to a specialist at a later date.

After a number of years, Nick’s behaviour became unacceptable to Gabby. During arguments he had taken to holding the rifle that he had for farming purposes, and Gabby found this very threatening. On a number of occasions, items that Nick threw hit Gabby and she was increasingly afraid for their daughter. Gabby decided to leave and consulted the local women’s service, who assisted her to get an intervention order against Nick.

Once Gabby had taken Jane away from Nick her behaviour changed. Jane’s development seemed to speed up and Gabby couldn’t understand why. As part of her counselling at a local women’s service, she discussed this issue and her counsellor recognised the developmental delay, stutter, irritation and separation anxiety as effects of Jane’s having lived in an abusive situation.

This could be seen as a missed opportunity for identifying family violence. If the family doctor could have asked Gabby or Nick (who had presented with chronic back pain) about their relationship then what was happening to the family, and specifically to Jane, could have been identified much earlier.

Resources

Please refer to Appendix 7 for resources nationally and in your area.

Further information

Management of the whole family when intimate partner violence is present: Guidelines for primary care physicians – outlines information relating to management of the entire family. Developed by an international group, this document explores the evidence surrounding identification and management of IPV.

Roberts G, Hegarty KL, Feder G, editors. Intimate partner abuse and health professionals: New approaches to domestic violence. London. Churchill Livingstone Elsevier, 2006 – provides an overview of the literature on abuse and violence in primary healthcare. Explores the prevalence and barriers faced by GPs addressing abuse and violence.

World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013. 
Taft AJ, Hegarty KL, Feder GS. Tackling partner violence in families. Med J Aust 2006;185:535–6.
Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet 2002;360:1083–8. 
Heise LL. Violence against women: an integrated, ecological framework. Violence Against Women 1998;4:262–90. 
Rees S, Silove D, Chey T, et al. Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function. JAMA 2011;306:513–21. 
Aldridge ML, Browne KD. Perpetrators of spousal homicide: a review. Trauma Violence Abuse 2003;4:265–76. 
Laslett, A-M., Catalano, P., Chikritzhs, Y., Dale, C., Doran, C., Ferris, J., Jainullabudeen, T., Livingston, M, Matthews, S., Mugavin, J., Room, R., Schlotterlein, M. and Wilkinson, C. (2010) The Range and Magnitude of Alcohol’s Harm to Others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Health. 
Mintz H, Cornett F. When your patient is a batterer: what you need to know before treating perpetrators of domestic violence. Postgrad Med 1997;101:219–28. 
World Health Organization/London School of Hygiene and Tropical Medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: WHO, 2010. 
Danielson K, Moffitt T, Caspi A, et al. Comorbidity between abuse of an adult and DSM-III-R mental disorders: evidence from an epidemiological study. Am J Psychiatry 1998;155:131–3. 
Humphreys C, Regan L, River D, et al. Domestic violence and substance use: tackling complexity. Br J Soc Work 2005;35:1303–20. 
Sharps P, Campbell J, Campbell D, et al. The role of alcohol use in intimate partner femicide. Am J Addict 10:122–35. 
Thompson M, Kingree J. The roles of victim and perpetrator alcohol use in intimate partner violence outcomes. J Interpers Violence 2006;21:163–77. 
Taft A, Shakespeare J. Managing the whole family when women are abused by intimate partners: challenges for health professionals. In: Roberts G, Hegarty K, Feder G, editors. Intimate partner abuse and health professionals: New approaches to domestic violence. London: Churchill Livingstone Elsevier, 2006. p. 145–62. 
Gerbert B, Moe J, Caspers N. Physicians’ response to victims of domestic violence: Toward a model of care. Women Health 2002;35:1–22. 
Helfritz L, Stanford M, Conklin S, et al. Usefulness of self-report instruments in assessing men accused of domestic violence. Psychol Rec 2006;56:171–80. 
Adams D. Guidelines for doctors on identifying and helping their patients who batter. J Am Med Womens Assoc 1996;51:123–6. 
Taft A, Broom D, Legge D. General practitioner management of intimate partner abuse and the whole family: qualitative study. BMJ 2004;328:618. 
Miller D, Jaye C. GPs’ perception of their role in the identification and management of family violence. Fam Pract 2007;24:95–101. 
Featherstone B, Fraser C. Working with fathers around domestic violence: Contemporary debates. Child Abuse Review 2012;21:255–63. 
Smedslund G, Dalsbø T, Steiro A, et al. Cognitive behavioural therapy for men who physically abuse their female partner. Cochrane Review. The Cochrane Library, 2011. 
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