Motivational interviewing (MI) is a patient-centred clinical intervention intended to assist in strengthening motivation and readiness for action.67 With intimate partner abuse, a woman’s ability to change her situation may be very limited. It is important that MI is done with safety as the foremost concern for women and their children.
One goal of MI is to elicit and reinforce ‘change talk’ from the patient.67,69,80 In MI, the focus is on reflections and questions on topics that relate to ambivalence and action – what might promote action and what makes it difficult or inhibits it. The skillful MI counsellor is attuned to change-relevant content in the patient’s behaviour and communication. Their thoughtful reflective listening statements help to facilitate action. At the same time, adopting the spirit of MI helps to affirm explicitly the client’s autonomy and choice with respect to what, whether, and how to change.
A core component of the MI approach is the MI spirit – a mix of skilful counselling style blended with a clear patient-centred approach. Key elements of the MI spirit include:69
- A collaborative, rather than authoritarian, approach – the GP actively fosters and encourages power sharing in the interaction in such a way that the patient’s ideas substantially influence the direction and outcome of the interview. Gaining a better understanding of the patient’s ideas, concerns, expectations and preferences through using the MI approach increases shared decision making. Information is actively shared and the patient is supported to consider options and to achieve informed preferences.
- Evocation – the focus is on the patient’s own motivation rather than trying to instil it. The GP works proactively to evoke the patient’s own reasons for action and ideas about how change should happen. All patients have goals, values and aspirations. Part of the MI approach is to connect health-related behaviour with the things that patients care about.
- Honouring and respecting the patient’s autonomy – the MI process actively supports autonomy by building good relationships, respecting both individual expertise and competence and interdependence on others. Patients can and do make choices and it is ultimately their right to choose what they wish to do – patient self-determination is respected. Specifically, patients have the right to follow their own preferences and make their own decisions even if these are regarded as problematic by others.
MI is different to the transtheoretical model of behaviour change. The latter is intended to provide a comprehensive conceptual model of how and why changes occur, whereas MI is a specific clinical method to enhance personal motivation for change.81
The transtheoretical model of behaviour change (TTM) is commonly referred to as the ‘stages of change’ model and has been used in many clinical settings to determine patient readiness for action, including intimate partner abuse and other types of abuse and violence.2,82–84 While the stages of change model can be useful, transition through the model is not usually linear. External factors, for example, social isolation or a lack of finances, may inhibit a woman being able to make any changes to her situation. More importantly, there is limited rigorous evidence of the effectiveness of the stages of change approach as the preferred counselling approach for women who are victims of intimate partner abuse.2,83,85 It is preferable to maintain a degree of flexibility rather than adopting a rigid approach when choosing intervention strategies.86
The stages of change, as applied to intimate partner abuse, can be categorised into five components outlined below. It is important to keep in mind the limitations outlined above.
- Pre-contemplative – the woman is not aware that she has a problem or holds a strong belief that it is her fault. Awareness is a key issue that you will wish to work on with your patient.
- Suggest the possibility of a connection between symptoms and feelings of fear using the woman’s terms.
- Contemplation – she has identified a problem but remains ambivalent about whether or not she wants to or, more importantly, is able to make changes. If the perpetrator is also a patient of the GP, this may generate ambivalence in the GP.
- Encourage possibilities for change should she decide she needs them. Point out that you are available to help and support her on the journey.
- Preparation/decision – the catalyst for change has arisen, whether it is concern for children or a realisation her partner won’t change. Change talk is more apparent.
- Explore resources. Respect her decision about what she wants to do – for example, talk to family/friends/counsellor, leave the relationship, obtain a restraining order.
- Action – a plan devised in the previous stage is put into action.
- Offer support to carry out the plan and ensure safety planning is in place.
- Maintenance – the woman’s commitment to the above actions is firm.
- Praise whatever she has managed to do and support her decision.
- Returning/relapsing – the woman may feel compelled to reverse action. Reasons include finding life too stressful, having limited or no access to children or resources.
- Support her even if she returns to the relationship, doesn’t see a counsellor or fails to report abuse. Reassure her that this pattern of behaviour is common for women.
Getting started – raising the issue
Raising the issue can be challenging ( refer to Chapter 2 ). Women are not likely to disclose abuse unless directly asked87 and many GPs don’t ask.88 Understanding the factors that contribute to disclosure and engagement in discussion is the first step in the process. It is also important to have an index of suspicion, especially with some typical presentations. For example, it may be a patient you have seen for years for depression, persistent headaches or vague somatic complaints. Begin to explore the possibility that they are experiencing violence or have experienced violence in the past with general and then specific questions ( refer to Chapter 3 ).
It may be important that you simply suggest the possibility of a connection between what may be happening at home or in the past and their presenting symptoms.
Often people who have these types of health problems are experiencing difficulties at home. Is this happening to you?
Sometimes these symptoms can be associated with having been hurt in the past. Did that ever happen to you?
It is useful at this, and any, time to signal your support and acknowledgement that any violence is not acceptable. It is ineffective at this point to suggest leaving the relationship, but any message of support and identifying that alternatives exist, may be a trigger for action.2,72,85,87 Remember that women are at greatest risk of being a victim of homicide around the time of leaving. Therefore, planning when, and how, to leave needs to be done carefully to maintain safety.
There are a number of barriers ( refer to Chapter 2 ) to disclosure, particularly in small or rural communities – for example, not wanting the GP to think badly of the perpetrator, particularly if there is a family doctor who also sees other family members. There is often also a fear of repercussions and consequences, particularly in small, interconnected and isolated communities where anonymity cannot be maintained. Women in rural and remote areas may also find it more difficult to seek help or end a violent relationship. A range of factors may compound the isolation that survivors already experience as part of the abuse, such as:
- access to services
- concerns about maintaining confidentiality and anonymity
- the stigma attached to the (public) disclosure of violence
- lack of transport and telecommunications.89,90
Table 8 outlines some of the contributors to both disclosure and engagement.
Strategies to increase disclosure, engagement and readiness for action in women who experience intimate partner abuse
Many women who are abused express ambivalence about taking action, even if they have identified a concern (or perhaps even a problem).
Yes, I know my husband beats me occasionally, but in between he’s okay. He’s not nasty to the children and he treats me well.
Yes, my father was very hard on us … but we were really a happy family.
’Yes, but’ is the classic phrase associated with ambivalence. Part of the person wants to acknowledge the abuse and another part does not.
It is useful to encourage patients to look at possibilities should they decide to do something. Just pointing out that there are options, that violence in any form is wrong and that they do not have to put up with it, will help to establish trust, build self-esteem and identify you as a supportive agent.100
Whatever you decide to do about the situation, if you think I can help, please let me know. I am happy to discuss this with you and we can explore the options together.
To gain some understanding of how a relationship is perceived by your patient, you could get her to fill out a healthy relationship tool and motivational interviewing tool. Ask her to rate how the relationship is going, on a scale from 1 to 10. If she rates it as only 1 or 2, ask what she would need to happen to change this to a 4 or 5. This should provide some insight into what the woman thinks might contribute to a turning point.
Similarly, if she rates it as a 7 or more out of 10, try to get a more complete picture of her situation by asking her why the rating was a 7 and not a 2 or 3. This should give you a sense of why this relationship is important to the patient. Asking what would make it a 9 or 10 may also shed light on what else needs to happen. A decision-balance matrix is also a constructive tool to explore a patient’s ambivalence about her partner and the relationship.80 Emphasise that the reasons entered in the boxes should be her own reasons, not what someone else has told her.
The GP needs to consider both dimensions of exploring a ‘decision balance’ – the emotional as well as the cognitive. On an intellectual level the woman may have a clear understanding of her circumstances and may acknowledge that she should leave. However, the fear associated with leaving the relationship and coping alone may be incredibly strong, and she may feel emotionally ill equipped for the enormous physical and emotional effort involved in making the changes.
Fear and the sense of powerlessness engendered by intimate partner abuse can be a prevailing deterrent for survivors trying to move forward and away from abusive partners. Often regaining confidence and emotional strength can be a gradual process, so that even small advances are initially viewed as real hurdles. GPs need to be aware that moving out of an abusive relationship may take quite some time; sometimes years. The GP can be an important source of ongoing support and strength if they are non-judgemental of the rate of change and supportive of the decisions and choices the survivor makes along the way.
Useful interventions include:
- affirming the abuse is occurring – that is, believing the patient
- assessing the risk to safety of the patient and any children
- assessing the level and quality of social support available
- documenting the abuse
- educating the patient about abuse and the cycle of violence and how it affects health
- exploring options
- discussing a safety plan
- knowing resources for domestic violence support agencies
- making appropriate referrals.
What finally prompts women to take legal action, leave or change?
Most victims have to begin to reject their own reasons for staying in the relationship. The abused woman needs to stop believing that violence is normal. This may be a greater problem with women whose own parents have been violent. In order to be able to leave or take legal action a woman needs to:
- stop excusing her partner of being sick, mentally ill, alcoholic, unemployed or under great stress
- stop blaming herself, and stop believing she is bad, provocative or responsible for the violence
- stop believing and hoping that if she is good her partner will not abuse her
- stop pretending that nothing is wrong, and hiding or minimising her injuries
- stop believing her children would be disadvantaged if she and they were to leave
- stop believing that her partner will change
- start believing that there are other options.
Often something happens to tip the scales in favour of taking action. This may be triggered by a specific event or just an accumulation of experiences.
Common reasons given for reaching a turning point include:85
- protecting others (eg children) from the abuse and the abuser. It may be that the perpetrator has started to hit the children. Many women in abusive home situations tolerate the violence ‘for the sake of the children’, but when they too are subjected to it, this can be the catalyst for change
- increased severity or humiliation with abuse. The abuse may have escalated to a ‘new’ level. It may be that the first incidence of physical abuse has occurred or a more serious episode of physical abuse has occurred causing injury, or a serious threat has been made which leads to a change in the woman’s sense of her and her family’s personal safety if she does nothing
- increased awareness of options and access to support and resources
- fatigue or recognition that the abuser is not going to change
- partner betrayal or infidelity.
Common ‘change talk’ statements when a women has reached a turning point may relate to desire to change (I would like to …), ability (I can ..., I might be able to ...), reasons (I would probably feel better if I ..., I’ve had enough), need (I ought to, I really should …) commitment (I am going to, something has got to change) and taking steps (this week I started to …).
It is important that the GP is aware of local and other resources the patient may have within their own social network and family. It is good to clarify:
- What is it that the patient wants to do? Is this realistic and possible? The patient may need to explore alternative options.
- How does she intend to go about it? Assess current level of risk and discuss a safety plan.
- What role does she want you to play? Consider the legal issues – for example, documenting injury and impact and referrals to intimate partner abuse counselling and services).
The GP has a role when the patient has decided to act and taken some initial steps. Non-directive problem-solving techniques can help at this time (refer to Tool 5. Non-directive problem-solving/goal-setting tool).
Understanding and discussing her plan is helpful. Actions may include:
- talking to family and friends
- changing the locks on the house
- going to see a counsellor
- talking to someone at a refuge or shelter
- leaving the relationship
- taking out an intervention order
- reporting the abuse to the police.
Maintaining change is often extremely difficult. Most of the time it does not become apparent what change actually means until it has been achieved. For example, if a woman leaves and finds it emotionally more difficult to be on her own than to deal with violence, she is likely to return. If through leaving she has been denied access to her children, she may also feel compelled to return.
Providing ongoing support and assistance is vital.
There are many reasons why people return to violent situations, but enjoyment of the violence is not one of them. It may be that several attempts to leave are made before long-term success is achieved. While it may seem that the patient is making an unwise choice, it is more productive to get a better understanding of why the patient chooses to stay. There may be very compelling reasons why the victim believes they cannot leave. Making judgements about the merit of the decision is rarely useful and may alienate the victim. It is useful for GPs to understand the circumstances why this has occurred and what the woman wants.
What happens to women after they leave?
Some women receive help from family and friends. Women’s shelters or refuges are available, although this support may be limited depending on location and whether a bed is available. In the situation of a patient leaving her partner, it may be at this point that you lose contact with the patient. The patient may move to safety at a friend or relative’s home, a refuge or out of the area, and there may be extremely good reasons why a survivor needs to sever links with her GP.
Problems experienced by women once they leave an abusive partnership include:
- risk of further abuse
- financial – many women experience a dramatic fall in living standard – for example, they have to claim the Supporting Parent’s Benefit
- loneliness – the need for companionship and a sense of belonging is important to most women
- the need to rebuild their lives and those of their children.
Many women re-partner, but the longer a woman stays in an abusive relationship, the harder it becomes to leave and re-establish a normal life. Some women carry the scars of physical, sexual and emotional abuse into the future. Anecdotally, around 50% of women who leave a relationship will return to that relationship at some point. Some may enter another abusive relationship. Few will recover totally from the experience.