Sue Gedeon:
Hi everyone, welcome to this evenings Risk assessment in a pandemic: Assessing survivors of family violence in general practice webinar. My name is Sue Gedeon and I'll be your host for the evening. Before we get started, I would like to make an Acknowledgement of Country.
We recognise and acknowledge the traditional custodians of the land and sea, on which we live and work and pay our respects to elder's past, present and future.
Just a few housekeeping notes, this webinar is being recorded and will be uploaded on the RACGP website. We have put everyone on mute to ensure that the learning will not be disrupted by any background noise. If you have any questions during the webinar, please add these using the Q&A box at the bottom of your screen. You can also interact with the panelists and attendees using the chat function. We will try and address questions throughout the presentation. If we don't get to your question, we will review these and provide a response offline. If you're not comfortable asking a question during this webinar please don't hesitate to email me your question privately and we'll answer it offline. I'll put my email in the chat box.
I'd like to introduce Dr Jennifer Neil. She is a senior lecturer at Monash University and has worked as a GP family violence educator for several years both with the harmony study at Latrobe University and safer families through the University of Melbourne. She has co-authored three chapters in the RACGP guideline on abuse and violence, otherwise known as the White Book, the update of which is due for publication at the end of November. And she is on the safer families Victorian MARAM and information sharing advisory group and is a member of the RACGP specific interest group on abuse and violence. She works clinically as a GP in Bowen Victoria and supports a large number of victim/survivors in her practice. Thanks Jennifer.
Dr Jennifer Neil:
Great, thanks very much for the introduction, Sue and I'm very honoured to have with me today a couple of people who I think are really amazing and I'm really pleased to have with me Jac Dwyer, who is a specialist family violence practice development and training officer at Berry Street. Jac has worked in mostly direct practice roles in the Community sector for over 12 years and has been in the specialist family violence role for the last three. In her current role, Jac supports Berry Street's family violence services to align to policy and practice frameworks and facilitates family violence training externally, including with the pathways to safety training program for general practice clinic, so Jac and I have done some of the training sessions per se for families together.
I'm very pleased also to have with us Fiona, who is a family violence survivor and is a member of WEAVERs. WEAVERs are a group of women who've experienced family violence and who play a role in weaving lived experience into research and training at the University of Melbourne. Fiona ran away from her 28-year domestic violence relationship with what she could put in the back of her car and then her son perpetrated violence against her for the following six years. Being on the WEAVERs panel has been pivotal to her healing journey and has given her a voice that she never knew she had, and it's been a real opportunity to make change for women and children. Such as being a keynote speaker at the first international domestic violence conference in Melbourne and working on the experts by experience framework research project collaboratively with research staff. So, thank you very much for joining us Jac and Fiona.
So, I just really before we begin, I just want to introduce to you something called The Readiness Program. Safer Families is a centre for research excellence, which is part of the University of Melbourne and headed up by Professor Kelsey Hegarty, who some of you may know. As part of this program they are running the Readiness Program which is really to ensure that GPs are ready to respond to victim/survivors of violence within their clinics. The readiness program, this just gives you a little overview of it, it firstly involves webinar series and a suite of eLearning modules. Then the Pathways to Safety program involves two 90 minute sessions which are headed up by both a GP family violence educator and also a family violence connector such as Jac, and then these two sessions are you know really interactive they involve the whole clinic firstly, in the first visit, and the second visit, they involve the clinical staff and then this program then involves online training workshops as well, so really the aim is to get GPs ready to respond to victim/survivors of violence. So you can find out more about that, through Safer Families and we might actually put up a link for you a little bit later on in the evening.
So our objectives today we're going to identify and describe factors contributing to increase rates of family violence due to the COVID-19 pandemic. I'm sure you've all heard about the fact that this has been a real issue during the pandemic in 2020 and 2021.
We're also going to talk about performing risk assessments with victim/survivors, in the context of the pandemic, but also giving you lots of information about how to do risk assessments outside of the pandemic context as well.
And we're going to talk about safely assessing and supporting victim/survivors via Telehealth because of course we all know we're all doing quite a lot of Telehealth at the moment, particularly those of us who have been in places like New South Wales and Victoria like I've been in Victoria, and so I'm based in Melbourne.
I also just want to acknowledge that given the commonness of family violence, the World Health Organization estimates that about one in three women will at some stage in their life be victim/survivors of family violence which is an incredible figure really isn't it. There will very likely be survivors amongst us tonight, and I just want to acknowledge your strength, and I just want to say that if anyone finds this topic difficult then I’d encourage you to seek help from trusted friends or family members, from your GP or you can always call 1800 RESPECT for support too.
I also just want to mention I’m going to mention about three cases tonight in brief. I want you to know that those cases have fully been de-identified and I've changed quite significant details of them so that they cannot be identified.
So just very quickly, what are we meaning when we're talking about family violence, domestic violence, intimate partner violence, there's lots of terms. Well, the word family violence really encompasses all the other forms and types of violence that can occur so whether it is between a partner or you know current or previous partner, and we call that intimate partner violence which is any behaviour within an intimate relationship that causes physical, psychological or sexual harm. Sibling abuse, elder abuse, child abuse, the abuse of a parent by a child for instance can also occur too, so there are many different forms of family violence. Some people use the term domestic violence interchangeably with family violence and some use it more to be specific to intimate partner violence. A lot of what we're talking about tonight we'll be talking about intimate partner violence, but all the things that you learn from it can be utilised for any of these other forms as well.
And you know I want to just point out the fact as well that we are going to be using very gendered language and there's a reason for that this is a very gendered issue and, yes, although we're going to be talking about the fact that victim/survivors as being women and perpetrators as being men. Of course, men can be victim/survivors as well, and the similar thing though is the principles that you learn can be used for either a male or female, being a victim/survivor, but we will use gendered language because, as you'll see when we talk about the prevalence, it is much more common for a female to be a victim/survivor. We'll also tend to focus on heterosexual relationships, mainly because that's where most of the research has been done, but this is also very much an issue in the LGBTQIA+ community, and so you know again the principles that we talked about can be used for that community too, but there are some specific things that we'll talk about later on.
In terms of forms of abuse, I'm very quickly going to go over this so that we can get on to the rest of what we want to talk about tonight just to give you some background. I mean we all know that family violence can include physical violence, so slapping, hitting, kicking, choking, strangulation as well. And most of you would also know about sexual violence as being a form of abuse as well, including things like sexual coercion, so you know, forcing a woman to have a baby when she doesn't want to have a baby, for instance. Emotional/psychological abuse, you know belittling, humiliation, threatening her life, threatening to harm her, threatening to take away the children, it can be incredibly damaging. And then there's this thing called coercive control and a lot of you will have heard of coercive control, but some of you may never have actually heard of this before. Now abuse stems from the need to have power and control over the survivor, it's not about losing it, it's not about anger, it's actually about power and control and Jac I was wondering if you might like to just tell us a little bit about coercive control.
Jac Dwyer:
Sure, so we think about coercive control as a pattern of behaviour that restricts the victim/survivors' access to choice and also keeps them from doing things they want to do, having freedom and might make them feel fear about taking certain actions, and will otherwise make them feel fear for themselves or fear for someone else that they love, like a child or pets or anything like that.
Dr Jennifer Neil:
Absolutely thanks for that Jac.
And so now that we know about the forms of abuse, how common is it in Australia? This is from the Australian Bureau of Statistics, they did a big survey in 2016 and found that one in six women have experienced physical or sexual violence, so this is not even including any emotional abuse or coercive control or anything like that, but physical or sexual violence by a current or previous partner, since the age of 15 compared to one in 16 men. It's a bit more common for men to experience emotional abuse, so one in four women and one in six men. And then, sexual violence, one in five women and one in 20 men and none of these figures talk about a coercive control either.
What I think is really important to recognise is that abuse is not necessarily something that's just perpetrated by a current partner, it's very common for abuse to continue once a woman has left or even get worse, once a woman has actually left, and so it can absolutely be perpetrated by a former partner as well.
So what is happening in general practice in Australia. So a prevalent study was done in 2002 and it was found that 8% of women attending GP have been subjected to violence in the last 12 months. Now I want you as a clinician to think of how many women have walked in the door of your consulting room this week. And I want you to think of roughly eight which is close to 10% so closely one in 10 of those women are actually current you know current victim/survivors of violence, you know within the last 12 months. So it's very, very common. General practice is a place that victim/survivors go. GPs are in fact the most common health professional for a woman to disclose to and apart from friends and family members, women are more likely to disclose to a GP than to anyone else, but there's lots of barriers to women disclosing and to GPs asking and Fiona I'd just like to ask you, do you want to just comment about the barriers to women disclosing to GPs.
Fiona:
Yes it's actually incredibly hard to disclose to a GP and I had multiple forms of abuse which one of the biggest romance was the coercive control, so my partner my husband had actually said I wasn't allowed to go to the doctors and in fact would interrogate me if I went to the doctors, so even getting to the doctors itself was very difficult.
I also live in a semi-rural area, so if I go to the doctors, is the receptionist going to know me, who is actually in the waiting room, um I would be scanning the room to make sure that there was no one there. Also when a woman goes to the doctors, she may have had a multitude of things and behaviour perpetrated on her before she even gets there. So she may have had issues with the children, he may have abused her in the morning, he may have screamed, he may have hit her in the morning. And he may be threatening to kill her, kill her children, and so, then when she presents at the doctors, you may appear like someone who really hasn't got themselves very together.
Dr Jennifer Neil:
Absolutely, I mean there are so many barriers aren't there.
And the GPs, you know only one in 10 GPs are actually asking women about violence, so you know it's unfortunately not common and one of the reasons for this is you know the time factor, you know, do I open that can of worms at the 15 minute mark knowing that it means that I'm going to be running really, really late, we all know that feeling.
A lack of education, a lot of the GPs that I've talked to, and I've talked to many GPs in the training sessions we do, a lot of them say look the reason that I don't ask or I don't think about it is because I don't know what to do next, if I ask, what happens after that, I don't know where to refer, I don't know what to do if they actually disclose it, so a lack of education and a lack of skill.
There's also a fear of the abuser as well and it's not uncommon because we manage the whole family for GPs to be managing both the perpetrator and the victim/survivor and possibly also the children as well, and that makes everything a little bit more complicated as well.
So only 13% of Australian survivors have actually ever been asked by their GP about abuse, but women who are abused in general actually want their GPs to ask them about family violence. Particularly they want them to ask about family violence if they're going to be asked in a non-judgmental way.
So we know that in general practice, women are attending, victim/survivors are attending. And we know that the victim/survivors, would like to be asked, and we know that not a lot of asking is happening and then of course everything got complicated by the fact that COVID came along, and we all know about that story.
So I just want to illustrate it very quickly by telling you about a little bit of a case. So this is a patient that I've seen and, as I said I've changed some details so that that patient is not identifiable.
A 63 year old woman came to me, she's retired, she lives with her husband, I've actually seen her a few times before, she's had quite a few physical presentations that have been fully investigated. No one's ever really got to the bottom of what the cause of these particular presentations have been, she's been to multiple specialists, she's also been to multiple other doctors within the clinic and doesn't always come to me. And every time I've seen her she's actually been accompanied by her husband to the appointments. And so during the COVID lockdown in Melbourne, we tried very hard to get patients to come in on their own, so that we had less people, so it was easy to social distance and so she actually came in on her own at one point, and she came in to get a script. And I was making it a habit to ask every single person that walked in the door how things were going in the lockdown and how things were at home, knowing the difficulties that this was causing to so many people, and she just said to me I'm sick of him following me around everywhere and I thought oh that's interesting, I wonder what she means by that. And she said well he's actually following me into every room of the house. I'm not allowed to go to the toilet without him watching me, I can't have a shower without him watching me, I actually haven't been on my own for weeks because none of us are going out anywhere, we're not socialising with anyone, I have been able to go out to the shops a few times to get food, but every time I do he calls me every few minutes saying where are you, where are you right now, why are you taking so long, checking receipts, see what she's bought, checking her phone to see who she's called, who she's texted, who has texted her. She's very isolated, she really had no longer has any friends because of this, you know, the isolation that she's supposed to be in because he's not really been allowing her to actually have contact with people. There's never been any physical abuse, but quite significant emotional abuse, saying things like it's all your fault, you're such a bad person. So I want you just to keep that in mind as we illustrate the effects that COVID and lockdowns, in particular, but COVID as well, has had on presentations of family violence.
So we know that in times of disaster, domestic violence tends to increase, but we've known this for a really, really long time I mean this was stated in a study back in 2008 so you know, we know that during the Ebola epidemic, which is you know, you could probably say that there's parallels to the COVID situation in some ways, then the Mount St Helens eruption, hurricane Katrina, black Saturday bushfires, the Haiti earthquake in 2010. All of these natural disaster, not all of them are natural but most of them are natural disasters, we saw domestic violence tend to increase and what we also know that is after a disaster, domestic violence tend to increase for at least a year after the disaster.
Now COVID is a much more prolonged disaster than any of these disasters and it's been complicated by lockdowns. So we're seeing something that we haven't ever really seen before. So these figures are from early on in the pandemic, these are from 2020. So straightaway in Hubei province China, there was a three times increase in domestic violence reports in Feb 2020 in a month of their locked down compared to the year before. They were also you can see these figures, significant increases in domestic violence calls and reports. Now how do we measure what is happening at that early stage, things like calls to help lines, calls to services, Internet searches for help lines, referrals to the police, but really what we were seeing then is very much likely to be the tip of the iceberg because a very large number of victim/survivors won't have reached out for help, and won't have actually searched for help lines, they may not have been even able to search for help lines, because the perpetrator might have been watching what they were doing.
What about Australia, so there were very early signs that family violence was increasing. Interestingly, a 75% increase in Internet searches relating to domestic violence support in 2020. There's a Melbourne domestic violence organisation who saw their weekly services increase from 120 to 209 per week during the lockdowns in 2020. A survey of 400 frontline workers said that there was a 40% increase in pleas for help and 70% reported increased complexity of cases. And 11% increase in calls to 1800 RESPECT and also an increase in calls to Mensline.
Now Jac, I just want to ask you from your perspective working in family violence, what did you all notice?
Jac Dwyer:
So, I guess, the first thing that we noticed was that there was, with our service, in particular, there wasn't an increase in calls necessarily but there was an increase of reported instances of violence, so there was an increase of instance and an increase of risk. So, family violence was being perpetrated more often and it was much more extreme and complex. We also noticed that perpetrators were weaponising COVID-19, so I really think really using COVID as an excuse to be more creatively abusive.
One of the things that we know in specialist family violence work is that violence tends to increase when the perpetrator's unemployed because of his capacity to use violence much more frequently, to think about it, to have more control, and we saw similar things around the lockdowns in Melbourne in particular. We knew that as soon as lockdown ended the calls through to our service would increase because suddenly there would be victim/survivors that would have more capacity to call and reach out for help.
Dr Jennifer Neil:
And Fiona, in your discussions with other victim/survivors, was there much discussion about the effects that COVID was having on victim/survivors?
Fiona:
Um well, I do have a close family friend that I was discussing it with, and they said that the instances in their household were just off the walls, this person was just screaming for three and four hours a day, just venting out anger because they couldn't control anything, their whole world had crumbled and they were being told what to do by other people, which they didn't like, particularly in Melbourne where we are with the lockdowns, it was causing increased violence, yes.
Dr Jennifer Neil:
And so we also know that last year now, this was the UN Secretary General labelled the increase in family violence due to COVID the shadow pandemic well before some professor in Australia started calling it that for the adolescent mental health issues. So this paper was called the shadow pandemic. And this was practitioner views on the nature and responses to violence against women in Victoria, Australia and what this actually found when they interviewed family violence workers in Victoria, that 59% reported that the frequency had increased, 50% said the severity had increased, just like Jac was saying, 86% reported an increase in complexity of the needs of the victim/survivor. But interestingly as well, 42% increase in first time family violence reporting by women as well, but also this comment about new forms of violence and the way that perpetrators were actually able to weaponise the COVID pandemic. Various different papers have reported this and there are a few examples that I've written here.
So intimate partner violence is about power and control, so being stuck at home with your abuser allows increased control and how it could be exerted over a woman, and her usual safety supports, such as access to friends and family members are lost, and there's increased isolation, which makes it harder for a woman to leave. So for instance perpetrators telling their partner that they have the virus, therefore, that you know, none of them can leave the house. Inviting people over to the house, saying that they're going to infect her with COVID, increase like my patient that I mentioned, increases in surveillance and control, withdrawing of essential items and misinformation about the pandemic or refusing to allow their partners to seek medical attention if they needed to.
And there's a lot of factors involved with this increase in family violence but remember when we write down all these factors, and these come from for from a study that was published in 2020, remember that the underlying cause is because of the gender norms that state that a man should have power and control over his partner. And where that attitude is already lying, that can allow these stressors to increase the risk of violence, but you know I like what you said Jac about the unemployment and the fact that it meant that he'd actually be at home more often so more able to perpetrate violence. Have you noticed any of these other factors Jac?
Jac Dwyer:
Yeah these are definitely some of the things that can increase risk, I think I just want to mention that none of these things cause the violence, as Jennifer just said that it's the perpetrators choice to use violence and what we know is that these stressors are things that, I actually don't know anyone in my personal life who hasn't had a really stressful 18 months, and most of us are not choosing to use violence, so I just want to make sure that we're really clear about that.
But we know that things like increased alcohol use, increased drug use, can make perpetrators, a lot more, sorry it's been a long day, and a lot more, kind of, what's the word, sorry um, unpredictable, yeah, unpredictable and chaotic and that can increase the risk.
Dr Jennifer Neil:
Absolutely, and this comment here about the pandemic paradox is basically saying at the beginning of the pandemic there's these comments stay safe, stay home but in reality, what we know is that home is the most dangerous place women and children worldwide as said by the UN. And the UN estimated that for every three months of worldwide lockdowns, there would be an additional 15 million cases of domestic violence that would occur worldwide, but those reported cases very much likely to the tip of the iceberg.
So in general practice, who should we be asked me about family violence? Now I'm not saying that you should be asking every single female that walks in the door, although I do check every single patient I'm seeing I'm asking them how they're going, given the stress of the current situation, but we certainly should always be asking anyone who's pregnant, because we know that violence often increases in pregnancy, we should be thinking about women who've had physical injuries, with mental health presentations, women with chronic somatic complaints, women who've had STIs or unplanned pregnancies, who are frequently presenting, who have a company in partners because maybe it's that the partner doesn't want them to actually be able to disclose. And when things just don't add up, and you think maybe you're missing something in the story, that's when you should be considering asking about violence.
And just before I get on to talking about Telehealth, just how do we ask about intimate partner violence when you've got someone in your room, first of all, she needs to be alone. You can't ask her when her partner is present, because either she will lie to keep herself safe or if she says something it might put her at risk. So you might start with, we use really a funnelling approach, where we start very general and then start to get a little bit more specific, so you might say something like how are things at home, how are things with your partner, what happens when you argue. You might say something like, because of COVID I've seen an increased number of women being abused by their partner, is this something that's happening for you? And then you know, I think that question about whether there's someone who's been making you feel unsafe or afraid is really important as well.
So these are some of the questions that you can use to ask about family violence, but of course that all gets really complicated by the fact that we're all using Telehealth. What's interesting though is that in fact there is evidence that there are improved outcomes for survivors using Telehealth. It can actually make things much more accessible for survivors and may improve contact with survivors and potentially decreases isolation. And, of course, we all know, it reduces the risk of catching COVID so sometimes it's the only way to do it in the midst of a pandemic and the only safe way to do it, so there's a lot of benefits to using telehealth.
But there are a few issues that you need to be aware of when you're thinking about asking a woman about family violence over the phone. You cannot tell who else is on the call now, even if it's a video call, you might think you know who's in the room but you actually don't. You don't know who's standing behind the computer. Telehealth can leave a digital footprint as well, so if he is to check her phone later, he can see that there's been a phone call and he'll say who was that that you spoke to, who was that phone call to, even if it was a no caller ID ,he might even say who was that that you spoke to. So one of the first things is to set up a safe time to talk so you might, you know, if you're seeing her in person first, you might say okay I'm going to speak to you on the phone, what is the right time for me to call that you know is going to be a safe time to talk and so set up a safe time. And then to use yes, no questions initially so that she can actually answer safely. So you might say something like, is now a safe time to talk, are you alone at the moment, do you feel safe at home. They're all yes, no questions that she can ask and if she's not feeling safe she can say no, so you know that now is not the time to ask in detail about actually what's going on for her right now, because it's not a safe time to talk.
You may be able to make an excuse for face to face, so that's what I did with the patient in the case that I mentioned, is that I she wasn't keen on a referral to services and in fact, it was very, very difficult because any phone call that I made he would know about. But what I did was I realised that she was due for her Prolia injections, so I actually organised for her to come back to have that and made the excuse that she had to come alone because of COVID, so I was able to actually get her back to be able to talk to me because in fact I'm the only one at the moment that she can really talk to.
So I wanted to just ask Jac in your experience, because you use a lot of telehealth when you're speaking to victim/survivors, what's your experience of using telehealth?
Jac Dwyer:
I think that, as you said, it's a really good opportunity, I know that specialist family violence services in Melbourne, a lot of us have been working primarily over the phone or over the Internet over the last 18 months and it has been effective. I think that you're right, there's some risks and with that, sometimes we'll notice if someone's on speakerphone, so you might hear something in the background or they just might sound a bit distant and then I'll make an excuse and say you know, I've got a meeting I need to go to, I'll call you back later, or they might make an excuse to get off the phone and I will be alert to that, oh okay it's not safe enough to talk right now and we'll talk later when it is a safe time to talk. We might set up a code word so that we know if it's not a safe time to talk, they might say something like hey have you been able to get me funding for something or that's for us, obviously it would be different in a GP situation but yeah I'd highly recommend the code word and also to trust your gut because sometimes things will just not feel right. victim/survivors are the best people to judge their own safety and just really follow their lead.
Dr Jennifer Neil:
Absolutely, so these were some tips published this year, and this is really in relation to nurses using telehealth. Making a safe time wearing earphones if available so other people around can't necessarily hear what's being said, not to use the speakerphone if at all possible, video conference might increase safety by you know, the ability to use visual clues, although we talked about the limitations of that as well, and the yes, no questions we've spoken about.
If for some reason the call's disconnected who's going to call who. Because you know you don't want to be calling her again if she's disconnected for a reason because she's trying to keep herself safe.
And the use of code words exactly as Jac mentioned, but I want to show you this, this is, this is actually really interesting, the hand signals that can be used in an emergency, because, in fact, very recently, you might have seen reported in the news just within the last few days, there was a case of a 16 year old girl who was in a car and actually used this exact hand signal which actually originated from Tik Tok, where basically you hold your palm out with your thumb tucked in, and then you trap the thumb with your fingers. And that's basically saying help I'm trapped, please, you know, I'm in a really difficult family violence situation, and someone actually noticed her doing this in the car and she was able to be rescued from that situation because of this hand signal. And so it shows that these things can actually be really useful and that's something that you can potentially teach to a survivor as well.
Remember though, even if you can't talk to her on the phone, you can actually still offer resources to her. So you know, although she can't say anything to you, you may well still be able to say, I know you can't talk right now but I'm just going to give you a phone number that you can remember, that if you need to, you can call it, it's 1800 RESPECT. And the reason for that number is it's a 24/7 counselling service, it is not a crisis service but it's an Australia wide phone number and it's really easy to remember, you don't have to write it down to remember it and that's one of the reasons that it's quite a useful phone number.
You could also suggest that she use what's called the Daisy app and that might be something that when you're together in person that you know you might be able to set her up with. So you might not be able to see this slide very easily, but this is essentially straight from the app store about this Daisy app. So what it does is it has lots of resources, Australian resources and local resources for family violence and for help and support. If you view any websites through the app it will not leave a history in the browser, there's a get help button that you can call for help in an emergency and there's a quick exit button that returns it to the front of the screen that doesn't necessarily show you, you know, that it's anything to do with family violence in order to keep her safe.
This is really just to show you that in our pathways to safety program that we run, we actually go into this in a lot of detail, but you know, the fact that when you're responding to a disclosure, this is what the World Health Organization recommends that all health professionals do, we're obviously going to listen to her story, we're not going to be judgmental, we're going to inquire about her needs we're going to validate her, you know remind her that it's not her fault, remind her that she's not to blame and what's happening to her is not okay. And then we're going to enhance her safety by doing a risk assessment and safety planning and that's what we're going to talk about now. And we're going to offer her supports, including a referral as well.
So the risk assessment process, so this comes directly from the government of Victoria MARAM website so basically, there are four things, well three things, that you take into account to form a professional judgment about the victim/survivor you have in front of you risk. And the first and most important thing that you are going to take into account is the victim/survivors self-assessment and just like Jac said before, the reason for this is she is actually the best judge of her own safety because she's an expert in her own safety, this is her lived experience.
And so it's always really important to check on her immediate safety, so how frightened do you feel? Do you feel safe to go home today? And look, I just want to throw to Fiona and just in terms of a victim/survivor self-assessment of safety. So Fiona, in your own experience, how did you know whether you were safe or not?
Fiona:
Um well, this is a really curly question because and I'm being very open about this, I didn't actually realise that I was in a domestic violence relationship, because it had been done so covertly to me for so many years that I actually had no idea.
So for me, I found out looking on a website, so that was quite shocking for me to find out that I was in this kind of relationship, but as time wore on, I did make sure that my children and I were as safe as possible.
Dr Jennifer Neil:
Hmm absolutely, and so you know, this is a really important part of the assessment, to ask her how safe she feels. And then what we're going to do is use evidence-based risk factors and I'm going to show you them on a slide in a moment.
We're going to put them together with any information sharing that has occurred so, for instance, if you've had a conversation with a domestic violence worker, if you've had a conversation with the police, and in Victoria there's actually laws around information sharing, which I'll tell you a little bit about later on. And we're going to put those three things together to then form a professional judgment as to whether you know, she's high risk, intermediate risk, or at low risk currently. Now what you need to remember is this risk assessment needs to be performed each time you see her because her circumstances may have changed, her risk level may have changed.
And I'll get you in a moment Jac, but I'll just pop this slide up before I do.
Just to show you these evidence-based risk factors. So we know that these risk factors increase the risk of a victim/survivor dying or being seriously harmed as a result of family violence. So the most risky time is leaving, planning to leave or a recent separation. There was a study done that showed that in New South Wales, 65% of women killed had ended the relationship within three months of the homicide. So you know, this is the most risky time, and this is a significant barrier to women leaving because they actually know that they may well be at increased risk when they leave rather than decreased risk, and everyone's like why doesn't she just leave, I would just leave, but not understanding she knows that the risk may well increase if she leaves.
Strangulation or choking, so women who, where non-fatal strangulation has occurred are at seven times increased risk of homicide and there's also a significant increased risk of an acquired brain injury as well. We also know that when there's been an increase of severity and frequency of violence that this significantly increases her risk. A physical assault while she's pregnant increases her risk as well. But the most consistent risk factor for dying is a previous history of violence, so we know if there's you know what we're really I think what these evidence-based based risk factors are about is, this is about perpetrator behaviour.
So what we need to know when we do a risk assessment is what has the perpetrator behaviour been because what the previous behaviour of the perpetrator has been illustrates what may well happen in the future. And I might just throw to you Jac just to talk on this and doing a risk assessment.
Jac Dwyer:
Yeah sure, so there's some of these evidence-based risk factors that are often misunderstood. One of the ones that I think about is the perpetrator threatening to self-harm or actually self-harming in front of the victim/survivor or threatening to suicide and what we know is that that's an extreme form of controlling behaviour and is linked to an increased risk of murder suicide, so we need to take that really seriously as part of our risk assessment, thinking about his risk of killing her.
We also think about physical assault while pregnant, is also linked to an increased risk of harm to that child when that child is born. We also know that as, as we said before a little bit, drug and alcohol misuse or abuse is about the behaviour being chaotic, it's not because the drugs or the alcohol caused the violence, it's because it can lead to an escalation of violence. So, it's really useful to get really familiar with these evidence-based risk factors so we can really highly tune our alarm bells and when we’re talking to victim/survivors, we can have these in mind when we're talking about what's happening or what the perpetrator's currently doing.
Dr Jennifer Neil:
Yeah absolutely and one other one that I want to highlight is if threatened with murder, a victim/survivor is 15 times more likely to be killed. So it's very significant.
So I'll just very briefly mention MARAM because I know that this isn't relevant to all of you, this is about Victoria, but I actually think it highlights a really interesting way that things are being done. So the reason this happened was, you probably have all heard of Rosie Batty and Luke Batty, her son who was killed, and there was a Royal Commission as a result of that in Victoria into family violence and this multi-agency risk assessment and management framework came out of that. And as part of that, this allows information sharing between agencies that also allows for standardised and evidence-based risk assessments and so Jac, when she is doing risk assessments, she'll be using this MARAM framework and the MARAM risk assessments to do the risk assessments.
The aim is to keep the perpetrator in view, so what we're doing is we're recognising that the issue is the perpetrator's behaviour not the victim/survivor's behaviour. So actually keeping in view what the perpetrator is actually doing and as part of this GPs are actually, what's called an information sharing entity, which means that there are laws around this and consent is required in many parts of this unless there's imminent risk, but a GP can actually talk to domestic violence workers with the police and other agencies if necessary, and with the victim/survivors consent to gain more information, because we know that what happened in Luke Batty's case is one arm of the police was not talking to the other arm of the police, which meant that his dad, the perpetrator, should really have been locked up and if information had been shared, he probably would have been locked up and not able to actually kill.
So I just want to show you this, this is the brief risk assessment tool from MARAM. Now it is actually useful to be able to use a tool and a lot of you may well find that within your states or even through a PHN you may be able to actually access a tool, but this is freely available on the website, and I think we're going to put a link for you into the chat as well, so that you can see that, because this is something that you might be able to use yourselves. The little red stars, which you can hardly see, but the little red stars indicate an increased risk of the victim being killed if those things are, and a lot of these questions are relating to a lot of the things that we just mentioned in terms of those evidence-based risk factors. And this is the second page of it, you can see again, these are really those evidence-based risk factors that we just mentioned. But I think a really important question that's just in there, in terms of the self-assessment, do you believe it possible that they could kill or seriously harm the children or other family members, or do you believe that it is possible that they could kill or seriously harm you. A really important question and Jac you use, I mean you do a more thorough risk assessment than this particular one, but do you want to tell us about using a tool, how do you find it when you were doing it with the victim/survivor?
Jac Dwyer:
Um so I guess, one of the things that as you become more familiar with the tool, it becomes more of a conversation, which is best practice. As we said before, if you become really familiar with the evidence-based risk factors, you can integrate this a little bit more seamlessly in conversation.
And I guess one of the things that we do is we rely a lot on the evidence-based risk factors, one, to understand when we're thinking about the MARAM structured professional judgment model, sometimes the middle bit of the victim/survivor's self-assessment and the evidence-based risk factors can kind of feed into each other. So, we'll say what we know based on evidence and family violence death reviews is that it's much more likely that a victim/survivor is going to be killed if there's been a history of strangulation or you know, like we said before about the, what we know, based on the evidence is that there's much more likely to be a murder suicide if the perpetrator's got a history of threatening self-harm and suicide. So, it can just feed into, it can help inform victim/survivors about their own self-assessment or feed into their own self-assessment and it can help guide the conversation.
Dr Jennifer Neil:
Yeah, absolutely. So, what do you then do with the risk assessment? So, you're a GP and you've done the risk assessment and you've asked all these questions about the evidence-based risk factors.
Look, the first thing I would say is that respecting a woman's wishes about what she wishes to do. So the vast majority of women that you will see in general practice will be going home at the end of that visit and back to the perpetrator. Okay, occasionally, you might have someone who needs crisis accommodation and is wanting to leave immediately. But the vast majority of women that you see will be wanting to go back home and it's important to respect her wishes and understand the many reasons why that might be.
Now I do want you to note that Northern Territory does actually have mandatory reporting of family violence, whereas none of the other states do. And the New South Wales Department of Health does recommend that health workers notify serious injuries, such as gunshot wounds or broken bones. So just, you know, there are differences between states in our obligations.
Now, if there are high risk factors present and an increasing severity and frequency of violence that may well mean that we say that she's high risk. And if she's high risk, what we need to do is what's called a warm referral to services with her consent. So a warm referral is not when you just give her a phone number and say go and call this number, a warm referral is where you actually while she's still present and with her consent, get on the phone and actually say I'm going to call and organise for someone to speak to you and you actually make the referral to family violence services yourself and she needs really close follow up, obviously.
If she's intermediate risk, you know a referral will still be a really good idea, there may be a fewer number of risk factors present but you feel that the likelihood of a serious outcome is not high.
Or it may be low risk because there's no high risk factors present, but there is still family violence occurring, but there are some protective factors, and maybe there's already some risk management factors in place and her level of fear is not high and so you'll continue to provide ongoing support to that victim/survivor, you'll give her appropriate phone numbers.
Now the question that I often get then is well what happens if she's at imminent risk? So what happens if you think to yourself, goodness if she goes home she's very likely to get killed, he's threatened to kill her, there's a weapon available, there's a track record that he's really done a lot of you know evidence-based risk factors that you know to harm her in the past. I'm really, really worried of what might actually happen. So the RACGP White Book says that you should seek consent to report the matter, but if the patient is unable to give consent, maybe she's being intimidated or she's declining to give consent, it may still be necessary to disclose to safeguard the patient's immediate wellbeing and if you're not sure you can seek medicolegal advice if you need to, and who would you even be disclosing to? Well it may be a family violence worker, it's probably ideally a family violence worker, but sometimes it's really imminent risk that may potentially be the police. Now, in this situation and look it's a rare situation, but if that did happen, she needs to know still that you are actually disclosing because she needs to be able to keep herself safe, so she absolutely needs to know what's going on and in Victoria, we are actually currently covered by these MARAM and information sharing laws in the case of imminent risks, so we are actually covered legally, it is part of the MARAM framework and if you're in Victoria, it is worth you seeking out to do some MARAM training so that you understand what your obligations are, what you can and can't do under MARAM.
I want to just also ask Jac in this situation, you know the difficult thing of that imminent risk, any thoughts about that, anything else you want to add?
Jac Dwyer:
So I think that, as you said, it's really important to be led by the victim/survivor. There are some circumstances where calling the police might actually escalate her risk. We have worked with victim/survivors, where the perpetrator is actually a serving police officer. So it's really important to understand what her reasoning is for making the decisions that she's making and really understanding because and I know that Fiona, we've spoken about this a little bit outside of this, but there's always 1000 things that victim/survivors are doing to keep themselves safe so it's really important that we're understanding of what they're doing and what we can do to support that.
Dr Jennifer Neil:
Absolutely, I 100% agree with that. Fiona, I just want to ask you, from the perspective of a victim/survivor about the risk assessment process and your experience or also any of the experience of those that you have in contact with.
Fiona:
Um I didn't have a lot of experience myself with the risk assessment, because unfortunately my GP didn't pick up that I was in a domestic violence relationship, so it was quite hard. I have had some experience seeking help through a family violence agency, where I lived and unfortunately they actually sent written information to my house under the request not to do it. So just as there are many wonderful you know examples of the services working, sometimes they don't work either so I'm sorry, that's all I've got on that.
Dr Jennifer Neil:
You raised some really important points there Fiona.
And you know confidentiality is absolutely vital and actually that's very much part of this risk assessment process, isn't it, the need for confidentiality. And when and where can you break confidentiality and of course, in your situation, it was absolutely not okay and it put you at increased risk to break confidentiality. In terms of our obligations as GPs, there's probably two main reasons that we would ever break confidentiality. One is mandatory reporting laws and I'll talk about that in a bit more detail in a moment, but in terms of children, I mean. And in the Northern Territory, obviously the mandatory reporting laws for family violence, but also in this situation where there is imminent risk and your professional judgment is that there is imminent risk, and you feel that there's something that needs to be done, but I 100% agree with what Jac was saying is that you just need to be very mindful, is that there may well be a reason that she actually does not want to disclose to an agency or to the police.
Now the whole point of doing the risk assessment, then, is to inform safety planning and and to work out what to do next, and I'll get onto that in a moment, because I just very briefly want to talk about children because, of course, you know, children, you know are in many of these households that family violence is occurring and we actually know that there's a significant crossover of child abuse and family violence. In fact where family violence occurs and children are in the household, in 50% of cases child abuse is also occurring, although in reality any child witnessing a family violence, I mean that is a form of child abuse in of itself, and we know that about 90% of children in households where family violence is occurring have witnessed violence but it's probably more like 100%, to be perfectly honest. So any child living in a family violence household where family violence is occurring should be seen as a child who has had significant trauma.
So how do we ask children about family violence and it obviously depends on the ages to you know the kinds of questions that you're going to use, but you might ask them things like tell me about the good things at home, is there someone that makes you feel safe, what don't you like about home, what happens when people argue, is there anyone that makes you scared. And those sorts of questions are really useful to just find out a little bit more about what's happening at home with the children.
This is also from the brief risk assessment from MARAM that I showed you earlier, and these are some questions regarding children. Has the perpetrator ever threatened to harm the child, have they ever harmed the child, have the children been present or exposed to family violence incidents and are there any children who are under the age of one. And every child should have a separate risk assessment done. And you can ask the victim/survivor, do you have any immediate concerns for the safety of the children, so you're screening for any imminent risk. And, have you, you know older children, teenagers, have you ever phoned for emergency assistance, have you ever been removed from parental care, have you ever intervened in an incident of violence in your house.
These are all things that you could be asking about. So when you're doing a risk assessment of children who are living with violence, remember that they're considered to be a victim of abuse, whether they've witnessed it or not.
Mandatory reporting requirements vary significantly between states and territories. So it's really important that you are familiar with your own state or territory and what is reportable. For instance in New South Wales being witness to family violence is reportable, whereas in Victoria only physical or any risk of physical or sexual harm is reportable so it's different in different states. Remember though, if the child doesn't fulfill the requirements for mandatory reporting, you can still refer them to a vulnerable children's organisation. And I think this is something that's you know, really, really important, because this is where they can actually access quite significant help or potentially even case management.
Jac, what's your experience with children and referring to vulnerable children's organisations?
Jac Dwyer:
So we obviously, not obviously, obviously for me, not for everyone else, I work at Berry Street, which is an organisation that's very much focused on children. We do have programs that support children who have experienced family violence, therapeutic programs, but I think that supporting children comes in a lot of different ways, sometimes by supporting the perpetrator to take accountability for his choice to use violence, we are supporting the children to be safe.
And there's some fabulous programs that work with dads who have been using violence to help him change his behaviour and recognise the impact that his choice to use violence, even if it's not directly towards the children, the impact that's having on children.
Dr Jennifer Neil:
Absolutely. So just very briefly want to mention just a few particular communities that there may be some other issues that you need to consider in the risk assessment.
Migrant and refugee communities, please remember to think about visa status and financial issues, whether they're having any restrictions with contacting friends and family overseas. Visa abuse is a thing, this is something that I've seen, I'm sure Jac has seen this as well, where in fact you know if she's on a spousal visa and he says well if you leave me then you know you're going to have to go back home because I'm not going to support your visa status anymore, and puts her in a really difficult position.
So Aboriginal and Torres Strait Islander communities, asking them whether they have support from their community, whether they've been forced to go or stay somewhere that they don't want to be.
LGBTQIA+ community, have they been outed or have there been threats to out them, has anyone refuse to accept their identity.
With the people living with a disability, is the person abusing the one who provides their daily needs, are they actually providing the care.
And the rural issue, which Fiona actually mentioned earlier was you know that this is obviously a really difficult one, Fiona just in terms of living rurally, how did that affect you as a victim/survivor?
Fiona:
Um well because living in a very tiny community where everybody knew everybody is a wonderful thing, but when you're trying to seek help as a survivor or victim, it makes it very difficult because things like you know, I would never go to my local police station because there's serving members in there who know my husband and have been at parties in my house.
Trying to seek similarly, domestic violence services or mental health care services. On a couple occasions I've actually travelled out of my area to go and try and find them.
Dr Jennifer Neil:
Yeah. I also just want to thank Dr Magdalena Simonis for this slide. This comes from a module that's actually coming out from the University of Melbourne.
So I just want to again briefly mention a case that I saw during COVID, this was actually 2020, whereas the other one was this year. A 50 year old woman, survivor of abuse, now separated from her ex-husband but lives with her late teens son. Then the COVID lockdown occurred, they're working from home, neither of them are going out much at all. The son starts threatening to kill her, attempt strangulation on more than one occasion, is throwing furniture at her. She's afraid for her safety, doesn't want to call the police because they fear that her son will then become homeless and this is something that I've seen a few times now, where women have actually not wanted to leave the abuser, to leave when it's their son, because of the issue of the son becoming homeless and well I still love him, so I don't want him to be homeless.
We actually did all of this by telehealth, I actually didn't see her at all in person. We made times to talk that were actually safe times, like we were mentioning earlier, morning was the safe time because he had some sort of zoom call organised with his friends, we did a safety assessment, I have to say I was really concerned about her level of risk, she thought she was at high risk. She didn't at that point want to involve the police or anyone else so she wasn't at imminent risk, so what we did was we organised a safety plan and I'm going to talk about that in a second. And then I got in touch with her the next day and there'd been another violent episode and she actually decided then that it was time to contact the police and I assisted her in that process and the son was removed from the house and taken to his dad's house and an IVO was put in place. So an example of using a risk assessment of doing it during COVID, of doing it over the phone, and informing them the safety planning.
So when you're doing a risk assessment, the other thing to take into account is actually the protective things. So what are the things that actually mean that you know, there is strength in the situation, does she have access to money, are there any court orders, does she have access to transport, is she already connected with professional services, does she have lots of supports within the community as well.
So safety planning, so the whole point of safety planning is to say, well look it may well be that in the future that you're actually going to have an increase in violence, so if that happens where are you going to go, how are you going to get there, who are you going to go with, and what are you going to take with you, and you need to decide those things now because when you're in a crisis you're not going to be able to decide those things.
And so, like I said, the majority of patients we see in GP will go home after the consult and COVID-19 may well have changed previous safety plans that have been put in place, so you do need to reconsider safety plans in the light of the pandemic. So some of the things that you're going to talk to your victim/survivor about is you know, the fact that obviously if they are at you know, current risk or imminent risk, if they think that you know that their unsafe, they need to call triple zero. Do they have access to a phone or the Internet or even a spare phone that can be put somewhere that the perpetrator won't know about. Access to money, access to transport, supportive friends or family members, having important documents and clothes and any items for children, and you know, are you going to take the children with you in a crisis or not, decide that now and put these things at a friend or family member's house or in a safe place that you know that he's not going to actually find it. And during the COVID pandemic, just a few extra things you know that the article by Simon mentioned you might need to consider making sure that you've got access to face masks and hand sanitiser, paracetamol, those sorts of things as well.
So we're almost done, but I just wanted to very briefly talk about trauma informed care and I just wanted to first of all ask Fiona do you want to read out this quote Fiona, and just tell us a little bit about it.
Fiona:
I can't pronounce the lady's name and I'm so sorry but I cannot pronounce the name but to me this quote spoke to me in so many ways. It says trauma informed services assume that people are doing their best they can at any given time to cope with the life altering and frequently shattering effects of trauma. So for me having recently accessed some services that are trauma informed is huge, because I know I don't have to repeat my story and it's not a story actually, I didn't make it up, it's actually my life. Trauma informed services are for a survivor a breath of fresh air, it's like going somewhere and feeling at home and feeling so comfortable with those services.
Dr Jennifer Neil:
Yeah I absolutely agree with that. Jac, did you want to make any comments about trauma informed care just quickly?
Jac Dwyer:
I just think that one of the things that we need to think about is that family violence has impacted on victim/survivors ability to use their own choice and control. And it's really important that we don't replicate those power dynamics in our relationships with victim/survivors. So we need to make sure that we allow them to have choice and to really lead the way, we're partnering with them rather than helping them.
Dr Jennifer Neil:
Yeah, absolutely. So the last step after you've done safety planning and sorry I had to rush a little bit over the safety planning process, obviously safety planning is going to be different for every victim/survivor that you have in front of you, depending on their situation and circumstances, but is referral, and so I guess, I just want to ask you Jac, when you refer to a family violence organisation, what actually happens next?
Jac Dwyer:
Okay, so, that's a good question. It's a bit different with different services. I know that we will only take direct referral from victim/survivors to make sure that they are freely choosing this service and that they really want to engage with it and it's not going to be further risk to them. So some of the things that we would do immediately is work out what the current risk level is, so talk about the perpetrator's pattern of behaviour, and talk about, you know, tease out those evidence-based risk factors, think about our own as a specialist family violence service, our own professional judgment in that, and ask the victim/survivor what their current safety plan is, what they want out of our service. So often victim/survivors will have a really clear idea about what they want, sometimes they may not and we may talk through what the options are and what people might choose to get from us. But definitely thinking about what does that person need to promote their safety, what are they already doing to promote the safety and wellbeing of their children and what can we do to support them in that.
Dr Jennifer Neil:
Great, thank you. We're just finishing up just very quickly mention this story, so a 33 year old who's married with one young child, has been a survivor of significant physical and emotional abuse, you know, a high-risk situation, known to me, doesn't want services involved. We put a safety plan in place. The safety plan is that she's going to flee to her mum's house if she needs to, and I say to her although it's a lockdown, you are allowed to leave. You can leave if you need to for your safety so I've given her that permission that she can leave. And so, it ends up happening a few weeks later, that things escalate and she takes her child, and she goes to her mum's house and an IVO has been put in place. Domestic services have been involved at this point as well, so just an example of where a safety plan has been put in place and it's actually been enacted.
So, we're just going to finish up there, and just invite any questions that you may have. Sue, do you want me to stop sharing the slides now, or just keep them up, what would you prefer?
Sue Gedeon:
All good, you can just keep them up. So, thank you Jennifer, Fiona and Jac. if anyone has any questions, please pop them in the Q&A box.
So, what organisation would you be contacting to speak to a family violence worker?
Dr Jennifer Neil:
Yeah, that's a really good question, because in fact it varies enormously depending on where you are actually located. So what you need to do is find out your local pathways now there's a few ways that you can do that, if you have a local HealthPathways they may well have a family violence section where they actually talk about where your, what your local, you know, referral pathways are. So that's a really good way of finding out. Your PHN will no doubt have that information so that's another way that you can find out that information if you're not sure.
We also, for anyone, any of the regions who are currently doing the pathways to safety program, we've actually got lists of local pathways as well. So, particularly in Victoria, but I think it's been rolled out now to some places in New South Wales as well and it's going to be rolled out to Tassy soon, and I think it's being rolled out to other places in Australia eventually as well.
Jac, do you know of any good resources where people can find local information?
Jac Dwyer:
It does vary state to state. I know that in Victoria if you google the orange door, you can type in your location and it will tell you if there's an orange door in that area, or if not, who the specialist family violence service for that area is. And it will be. I'm not sure in other states, but if there's a specific area that you're wanting, I'm happy to follow up that outside of this and get back to people.
Dr Jennifer Neil:
And the other thing is, if you ask her to call 1800 RESPECT, they will give her the right organisation depending on where she lives as well, so they will know all the local information and they'll give her that information.
Sue Gedeon:
Thank you.
Any other questions?
Dr Jennifer Neil:
It's okay, if anyone's got any questions that they specifically want to ask me I'm really happy if you just send a message to Sue or email Sue, she'll get in touch with us and we can certainly answer any questions that you might have.
What I also should do that I haven't done is actually to mention the White Book. So, the fifth edition of the White Book is coming out at the end of the month. We're really excited about this edition, you know, it really builds a lot on the work that's already been done previously and now incorporates a few new chapters that weren't there previously. And if you're interested in finding out more about family violence, it's actually a fantastic resource to actually read through to get more information about family violence and talks about some very specific groups and how family violence affects them as well.
Sue Gedeon:
Great.
Thank you to everyone for attending and we hope you enjoyed the webinar. Like Jennifer said, if you do have any more questions, just email them through to me And I'll organise a response.
Thank you so much to our presenters Jennifer, Jac and Fiona for sharing your knowledge and time this evening and yeah thank you.
Dr Jennifer Neil:
Thank you, thanks Sue.