October 2000 · Vol. 49, No. 10
Interventions that Help Victims of Domestic Violence
A Qualitative Analysis of Physicians’ Experiences
James Moe, PhD
Submitted, revised, April 16, 2000.
From the Division of Behavioral Sciences, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco (B.G., N.C., A.B., J.M.); the Department of Obstetrics and Gynecology, School of Medicine, University of California-San Francisco (N.M.); and the Center for Clinical Epidemiology and Biostatistics, Hospital of the University of Pennsylvania, Philadelphia (M.B.). Requests for reprints should be addressed to Barbara Gerbert, PhD, Division of Behavioral Sciences, University of California San Francisco, 350 Parnassus Avenue, Suite 905, San Francisco, CA 94117. E-mail: email@example.com.
BACKGROUND: The barriers physicians face when providing care to victims of domestic violence are well detailed in the literature, but few studies provide insight into how physicians overcome these barriers. Our goal was to describe the domestic violence interventions used by physicians who are committed to providing quality health care to battered women.
METHODS: We conducted 6 focus groups with 45 San Francisco Bay Area physicians who had intervened with victims of domestic violence. The sessions were audiotaped and transcribed. We constructed, through constant comparison, a template of open codes to identify themes that emerged from the data.
RESULTS: Our analysis revealed that physicians viewed validation (ie, providing messages to the patients that they are worth caring about) as the foundation of intervention. Other interventions included labeling the abuse as abuse; listening and being nonjudgmental; documenting, referring, and safety planning; using a team approach; and prioritizing domestic violence in the health care environment. Physicians described a range of rewards for intervening with victims, from seeing a patient change her entire life to subtle shifts in the way a woman thinks of her relationship and herself.
CONCLUSIONS: Our study offers insight into how physicians can intervene to help victims of domestic violence. Recent interview and survey studies of battered women support the physician interventions described.
Delivery of health care;
physician-patient relations. (J Fam Pract 2000; 49:889-895)
In response to the public health consequences of domestic violence and the number of battered women whom physicians see in their practices,1-4 medical organizations including the American Medical Association and the American College of Obstetricians and Gynecologists have called for physicians to act as agents of change in abused women’s lives.5,6 In the late 1980s and early 1990s these organizations and others issued guidelines and mandates based on information from domestic violence experts that outlined how physicians should intervene.6-8 Unfortunately, these recommendations are not specific enough and do not seem to have improved their responses to violence against women9-11; many physicians are simply not asking women about violence,12-17 and women whose health problems result from abuse are not receiving the health care they need.9,10,18-20
Physicians cite many barriers to intervening with victims, including patient evasiveness and failure to disclose information, lack of time and support resources, lack of education or training, fear of offending the patient, inability to “fix it,” and frustration with lack of change in the patient’s situation or the patient’s unresponsiveness to advice.16,18,21-28 Primary care physicians in the qualitative study by Sugg and Inui28 characterized talking about domestic violence with patients as opening Pandora’s box and associated the act of even asking about domestic violence with unleashing their own fears and discomforts.
Despite the barriers, some physicians are committed to addressing the underlying health problems of abused women. How do these physicians intervene, and what motivates them to continue in their commitment? In previous work,16 we described how physicians with expertise in domestic violence identify victims. With this study we explored how physicians with experience in identifying victims tried to help.
Qualitative research commonly uses purposive sampling, a method in which the participants best suited to provide a full description of the research topic are intentionally selected. We sought a sample of physicians in the San Francisco Bay Area who had experience in identifying and intervening with victims of domestic violence. To identify important common patterns that cut across different settings29,30 physicians from 3 medical specialties were sought: primary care (family practice and general internal medicine), obstetrics and gynecology, and emergency medicine.
We conducted our recruitment in consultation with a professional survey research organization. Thirteen physicians known to have domestic violence experience, and additional physicians selected from the yellow pages, were screened and asked to participate in a study exploring the most effective ways for the health care system to meet the needs of victims of domestic violence. Eligible participants were asked to identify other colleagues who are concerned about and treated victims of domestic violence, and these individuals were screened and asked to participate and to identify others. Physicians were eligible if they worked directly with patients 20 or more hours per week, had identified and intervened with victims of domestic violence, and were somewhat confident or very confident about addressing domestic violence issues with patients.
Recruitment ceased when the goal of 12 to 22 physicians in each medical specialty who had the relevant domestic violence experience was reached.
Focus Group Method and Data Collection
In comparison with survey or one-on-one interview formats, the focus group approach allows for a more extensive exploration of the area under discussion. Participants can collectively explore different experiences and perspectives, generate ideas, and debate and compare their ideas with those of others in the group.31 Six focus groups ranging in size from 6 to 11 individuals were conducted during a 3-week period in January and February 1998. Each group was facilitated by 2 moderators who were members of the research team. The sessions lasted approximately 90 minutes and were held in professional focus group settings that allowed hidden viewing. Several researchers viewed the groups from behind 2-way mirrors and completed field notes that were later compared with the observations of the moderators. Before each focus group session written informed consent was obtained from all participants and a written background survey was administered to gather demographic and practice information. Participants received a small stipend for participating. Study procedures were approved by the University of California San Francisco Committee on Human Research.
We used a semistructured guide that allowed the facilitators to follow certain topics and open new lines of inquiry when appropriate.32 Open-ended questions were formulated based on our previous interviews with survivors of domestic violence33 and a review of the literature ( Table 1 ). Audiotapes of the focus group sessions were transcribed by research staff; the principal investigator reviewed these transcripts for accuracy.
Coding and Analysis
For initial analysis we conducted multiple readings of transcripts to identify prominent themes. The investigators independently reviewed the transcripts and then met to review and discuss differences of opinion about interpretations and to further refine themes driven by the words and phrases of the participants. Through this process and the constant comparison of new data against emerging themes, a template of open codes was constructed. The transcripts were coded and specific themes within the narratives of the participants were identified in accordance with standard qualitative analytic convention.34 Coded data were organized using NUD*IST 4.0 software (Qualitative Solutions and Research; Victoria, Australia). This software helps ensure the consistency of study findings and creates an audit trail.35 The data were interpreted in the context of the original focus group sessions and the current literature. The final coding scheme and analysis of the findings were reviewed, and disagreements were discussed by the team until consensus was reached.
To further enhance the credibility of the findings, a qualitative technique called member check was used.36 Results were directed back to 3 research participants to confirm that their experiences and those of other participants in their focus group were reflected in the findings.
Of the 80 physicians who were screened, 53 were eligible, and 45 were able to attend the focus group sessions. Their characteristics are presented in Table 2 . The participants reported that they had identified an average of 28 patients per year as having been physically abused by an intimate partner, and they thought they had helped approximately 60% of those patients.
Helpful Intervention Techniques
Even these physicians reported sometimes feeling overwhelmed, frustrated, and incompetent regarding their role in domestic violence cases. They believed, however, that addressing partner abuse was part of their job and reported various ways that they have tried to help battered women improve their situation and their health. Our data analyses revealed that the following themes were common across specialties.
Give Validating Messages. The most common aspect of intervention was validation. Whatever their approach to helping, these physicians gave compassionate messages that validated the woman’s worth as a human being and indicated that the abuse was undeserved. One participant put it this way: “Just my being there, caring about them consistently, giving another message [helped]: You are worth caring about, you are deserving, you are valuable.” Physicians tended to embed this kind of attitude and message into their interventions with abused patients, making validation the foundation of their interactions with them.
Break Through Denial and Plant Seeds for Change. Physicians reported that within the context of a trusting relationship they tried to break through the denial these women presented about the seriousness of their experiences. Some physicians reported labeling the abuse for what it is, blatantly wrong and criminal. They believed that over time they could help victims to begin to see this reality and change their situation. One participant said:
I let them know that what’s going on is outlandishly not right, that they don’t deserve to have that happen. It’s frankly illegal, and you can bring charges against someone for doing that. Sometimes people can be shocked by finding out that that’s the case. You can plant a seed about their self-esteem … and their ability over time to change that situation, but piecemeal.
Another physician reported showing women the photographs taken of past injuries to remind them of the partner’s pattern of abusive behavior: “We begin every session with: Do you remember that? Sometimes the reaction is: No, it didn’t happen that way. But the photograph just sits there.”
Listen Nonjudgmentally. Physicians described listening and attending to the whole person as central to providing good health care to all patients, especially victims of abuse. In the context of listening they reported on the need to maintain a healing attitude by banishing criticism, blame, and judgment, but agreed that achieving this was difficult and required letting go of the desire to fix it by treating the women as competent adults. One participant said:
I try to get across just from my tone of voice primarily, that I’m not judging them. Because I made that mistake quite a while ago—my judgment was right away: Well, this is terrible; you’ve got to get out. And I could watch the person psychologically fly away from me. So in order to maintain that [trusting] space, that connection with them, it’s really important for me to get clear that I’m going to listen and not judge them. And it’s all going to change on their time.
Document, Refer, and Help the Patient Plan for Safety. These physicians stated that they were careful to write down the specifics of what the woman said. In addition to medical charting, some took photographs of any injuries with color Polaroid cameras. One physician stated that for the photographs to be useful in court “you have to include their face so that a lawyer can’t argue that you’re taking a photograph of someone else.”
The most practicable example of documentation was the development of a domestic violence packet which included a body chart, an instruction list for documentation, a compartment for the color Polaroid photograph, a handy tear-out sheet for information services (resources, shelters), and a telephone number for the police.
In general when physicians knew or suspected abuse they offered information about domestic violence and referrals to local community resources, hot lines, and shelters. Some stated that patients often refused referrals and that they kept referral sheets in the waiting room so that individuals could decide on their own whether to take one.
Other physicians stated that on occasion women had made statements such as: “I can’t take that (handout) home … it’s like a flag in front of a bull.” To address this problem some physicians reported putting business-size cards with domestic violence hot line numbers (eg, local hot line numbers, shelter numbers, or community resource numbers) in all the bathrooms, sometimes the only place where the batterer could not easily follow a woman. Participants reported:
[The cards] are constantly replenished [by housekeeping] … and one of the things I tell people if they’re in an explosive situation is to put it in their shoe, in the insole.
I have a very small practice. I do only office gynecology, but I put about 10 cards a week [in the bathroom]. I would bet 2 disappear in a week. Isn’t that amazing? And this is a fairly affluent area.
Physicians described various ways they had tried to help women plan for their own immediate and ongoing safety. Some physicians talked about trying to stay aware and sensitive to the safety needs of women whose partners are controlling them through abuse, even when the partners are not currently threatening violence. One participant said:
I’ll try to role-play with them … how are they going to deal with telling their partner that they have this infection or that they really want to use this type of birth control. I’ll say, “Some people in your situation could have a fight with their significant other,” and go through predicting some possibilities. Sometimes you can see them start to close down because they know that could happen, or this is a repeated thing that they keep getting that they have no control over. So, I’ll say, “Well, I have other patients in this situation who sometimes need a safe place to go,” or I’ll talk about what somebody else did and at the same time give them some information.
Physicians also reported counseling victims to keep a suitcase packed and have 24-hour hot line numbers or contact numbers for safe places, and helping them to specify what circumstances should cause them to call the police.
Although physicians stated that acute cases were rare outside of the emergency department, they described attempts to ensure safety when the woman’s life was in immediate danger. These attempts included (1) working as a team to separate the partner from the woman (eg, the nurse talked with the abusive partner in the waiting room while the physician cared for the victim and, with the victim’s permission, called the police and a domestic violence advocate to remove her from the abusive home); (2) making excuses to separate the abuser from the victim in the immediate situation (eg, taking the woman for tests); and (3) admitting women who could not be placed in a shelter into the hospital under a false name. One physician reported that the hospital at which she had trained had a safe bed designated for victims of rape, domestic violence, and other assaults.
Using a Team Approach. In general, the physicians agreed that it takes a team approach to intervene successfully with victims of domestic violence. Some expressed frustration about accessing community referrals and discussed the benefits to victims of readily accessible resources on site. The on-site resources referred women directly to the nurse, rape crisis counselor, social worker, behavioral medicine counselor, or psychologist, who counseled the women and conducted follow-up. Some physicians without access to onsite counselors or social workers described making domestic violence part of every staff member’s educational process when they come on board.
Physicians described how intervention demanded a certain amount of flexibility of roles, with nurses and physicians playing off each other in tag-team fashion, as necessary. One physician said:
Sometimes when I finish with an exam, I’ll tell the nurse that I suspect something, so when the nurse is giving the discharge instructions, she’ll also re-approach certain kinds of issues and give the woman another opportunity to talk about [the abuse], once she has gotten dressed and composed herself. The door is closed. It’s one-on-one.
Some physicians described how their prenatal team takes advantage of a “window of opportunity” and has helped women get out of their situations and into counseling:
We have a prenatal team that really works together … our nurse, our social worker, our nutritionist, the receptionist, everybody.… It’s a real intense time. But I think once they get out of pregnancy, we really lose that ability to make a change in their lives. It’s a real window of opportunity.
Prioritize Domestic Violence. Even the committed physicians in our study expressed conflict about taking the time to intervene once they had identified abuse. Some physicians advocated dropping the medical procedure (even if that means the loss of reimbursement) to spend the rest of the patient’s time dealing with the abuse. Physicians also described prioritizing domestic violence by conducting continuing education courses and meetings for everyone in the department about rape, domestic violence, and child and elder abuse. One participant reported:
We try to create a culture of caring about domestic violence so that nurses who think they’ve recognized someone as being a nondeclared victim won’t be told, “I’m too busy” by a physician. And so when physicians say, “I think that might be a domestic violence victim, could you go talk to her?” the nurse will see that as a priority. And if anybody asks her, “How come you haven’t got that IV started?” she or he could say, “Because I was in talking to this person trying to determine whether they were a domestic violence victim.”
Small Victories Offer Positive Feedback
These physicians reported receiving little direct feedback about the effectiveness of their interventions with battered women. Yet, they also reported a range of rewards for intervening, from seeing a patient really change her life to glimpsing shifts in the way a woman thinks about herself and the relationship. One physician said:
And the rewarding piece for me comes when at some point she looks up and notices, and you can see this change of realizing that she’s cared about and then what that must mean to her, that she’s worth something. And then later on [there are] those little steps that you can see people make when they feel like they’re worth something. That’s the most ongoing and rewarding thing.
The themes described by the purposive sample of physicians in our study offer insight into the process of intervention with victims of domestic violence and help delineate practicable examples of how to apply interventions ( Table 3 ). The behaviors described are supported by quantitative and qualitative data from battered women.33,37
These physicians described the foundation of intervention with victims as giving victims the message that they do not deserve abuse and that they are worth caring about. Battered women themselves report that validation is an important message. In a recent survey,37 battered women rated validating statements and compassion from physicians as among the most desirable interventions, equal to safety planning and offering referrals. In another study,33 survivors of domestic violence described how validation from a health care professional had not only provided relief and comfort, but also “started the wheels turning” toward realizing the seriousness of the situation. These women reported that validation helped them, regardless of whether they had disclosed the abuse or the health care professional had identified it.
Women who are being controlled through abuse by an intimate partner live with debilitating feelings of denial, shame, and humiliation that are sometimes reinforced in health care encounters and keep victims from seeking and receiving optimal care.33,38-41 The physicians in our study recognized these barriers and made efforts to help women break through their denial and plant seeds for change. They also made efforts—and learned through trial and error—to listen and be nonjudgmental. Both of these behaviors were rated as highly desirable by battered women.37 Physician statements made within the context of a trusting relationship can serve to remind women of the seriousness of their situation. Physician behaviors that convey respect through tone of voice and body language could lessen a victim’s shame and help her make small changes over time to improve her situation and her health.
The data we presented on documenting abuse, providing referrals, and planning for safety concur with the practices recommended by Physicians for a Violence-Free Society.42 We suggest that health care settings develop a domestic violence packet containing a body chart, documentation instructions, and referral sheets. We also suggest they provide Polaroid cameras to document specific injuries, since pictures offer an inviolable record of the abuse.42 Survivors report that the process of documenting abuse can serve to validate the individual if accompanied by genuine nonjudgmental statements of concern.33
Although the physicians in our study were aware of the need to provide victims with referrals to community resources and assess their safety needs,6,8,42,43 they had developed their own styles of intervention and admitted that victims sometimes refused referrals. One solution offered by participants in our study is to put easy-to-hide business-size cards with local domestic violence hot-line and shelter numbers in all of the bathrooms. We also suggest that physicians continue to offer referrals time after time: repetitive offering or availability of referrals may help survivors feel like they are not alone and may reassure them that support is available within and outside the health care system when they are ready to seek it. Physicians should remember that a woman may be able to talk about the abuse long before she can actualize any change. They should also be aware that ending the relationship does not necessarily end the abuse; it may escalate it.44 The study physicians were careful to consider safety from the battered woman’s point of view and to take preventive measures. We suggest that physicians review their options for facilitating safety (ie, availability of resources and time) and, when necessary, connect the victim by telephone to an agency trained in assessing and planning for their safety. Battered women report that they want physicians to offer referrals and help them plan for safety.37
Although current guidelines call for physicians to play a large role in identifying, intervening with, and following up on cases of partner abuse,6,45,46 the physicians in our study emphasized the need to work as a team to identify and provide optimal care to victims. This requires flexibility of roles within the health care team and ready access to on-site and community domestic violence resources. In an attempt to improve health care for victims of domestic violence, experts and researchers in the field have proposed simplifying and limiting the tasks of physicians in this area. One model uses the acronym AVDR: physicians should ask patients about abuse; provide validating messages that battering is wrong and the patient is a worthy individual; document presenting signs, symptoms, and disclosures; and refer victims to specialists in domestic violence.47 At that point specialists on site or on call from the community would assess the patient’s safety, make appropriate safety plans, and perform other in-depth interventions.
Physicians face ever-increasing demands on their limited time, yet these physicians committed to helping battered women found multiple ways to enable them to intervene. The holistic approaches described here—using a team approach, prioritizing domestic violence, developing a culture of caring—send a powerful message of prevention and intervention to victims: Battering is not a private, shameful issue, but a health care issue of great concern to physicians. These approaches also provide health care professionals with systematic support for helping battered women, perhaps allowing committed physicians to act as agents of change in battered women’s lives.5
Women who are being controlled by the abusive actions of their intimate partners report that even small signs of compassion from health care professionals have made a difference to them. As stated by physicians in this study and by survivors in our previous study,33 these acts of caring plant the seeds for change. In their efforts to help battered women, physicians must remember that incremental changes and small moments of recognition can eventually lead to major shifts in the lives of these women. Every time physicians successfully intervene with a person whose health problems are caused by abuse they have engendered a positive outcome.
Our project has been supported by the National Institute of Mental Health Grant #1 R01 MH51580. We thank the physicians who participated in the focus groups and those who participated in reviewing the study findings. We also thank Stephanie Greer and Survey Methods Group for their assistance in recruiting physician participants and organizing the focus groups; Candace Love, PhD, and Richard Carlton, MPH, for assisting the authors with moderating focus group sessions; Priscilla Abercrombie, NP, PhD, for assisting with coding the data; Karen Herzig, PhD, for assisting with the literature review; and Jennifer Fechner for transcribing the focus group session audiotapes and proofreading the manuscript.
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