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Domestic violence

Domestic abuse is very common and can be physical, sexual or emotional. Consequences include traumatic injury and death, and victims are more likely to suffer from chronic illness and mental health problems.

Possible stations

  • A patient comes to see you with recurring headaches which they put down to difficulties at home
  • You are asked to speak to a patient who was initially reluctant to be examined but then found to have multiple bruises
  • A patient complains that their partner has ‘a bit of a temper’

Aims of the station

  • Be reassuring and non-judgemental
  • Don’t be afraid to ask about abuse
  • Assess risk to patient and their children
  • Don’t assume the patient wants to leave their partner immediately, just offer advice and support

Before raising the issue

  • Develop a good rapport with the patient and make them feel comfortable
  • Assure them about privacy, safety and confidentiality
  • Ensure their potential abuser isn’t present

When raising the issue

  • Use an open question to allow them to explain the situation: ‘Tell me about things at home’, ‘Do you feel scared/safe at home?’, ‘I’m worried someone may have hurt you’, ‘I’m worried you may not be safe at home’, ‘Does your partner’s behaviour upset you?’
  • Establish the details of the abuse
    • Type(s) of abuse:
      • Physical: ‘Has your partner ever hurt you?’
      • Sexual: ‘Does your partner ever make you do sexual things you don’t want to?’
      • Emotional: ‘How does your partner make you feel? Do they belittle you or try to control you?’
    • Perpetrator: Who is it?, What’s their relationship? 
    • Pattern: When does it occur? Are alcohol/drugs involved?
    • Timeframe: How long? Has the abuse been escalating?
    • Coping: How have they coped? Have they tried anything to stop it/get away?
    • Who else is involved: Are any children or vulnerable adults potentially at risk?
  • Explore their social situation/domestic environment
    • Who do they live with?
    • Are there weapons in the house?
    • Does the patient have an emergency safety plan? If not, consider trying to construct one with them and tell them they can always call the police
    • Do they work?
  • Tips
    • Try to be supportive, all them time to talk and offer tissues if they get upset
    • Be relaxed and compassionate with the patient
    • Don’t pressure them into telling you, but they may need to be asked several times before opening up

Risk assessment

  • NEVER FORGET RISK!
    • To patient:
      • From partner: Do they currently feel in danger? What would happen if they go home?
      • Risk of self-harm: Has it affected their mood? Have they ever considered harming themselves or taking their own life?
    • To others: Are any children or vulnerable adults potentially at risk?
  • Abuse risk factor assessment – consider the following if relevant
    • Victim: low self-esteem, low income, young
    • Partner: pregnancy, alcohol/drug use, psychiatric issues/personality disorders, unemployment, being a victim of poor parenting/abuse/physical discipline, convictions
    • Relationship: separation/divorce, poor housing situation

Management

  • Be non-judgemental, establish the patient’s concerns, and allow them to control the situation and make decisions
  • Acknowledge and reassure
    • Acknowledge complexity of situation and how difficult it must have been to disclose
    • Reassure patient it is not their fault and that no one should be treated that way
  • Explain about sources of support
    • Establish if they have any friends/family who could support them 
    • Counselling/support and helplines (e.g. national domestic violence helpline, WomensAid.org.uk) – give a leaflet
    • Refuge is available if they cannot go home
  • Offer referrals (and explain how they can help)
    • Police
    • Local domestic abuse service
    • Counselling/support services
    • Social services must be informed if children or vulnerable adults are involved/at risk

                  NB: if the victim is an adult with capacity, you can only refer them if they consent (unless a child or vulnerable adult is involved).

  • Encourage the patient to talk about it and seek help

Conclusion

  • Again acknowledge how difficult it must be for them
  • Formulate a plan together
  • Arrange follow-up and advise them they can come to see you at any time
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