CHAPTER 3

HEALTH CARERESPONSES TO

PERPETRATORS OFDOMESTIC VIOLENCE

BY ANNE L. GANLEY, PH.D.

Patients who batter their intimatepartners appear in a variety of health

care settings, including emergency depart-ments, specialty clinics and primary caresettings. Some seek medical care for issuesdirectly related to their abusive behavior,while others seek assistance for issues thatare unrelated to their violence. While themajor thrust of the health care effort isappropriately focused primarily on domes-tic violence victims and their children, thischapter is written to assist health careproviders in determining when and how torespond when they encounter perpetratorsof domestic violence in their practice.

This chapter is divided into sixsections. The first addresses strategies formaximizing the safety of the victim wheninteracting with a patient who is the perpe-trator. The second section reviews themultiple ways clinicians learn that theirpatient is a perpetrator of domesticviolence. The third is an overview of theinformation gathered as the practitionerinteracts with perpetrators. The fourthdiscusses the specific factors to consider inevaluating the lethality of the domesticviolence and the risk of future injury ordeath. The fifth presents crisis interventionstrategies. The chapter ends with a discus-

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HEALTH CARE RESPONSES TOPERPETRATORS OF DOMESTIC

VIOLENCE1

BY ANNE L. GANLEY, PH.D.

INTRODUCTION

1 This chapter was taken from a longer article, Identification, Assessment, and Interventions withPerpetrators of Domestic Violence, by the same author. The author gratefully acknowledges theediting of Patrick Letellier for this current version.

sion of additional health care strategiesthat may be implemented when treatingperpetrators.

When the patient is a perpetrator ofbattering, the health care provider shouldbe guided by the same understanding ofdomestic violence and by the same princi-

ples used in responding to victims ofdomestic violence.

These principles are discussed in Figure3-1. Ultimately, the health provider will bemore effective in responding to perpetra-tors when these principles are followed.

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I. STRATEGIES FOR INCREASING THE SAFETY OFVICTIMS WHEN INTERACTING WITH PERPETRATORSOF DOMESTIC VIOLENCE

GUIDING PRINCIPLES

1. Regarding the safety of victims and their children as a priority

2. Respecting the integrity and authority of each battered woman over her ownlife choices

3. Holding perpetrators responsible for the abuse and for stopping it

4. Advocating on behalf of victims of domestic violence and their children

5. Acknowledging the need to make changes in the health care system toimprove the health care response to domestic violence

FIGURE 3-1

Perpetrators of domestic violence reactin multiple ways to discussions of theirabusive behavior with health careproviders. Some use such conversationswith clinicians as one more excuse to retali-ate against victims, while others are recep-tive to such discussions. Some perpetratorsexpress relief that the issue has been raisedand others become angry or indignant.Certain perpetrators will use the informa-tion provided by the practitioner to startthe process of changing their abusiveconduct. Others reject the information and

their responsibility for their violence.Unfortunately, there is no way to predictfrom the initial presentation of the patientwhich perpetrators will benefit from adiscussion about their behavior and whichwill not. Regardless of the response of theindividual perpetrator, all interactions withbatterers must be made with the safety ofvictims as the highest priority. The follow-ing are strategies for increasing the safety ofvictims when talking with patients who areperpetrators.

A. Information from theVictim Must Be KeptConfidential

Relaying any information provided bythe victim about the abuse to the perpetra-tor may put that victim in danger. Victimsmay talk about the abuse in hopes ofgetting help. Some want all informationkept confidential, some want part of theinformation kept confidential, while otherswant the information they provide raisedwith the abuser. Given the lethality ofdomestic violence, the practitioner shouldavoid repeating to the abuser what victimshave said. The victim’s wishes about confi-dentiality must be respected (principle 1 inFigure 3-1). Furthermore, respecting herrequest for confidentiality (whether or notshe is the health care provider’s patient)conveys to her that she has the right tomake decisions about her own life and tohave others abide by those decisions(principle 2 in Figure 3-1).

Even when a victim asks the provider totalk directly with the abuser about theabuse, the health care worker should firstexplore with her the possible consequencesof such action. The clinician should reviewwith the victim how the perpetrator wouldrespond to knowing that she has revealedthe abuse. Is she in danger? Will he retali-ate? Will she be safe if the health careprovider discusses the topic directly withthe abuser? The health care providershould not presume that talking directlywith perpetrators will automaticallydecrease or increase her safety. Somevictims have not considered the outcomeand may, with further thought, want theinformation to remain confidential.Sometimes victims have carefully consid-ered the consequences and want the healthcare provider to proceed (e.g., the victimwho says, “I told him I was going to tellyou and if you don’t say anything, he willthink you agree with him that I am crazy”).If the health care practitioner is going tocommunicate any of a victim’s informationdirectly with the abuser, there should be aspecific agreement with the victim about

which information will be shared and howthe discussion will take place.

What is also problematic and danger-ous is revealing to the perpetrator what athird party (e.g., an EMT worker) has said,when the comments are based on victimreports. This information should not berevealed to the perpetrator. Obviously, useof information provided by the victimwould be an exception rather than a ruleand in even these limited circumstanceswould be used only for victim safety andadvocacy.

B. Discussions with thePerpetrator AboutDomestic ViolenceShould Never Be Donein the Presence of theVictim

When the health care provider wishesto discuss abuse with the perpetrator, thediscussion should be carried out with himin private. Victims, children, friends, andfamily should not be present during theseinterviews. Since medical personnel oftensee patients privately for assessment ortreatment procedures, domestic violenceissues can be discussed during that individ-ual time. Discussing the abuse with theperpetrator alone is one more way that theprovider can emphasize the perpetrator’sresponsibility for the abuse and forstopping it.

C. Taking Care in HowDomestic Violence isDiscussed withPerpetrators

The health care professional mustexercise care in how the discussions are

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carried out. Some approaches will increasethe likelihood that the perpetrator willbecome defensive and retaliate against thevictim, while others lower the risk. Evenwhen the clinician uses all of theapproaches described below, there is noguarantee that the victim will be safe.Unfortunately, simply remaining silent inthe face of batterers’ reports of theirabusiveness may also endanger the victims.Some batterers use the silence of thosewhom they know are aware of the abuse asfurther justification for it. And sometimesthey will batter their partners with state-ments such as “I told the doctor that youdeserved what I did, and he agrees. Heknows about my hitting you, but he hasnever said anything to you about it, right?”

The health care provider should useapproaches that:

1. VIEW DOMESTIC VIOLENCE ASA HEALTH CARE ISSUE.When talking directly with the perpe-

trator about the abuse, the health carepractitioner should emphasize that suchissues are discussed with patients in orderto best meet their health care needs. Theissue of abuse is a health care issue for thepatient who is abusive as well as for victimsand their children, and this should becommunicated to that patient who is aperpetrator.

2. EMPHASIZE THE ROUTINENATURE OF THESE DISCUSSIONS.As with all health care issues, the health

care provider is often in the position ofeducator, providing patients with informa-tion necessary for their health. Thepurpose of the discussion is not to investi-gate or prosecute a crime. While it isappropriate at times (e.g., when there is aduty to warn, state mandatory reportingrequirements, or victims seeking legalprotections) to refer specific domesticviolence cases to legal entities and toremind perpetrators that domestic violence

is a crime, the primary role of the healthcare provider is to meet the health careneeds of patients. If the health care workerfunctions as a police officer, prosecutor, orjudge then some perpetrators’ defensive-ness will increase and they may retaliateagainst the victim or health care worker.

3. FOCUS ON DESCRIPTIONS OFTHE ABUSER’S BEHAVIORS.When initially talking with perpetra-

tors of domestic violence, the providershould use descriptions of their behaviorsrather than terms like domestic violence,abuse, or battering. It is helpful with perpe-trators to make comments such as: “Whenyou threw her to the couch” rather than“when you abused your wife,” or “you hityour girlfriend with a closed fist” ratherthan “you beat her,” or “your use of physi-cal force against your partner” rather than“your domestic violence.”

Terms like “wife beater,” “perpetra-tor,” “batterer,” and “abuser” should alsobe avoided in initial contacts about thisissue. When the health care provider hashad multiple contacts with the patient andhas established a working relationship withhim about the domestic violence, thoseterms can be used, but not when firstencouraging the patient to discuss theabuse.

4. FOCUS ON THE ABUSER’SBEHAVIOR RATHER THAN THEVICTIM’S.As abusers talk about their domestic

violence, they often focus on the victim’sbehavior rather than their own. They glossover their actions and will go into longstories blaming victims or others for theirproblems. It is easy to be confused by someof these rationalizations and to uninten-tionally reinforce the abuser’s behavior bymaking sympathetic comments about theseexplanations (e.g., “I can understand whyyou are mad at her”). The discussionshould avoid such commentary and be

focused on the abusers’ behaviors and theirnegative consequences (e.g., “hitting neversolves problems,” “your violence isdestroying all of you”).

Even when the victim is available andhas given specific permission for the clini-cian to share information with the perpe-trator, it is safer for the victim when theprovider’s comments focus on the abuser’sbehaviors rather than on the victim (e.g.,“you said you threw your wife” rather than“your wife told the police officer you threwher”). The provider can also focus on whatthe health care worker or third partydirectly observes (e.g., “your injuries looklike someone tried to free themselves froma hold” rather than “your wife said she didthis when you were choking her”).

5. USE A DIRECT AND CALMAPPROACH.Care should be taken to approach the

topic directly, matter-of-factly and calmly.A health care practitioner who vents his orher anger, disgust or shock about this issueto the perpetrator may well endanger thevictim. While the health care practitionercan take a stand against the use of force inintimate relationships and can point out topatients who are perpetrators their respon-sibility for making changes, the methodsselected to convey those points can increaseor lower defensiveness. For some batterers,their defensiveness with the health careprovider translates into retaliation againsttheir victim.

D. When PerpetratorsDisplay Anger, Resist orReject the Discussionsof Abuse

If the perpetrator is not open to talkingabout this issue with the health care practi-tioner, then forcing the issue will raise resis-tance in the patient and may endanger thevictim. As stated earlier, some perpetratorsare willing to talk and listen about abusewhen it is presented as a health care issueby a concerned provider while others willreject this or any other approach to thetopic. While principle 3 is holding theabuser, not the victim, responsible for theabuse, it is important to remember that thehealth care system’s role is not to forcepatients, but to educate them about how tocare for themselves and, ultimately, forothers. The perpetrator’s display of angerand other tactics of control in the sessionwith the health care provider indicates thatthe perpetrator is not motivated to changeat that time. It is more productive to makea summary statement, calmly bring thesubject to a close, and then move back tothe presenting medical issue:

“Your using force against your partnerand property is damaging both of you. Iam concerned and will be glad to make areferral whenever you want it.”

“You’ve indicated that you areconcerned about your violence with yourwife. Let me (or a referral) know when youwant to talk about it further.”

“Unfortunately, drinking or druggingis only part of the problem. I would likeyou to think about how your abusiveness isdamaging to you and your family.”

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Perpetrators of domestic violence areidentified in a variety of ways by the healthcare system:

A. Medical Records orWritten Referrals

The domestic violence perpetrator mayhave been identified by another health carepractitioner and this may be noted in themedical records. Such information may beindicated by a clinician in the followingways:

■ “patient violent with spouse,”

■ “patient broke (hand, leg, arm, ribs,etc.) when attacking spouse,”

■ “patient missed appointment; in jail fordomestic violence assault,”

■ “patient’s wife unable to participate ascaregiver following the bone marrowtransplant due to no contact order,secondary to spouse abuse,”

■ “patient referred to clinic by domesticviolence program, requests evaluationfor high blood pressure (or any othermedical condition),”

■ “counseling note in chart from an on-site domestic violence perpetratorsgroup,” etc.

The more knowledgeable health careproviders and referral sources becomeabout domestic violence, the more frequentsuch notations may appear in medicalrecords. In medical facilities serving largenumbers of male patients, such as VeteransAdministration Medical Centers or U.S.military medical facilities, trained practi-tioners note domestic violence as a health

care issue in perpetrators’ medical records.As health care systems are integrated andbecome more comprehensive (HMO’s,managed care systems, etc.) then notesabout domestic violence may appear fromother parts of the health care system (e.g.,substance abuse programs, domesticviolence programs).

B. Reports by Victims orChildren

Sometimes victims or children accom-pany the perpetrators to their medicalappointments and are present with theperpetrator patients. Victims or childrenmay also be patients in the same setting(such as a family practice). The victim orchildren accompanying the perpetratormay tell the provider directly that thepatient is abusive. In the course of giving amedical history about the patient, thevictim may describe his violent behavior(e.g., “His asthma attacks have been morefrequent since he got arrested for assaultingme,” “My daddy broke his hand hittingmommy,” “Something is wrong with him,he drinks and hits me,” “He just keptthrowing furniture out the front window. Itold him he would injure his back”).

The victim or children may talk aboutabuse with the health care practitioner inthe presence of the abuser or privately.They provide such information seekingmedical help for the problem, believing thatthe abuser’s behaviors are caused by amedical issue, or believing that health careprofessionals have the authority or influ-ence to stop the violence. It is critical totreat the information seriously and respect-fully and to be aware that all parties willobserve how the situation is handled by theprovider.

If the victim tells the provider about the

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II. LEARNING THAT YOUR PATIENT IS A PERPETRATOR

abuse in front of the abuser, it is importantfor the provider to respond calmly to theinformation and indicate (a.) that somepatients act in these ways, (b.) that theprovider appreciates knowing about it, and(c.) that the provider will be glad to be of asmuch assistance as possible because thiskind of behavior hurts the health of allfamily members. At this stage the clinicianis welcoming all information and is notattempting an intervention. Additionalinformation will be needed before takingfurther action. The clinician should speak,then or later, separately and confidentiallywith the victim.

If the victim or the children discuss theabuse privately with the practitioner, theclinician should inform the victim that theirconversation is confidential unless sherequests otherwise or unless the health carepractitioner is required to make a report(see section on mandatory reporting onpage 100). In addition to referring thevictim for a confidential follow-up conver-sation for further assessment and safetyplanning (see victim’s chapter), the healthcare practitioner should ask victims if theywant their conversations to remain confi-dential. It is essential to obtain the victim’spermission to discuss the abuse with theperpetrator, and the victim’s perspective ofthe risks of talking with the perpetratorabout abuse. The practitioner should alsogive the victim a referral to a local domesticviolence program.

Always advise the family member thatthe information is valuable and that youare glad they shared it with you, even whenthe information is provided by telephoneand the victim is asking for strict confiden-tiality. Such reports provide opportunitiesfor responding to the victim’s needs andmay help the health care practitioner tounderstand what a perpetrator may bestruggling to conceal or disclose.

C. Reports by Third PartiesThe patient may be identified as a

perpetrator of domestic violence by a third

party such as the responding police officer,the Emergency Medical Technician, theperson accompanying him to theemergency department, or through phonecalls by other family members or friends.For example, the EMT worker states thatwhen he arrived at the house, he observedthe patient lying unconscious, the wife witha split lip and swollen left eye, and theChristmas tree lying outside, having beenthrown through the picture window. Thewife told the EMT that the husband had achronic heart condition and that he hadpassed out during the assault against her.She had called the hospital emergencyroom for medical help for “his heartattack.”

D. Self-Reports byPerpetrators

Some patients who are perpetratorsself-disclose their abusiveness. They maydo this because they are seeking help for theproblem or because they believe that theirabusive behavior is a symptom of somemedical condition (e.g., patients reportincreasing fights with their partners inwhich they strike out or “lose it,” reportincidents where they hit their partners orfurniture, or reports that family membersare afraid of them). For those battererswho are not in total denial and who aretroubled by their behaviors, the health caresystem may be their choice for seekingassistance. While they may be minimizingtheir behaviors and may not use the termsdomestic violence or abuse, they describebehaviors that clearly fit the definition ofdomestic violence and ask for help for their“tempers,” “marital problems,” etc.Occasionally because of public educationor the intervention of another party, thepatient may actually identify his behavioras domestic violence and turn to the healthcare system for assistance (e.g., “I saw thisprogram on TV and realized that I am awife beater and I thought you could giveme some medications for it”).

Sometimes patients self-disclose

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abusive behaviors not to seek assistancebut because they do not believe that whatthey are doing is wrong. For example, inthe course of the medical treatment apatient acknowledges using force againstfamily members. “I had to give her a popor two to keep her in line.” “She pulled aknife when I threw her down the hall.That’s how I got cut.” “We were arguingin the car. I just wanted to scare her so shewould shut up. I lost control of the carand we hit the embankment.”

Perpetrators will talk about theirviolence in many different ways. Theywill minimize, justify, or blame theirviolence on others. Some will brag aboutthe violence, while others will deny or lieabout it. Whether or not the patient sees itas domestic violence, the practitioner canmatter-of-factly characterize the patient’sbehaviors (“popping her,” “driving tofrighten someone,” “throwing someone,”etc.) as a serious and potentially life-threatening problem for him as well as forother family members. Once again, amatter-of-fact approach is important ingathering information about batteringand conveying to the patient theprovider’s concern about abuse.

E. Observation ofPerpetrators’ AbusiveBehaviors in a HealthCare Setting

Health care providers may identifypatients who are perpetrators of domesticviolence by direct observation of theirabusive behavior. Emergency departmentpersonnel have described incidents wherea perpetrator followed the victim into thehealth care setting and continued thebeating. “While they were waiting to beseen by the emergency doc, he startedyelling at her to stop bleeding andsuddenly he started punching her.” “Onebattered woman ran into the emergencydepartment yelling for help, followed byher knife wielding boyfriend.” “Just as

the nurse entered the cubicle to preparehim for stitches for a minor cut over hiseye, the man threatened to kill his partnerif she told the doctor what had reallyhappened.”

When the violence and/or threats ofviolence occur within the health caresetting, health care providers should inter-vene to immediately stop that particularabusive episode by calling security and byseparating the victim and perpetrator.The victim should be provided emergencyassistance while still at the medical facility(see victim’s chapter). The victim shouldalso be given information about the localdomestic violence program and assisted incontacting the program while still in thehealth care setting if she wishes. Directobservation of violence and/or threats ofviolence should be noted in the perpetra-tor’s medical records. The information isrelevant to the continued treatment of thispatient and is essential to the safety of thevictim. Copies of police reports shouldalso be included in the patient’s records.

When the health care providerobserves incidents of non-violent,coercive control used by the battereragainst his partner (e.g., during treatment,the staff observe the perpetrator conduct-ing surveillance of his partner throughexcessive telephone checks), furtherassessment would be necessary to deter-mine if that patient is a domestic violenceperpetrator before a provider canrespond.

F. Observation of theEffects of AbusiveBehavior

There may be no observable incidentor direct report that clearly identifies apatient as a perpetrator of domesticviolence. However, the health careworker may observe the results of possibledomestic violence: scratches, cuts, orbruises to the perpetrator’s face, arms orhands secondary to his own violent

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behavior; injuries to his body caused by hisattempts to terrorize the victim (e.g.,reckless driving, suicide attempts, breakingwindows, doors); or a medical conditionthat is aggravated by his abusive behaviortoward the victim (e.g., asthma attacks,heart attacks, etc.). As the patient talksabout the presenting medical concern, thedomestic violence may be revealed.

The health care provider may observe

the effects of the perpetrator’s abuse onvictims or children who accompany theperpetrator to his health care appoint-ments: visible injuries, their fear of thepatient, their excessive attention to hisevery move or wish, his attempts to controlthem, etc. These may be indicators that thepatient is abusive, but they alone would notwarrant a patient being positively identi-fied as violent.

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III. ASSESSMENT OF LETHALITY WHEN THE PATIENT ISTHE PERPETRATOR

One of the major issues in respondingto identified domestic violence cases is thereality that domestic violence is lethal.Domestic violence dramatically increasesthe risk for serious injury or death to anyfamily member. Injury or death occurseither through the acts of the abuser, thevictim, or the children. Typically it isabusers’ violent conduct against victimsthat results in serious injuries or death tovictims. Sometimes in pursuit of control-ling victims, perpetrators also injure or killchildren, others, or themselves. Sometimesit is the victim or children who injure or killthemselves or others as a response to theviolence of the perpetrator.

Assessment of risk for injury or death isdifficult as illustrated by the controversyabout the efficacy of assessments forpredicting homicides.2 The debate stemsfrom the fact that ultimately we cannotknow with absolute certainty which batter-ers will commit homicide. Dangerousnessassessments are not precise, scientific tools;they are attempts to identify batterers whoare more likely to kill their partners.Furthermore, predicting homicides is onlyone way to understand the risk in domestic

violence for injury or death. Unfortunately,there are similar difficulties when attempt-ing to predict injuries or death due todomestic violence as those found in predict-ing homicides. Overpredictions of injuryor death and underestimations of risk arealways possible. Nonetheless, since domes-tic violence can result in significant injuryor death, the responsible health careprovider should, at a minimum, attempt todetermine the danger of immediate harm.

Assessment of risk for injury or deathshould be conducted every time the healthcare provider has contact with an identifiedperpetrator or victim of domestic violence.The lethality assessment is used to deter-mine whether or not there is immediatedanger and what steps can be taken toreduce the danger level. The primarysource of the information is the patientpresent, whether perpetrator or victim. Acomplete assessment of lethality involvesgathering information from all who haveinformation relevant to the lethalityquestion.

While more research is needed toimprove predictions of danger in domesticviolence cases, the lethal nature of theviolence makes it imperative that clinicalassessments of lethality are routinelycarried out, using clinical judgment as aguide. The following are factors toconsider in assessing the lethality of the

2 Hart, B. J. & Gondolf, E. W. (June 1994).Lethality and dangerousness assessments.Violence UpDate, 4(10), 7-10.

domestic violence (see Appendix K forLethality Assessment with the Perpetrator).Each of these factors is important individu-ally and in interaction with the others.

A. Pattern of AbuseWhile it is difficult to predict which

perpetrator will escalate the severity of hisphysically abusive behaviors, an examina-tion of the current pattern will reveal whois already engaging in high risk behaviorssuch as choking, use of weapons, burning,throwing, and beating. By considering thefollowing areas, the health care providercan assess danger based on the current levelof violence:

a. frequency and severity of abusive actsin current, concurrent, and pastintimate relationships; possible escala-tion of frequency and severity;

b. availability of and use of weapons;

c. threats to kill self or others; credibleplans and means to kill;

d. hostage taking behavior;

e. use of violence outside family;

f. stalking behavior;

B. Perpetrator’s Access tothe Victim

When the batterer’s level of currentviolence is high and the perpetrator hasaccess to the victim, the danger potential ishigh. Reduced access, such as when thevictim is in hiding or the perpetrator is injail, reduces the risk of injury or death.Since battering is about having the oppor-tunity to abuse, then not having accessreduces the opportunity.

C. Factors that ReduceCognitive Controls

■ alcohol/drug dependence or abuse

■ certain medications

■ psychosis or brain damage

For perpetrators, any one of thesefactors combined with their violenceincreases the risk for injury or death.Certain prescribed medications (e.g., anti-anxiety drugs) as well as alcohol or illegaldrugs may act as dis-inhibitors, making theuse of physical force against partners moredangerous. For example, while under theinfluence, perpetrators may become lessconcerned about potential negative conse-quences, which have served as deterrentsfor some of the more lethal acts of abuse.As previously noted, alcohol and otherdrugs do not cause domestic violence.However, by reducing inhibitions they mayincrease a batterer’s potential to commitserious harm or murder. If present,psychosis or brain damage may lessen theabuser’s cognitive controls over his behav-ior, and those perpetrators may engage inmore dangerous behaviors.

Victims who are substance abusers,who are on certain medications, or whohave psychosis or brain damage may be athigher risk for serious injury or death. Anyof these factors may compromise theirability to protect themselves from theirpartner’s violence. For example, thesefactors make it more difficult to escape orcarry out any part of a safety plan.

D. Perpetrator’s State ofMind

■ obsession with victim

■ increased risk taking by perpetrator

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■ ignoring negative consequences to hisabusiveness

■ depression; desperation

Batterers who seem obsessed andpreoccupied with controlling their victims,who have been taking increasing risks (e.g.,assaulting partner in public, being morepublic with their tactics of control byincluding family and friends in the abusivetactics, stalking), who have been ignoringnegative consequences (e.g., arrests forviolations of no contact orders), and whoare expressing more depression or despera-tion (e.g., repeated, public displays ofcrying, agitation, etc.) are escalating theirtactics of control and becoming moredangerous.

E. Suicide Potential ofPerpetrator, Victim, orChildren

Suicide potential in domestic violencecases also needs to be evaluated using thesame techniques as any suicide assessment(threats, attempts, plans and means forsuicide). In domestic violence cases, suicideassessments should be done for all familymembers, including the victim, children,and perpetrator.

F. Situational Factors■ separation violence

■ increased autonomy of victim

■ other major stresses

As discussed in the overview chapter,there is growing evidence that one of the

most dangerous periods for the victim ofdomestic violence is the point of separa-tion. Some batterers will go to extrememeasures to maintain their control overvictims, by escalating their violence andeven committing homicide. Even whenthere is not an obvious, physical separa-tion, the batterer may perceive the victim asincreasing her autonomy (e.g., returning toschool, getting a work promotion, beingmore focused on parenting) and mayattempt to re-establish control by resortingto increased violence. Since many batterersexpect victims to take responsibility forvirtually everything in the batterer’s life,situational stresses like lost jobs, conflictswith friends, and increasing financialpressures can become excuses for theperpetrator to increase attacks against thevictim.

G. Past Failures of theCommunity to Respond

One factor often overlooked in evalu-ating danger is the previous encountersbatterers have had with the communityabout the abuse. For example, whenbatterers are rewarded (e.g., peer support,jokes by responding police officers) or notheld responsible for their abuse (e.g.,charges are dismissed, guns are returned,court orders are not enforced, othersengage in victim blaming), then battererscome to believe that they can do anythingto their partners and they will suffer noconsequences. Their abuse escalates.While there has been concern about thepotential for retaliation by some abusersagainst their victims when the communitydoes act (e.g., by granting a protectionorder), equal attention needs to be given tothe increased danger victims face when acommunity fails to act appropriately andthereby sanctions the perpetrator’s abuse.

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When the potential for injury or deathis high, there are multiple crisis interven-tion strategies that can be used with thepatient who is the abuser. The crisis inter-vention strategy selected will depend on (1)the nature of the threat, (2) who is indanger, and (3) the resources that are avail-able to deal with the crisis. This sectionfocuses on strategies to use with an abuserwho represents a danger to victims or self.

A. Duty to Warn When theHealth CareProfessional Believesthe Victim Is in Danger

Health care practitioners must beaware of their legal and ethical responsibili-ties to warn victims about potentialassaults against them. There is a duty towarn when there is a clear and presentdanger to a specific victim or victims. Indomestic violence cases, a specific victim istargeted and thus if the health care providerbelieves that the patient is a serious threat,then the victim of that patient should benotified. In some circumstances otherappropriate authorities must be notified.Health care personnel should be aware oftheir facility’s policies and procedures forduty to warn.

B. Legal Recourses andMandatory Reporting

At some time, providers may be facedwith the abuser who is likely to kill if notcontained. Depending on the situation, amental health commitment or call to lawenforcement may be appropriate. Giventhe variance in law enforcement interven-

tions, involuntary mental health commit-ments, and involuntary substance abusecommitments, it is beyond the scope of thismanual to make specific recommendations.Health care practitioners should becomefamiliar both with local laws and thepolicies and procedures of their practicesettings. If there are no procedures ineffect, they should be developed before thecrisis emerges.

While mandatory reporting is not acrisis intervention strategy, the issue is oftenraised in response to the most serious andlethal situations of domestic violence.Since health care providers may be requiredto report injuries they suspect result fromdomestic violence, it is important thatproviders become familiar with their state’sreporting laws. Mandatory reporting lawsare widespread. For example, 40 states andthe District of Columbia mandate reportingby health care personnel under certaincircumstances where the patient has aninjury that appears to have been caused bya deadly weapon. Statutory mandatesregarding reporting vary greatly from stateto state about who is required to report,what kinds of injuries need to be reported,and penalties for failure to report and/orimmunity from liability, and so forth. Tofind out more about individual practitionerreporting responsibilities, contact the legaldepartment of the facility and/or call thelegal department of the state medicalsociety. (Refer to Appendix N for a morelengthy discussion of the potential conse-quences of mandatory reporting and asummary of state statutes).

In addition to duty to warn proceduresand legal interventions, practitioners canuse a variety of other crisis interventionstrategies, depending on whether the lethal-ity risk is from homicide or suicide anddepending on who is in danger of harmingwhom. Some of the strategies require theperpetrator’s cooperation and some do not(e.g., being jailed for crime, mental health

IV. CRISIS INTERVENTION STRATEGIES

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commitment, victim going to the batteredwomen’s shelter).

C. RecommendingTemporary Separation

One cluster of crisis intervention strate-gies for domestic violence is designed tointerrupt perpetrators’ access to victims byhaving victims and abusers separate.Health care providers can recommend thatthe perpetrator temporarily separate fromthe victim during a crisis period (e.g., theabuser moves in with a friend, sleeps in hiscar, or somehow stays separated from thevictim). The practitioner can engage thepatient in suggesting ways to temporarilyseparate from the victim. Providers canalso indicate to the perpetrator that theysupport the victim’s decisions to temporar-ily separate through protection orders orthrough stays in a shelter. The patientshould be reminded that these temporarysteps are helpful in preventing injury andthe perpetrator will need to take additionalsteps to stop his violence permanently. Byrecommending crisis strategies the healthcare provider can emphasize to the perpe-trator the serious nature of the currentcrisis and his responsibility for stopping hisabusiveness.

D. Strategies to Diffuse theCrisis

When the perpetrator refuses to eventemporarily separate from the victim, thehealth care provider may recommend adifferent set of strategies: those designed todefuse an immediate episode where thebatterer is highly likely to strike out at thevictim. Examples of diffusion strategiesinclude: referrals to domestic violenceintervention programs or substance abuseprograms, recommendations to temporar-ily discontinue use of alcohol or otherdrugs until further interventions can beestablished, advising perpetrators aboutthe danger of weapons and recommendingthat weapons be removed from the crisis,and advising perpetrators about the poten-tial for arrest and incarceration. All ofthese crisis intervention strategies requirethe cooperation of the abuser to act to stophis violence. Some perpetrators will ignorewhatever suggestions are made, whileothers will surprisingly comply simply“because the doc told me to.” Since there isno way to predict which strategy to usewith which batterer, it is helpful forproviders to suggest several and to encour-age perpetrators to list out their ownapproaches to stopping their violence.

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V. OTHER HEALTH CARE INTERVENTIONS WITHPERPETRATORS

In addition to crisis intervention strate-gies, the health care practitioner canprovide to the perpetrator importantpatient education and referrals to battererintervention programs, where available.The practitioner’s interventions will varyaccording to the presenting issues, thepractice setting, and the amount of contactbetween the provider and patient.

Furthermore, the interventions used willvary from individual patient to individualpatient depending on what is learned aboutthe nature of the abuse, its impact on thepatient, other medical or mental healthissues of the patient, the patient’s motiva-tions, resources, and abilities to deal withhis abusiveness, his willingness to takeresponsibility for his battering behavior,

and the resources available to the practi-tioner. In spite of these variations there arebasic steps that can be taken.

A. Patient Education:Abusive Conduct andHealth Issues

A health care provider treats thepresenting medical (and/or mental health)concerns of the patient. When the patientis a perpetrator of domestic violence, partof that treatment is evaluating how theabuse may be a causative factor in thepresenting problem or how it may be afactor in the patient’s recovery or how itmay lead to future injury or death. Theseconnections will have to be pointed out tothe perpetrator (e.g., “your violence is self-destructive,” “your behavior isn’t good foryour heart,” “your violence leads to____(medical condition)”).

In addition to seeing the connectionbetween their behavior and their ownhealth, batterers often need assistance inacknowledging the destructive impact oftheir abusiveness on victims, children andothers. Those health care systems (e.g.,family practitioners or HMO’s) thatrespond to all members of the family arewell aware of how one person’s high riskbehavior shows up as the injury or illness ofa family member in another part of thesystem. Conveying to perpetrators generalinformation about the health impact ofvictimization can assist some to identifytheir behavior as an issue worth address-ing.

B. Patient Education:Domestic Violence, ItsImpact on Victims andChildren, andPerpetrator’sResponsibility

Because of their lies, distortion, andjustifications for individual episodes ofdomestic violence, batterers are able tokeep themselves from looking at the truenature of their domestic violence. Patienteducation about abusive conduct as well asthe impact of that pattern on victims andthe children should be explored with theperpetrator. For some perpetrators, thereality that domestic violence is a crime andthat there are specific consequences mustbe pointed out (“Did you know you couldgo to jail for hitting your wife?”).

Most importantly, batterers need to beeducated about their individual responsi-bility for battering. Because domesticviolence is so embedded in social customs,this education may be the first time theyhave heard from someone that they areresponsible for what they are doing and forchanging it.

This patient education can be directand brief. It can be presented calmly andrespectfully.

■ Your behavior is damaging to every-thing that is important to you and thefastest way to stop that damage is foryou to change those behaviors (listingspecific examples of physical abusedisclosed to the practitioner).

■ Using force will never solve theproblems in a relationship or family. Infact it makes them worse.

■ I see other patients with this problemand they said they were able to changeonly when they started taking responsi-bility for what they were doing.

Patient education can be repeatedduring future appointments, and if

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combined with other community effortsmay result in some individual battererschanging their abusive patterns. At aminimum such patient education by apractitioner ends the silence of the healthcare system and its perceived collusion withthe batterer.

C. Listening to the Patient’sConcerns

Listening to and working with abuserswithout colluding with them or participat-ing in their victim blaming is a very difficulttask. Some batterers are highly manipula-tive and will attempt to engage the healthcare provider in blaming their victims. Atthis point it is crucial to keep the focus ontheir abusive behavior and their responsi-bility to stop it. However, it is also impor-tant for the practitioner to listen for whatmay be a motivation from the abuser’sperspective for him to change. Listening tothe perpetrator’s concerns about hisconduct may reveal his awareness of thelegal consequences to his actions as well asthe negative impact on his partner, hischildren, his job, his standing within hiscommunity, his health, etc. By identifyingthose negative consequences and connect-ing them to the abusive conduct he choosesto use, he starts the process of changing hisdestructive patterns.

In listening to the perpetrator, thehealth care provider may hear informationabout all or some of the following:

1. THE PATTERN OF ABUSIVECONDUCT:■ types of abuse

■ frequency and severity of the physi-cal force used

2. IMPACT OF THE ABUSE ON THEVICTIM:

■ injuries and other health issues

■ depression, withdrawal, rage, fear

■ impact on her relationship withothers

■ employment and legal issues (SeeVictim’s Chapter regarding impacton the victim.)

3. IMPACT OF THE ABUSE ONCHILDREN:

■ injuries

■ behavior problems

■ relationship problems

■ emotional difficulties

4. IMPACT OF THE ABUSE ON THEPERPETRATOR:

■ health issues

■ impact on his relationship withvictim and children

■ legal issues

■ employment problems

■ prior interventions or attempts toget assistance

5. PERPETRATOR’S CURRENTMOTIVATION TO VIEW HISABUSIVENESS AS A PROBLEM HEWANTS TO ADDRESS.

■ This information is useful in devel-oping responses to individualperpetrators and in engaging theperpetrator in taking responsibilityfor changing his behaviors. Thereare very real time constraints inhealth care contacts with perpetra-tors and consequently the informa-tion from one contact may beincomplete. Furthermore, manyperpetrators minimize, lie and denyand will not provide a complete

picture of the abuse. Therefore, itis helpful to note any informationabout abuse in the chart. A moreaccurate description of the domes-tic violence is more likely to emergethrough the record of these multi-ple contacts.

It is important to reflect back to himthe ways in which his behavior is having anegative impact on him (list any of those hehas already indicated in his discussion ofhis concerns, such as the impact on thechildren) as well as his power to change hisbehavior and stop the abuse. These identi-fied consequences may become motivatorsfor change. If the provider joins the abuserin blaming the victim or some other exter-nal factor (e.g., drinking, stress) for hisabusiveness, then the abuser will use thehealth care practitioner’s comments orsilence to shore up his belief that he has aright to use violence to control his family.

It is important not to let the abuser usethe patient/doctor privilege as a way tofurther control the victim. The health careprovider has a unique and potentiallypowerful role as one who helps the perpe-trator by holding him responsible forchanging this self destructive behavior.While this approach may not be successfulwith all abusers, it can be very effectivewith some and can become part of acomprehensive, coordinated communityresponse to domestic violence.

D. Discussing Options

Part of the purpose of discussingoptions such as safety planning withvictims is to support their self-empower-ment and their safety. That is not thepurpose of discussing options with batter-ers. Batterers are already powerful in theiruse of violence and abuse to control others.They are misusing that power. Instead, thepurpose of discussing options with batter-ers, such as time-outs or temporary separa-

tion or referrals to specialized programs, isto engage the patient in taking responsibil-ity for changing his abusive conduct.Abusers come from diverse backgroundsand have multiple issues (cultural, sexual,substance abuse, mental or physical abili-ties, HIV, etc.) which may relate to inter-ventions for the domestic violence.Practitioners need to be sensitive aboutthese without letting abusers use them as away to avoid taking responsibility for theirviolence. The typical response of a battereris to make the victim responsible for fixingwhatever is wrong in their life. Discussingoptions is one way to keep the focus ofresponsibility for change on what theindividual batterer can do.

E. Making AppropriateReferrals

Unless the health care setting has on-site specialized programs for batterers,3 theprovider will most likely be referringbatterers to available community programs.In making these referrals, the practitionershould exercise caution and care.Traditional counseling (couples, individual,or family) or traditional rehabilitationprograms (substance abuse, mental health,etc.) do not appear to be effective. For thisreason, it is important for health careprofessionals not to encourage perpetratorsto seek traditional couples counseling fortheir abusive behavior. Couples counselingmay endanger victims of battering evenfurther, as they face violence or threats ofviolence for revealing information aboutthe abuse during therapy sessions.Additionally, couples counseling mayinappropriately indicate to both victimsand perpetrators that the perpetrator’sviolence is somehow a “relationship

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3 For example, some Veterans AdministrationMedical Centers, some military medical facili-ties, and certain substance abuse programs havespecialized programs for perpetrators of domes-tic violence.

problem” that the victim has some respon-sibility to fix. Unless the counselor isskilled in keeping the responsibility forchanging the abusive behavior squarelywith the abuser, the traditional approachesquickly become means for the abusers tocontinue to manipulate the victim.

The health care provider needs toknow which community resources areknown to be effective in responding tobatterers. The health care practitioner cancontact the state or local domestic violencecoalitions for information about perpetra-tor programs. A limited number of stateshave established standards for abuserprograms and some require a certificationprocess for those programs. If there are nospecialized domestic violence perpetratorprograms, the domestic violence coalitionsmay know of other appropriate resourcesavailable for abusers. (See Appendix K forAssessing Services for Perpetrators.)

Specialized rehabilitation and educa-tional programs have been evolving forbatterers. These programs use group treat-ment and education for men who batterand focus on the responsibility of theabuser to change their abusive conduct.The outcome data on their effectivenessremains limited. Those programs thatseem to be the most effective are embeddedin a coordinated community response thathas both a legal and a rehabilitativecomponent.4 For example, the batterers’treatment program operated by theDomestic Abuse Intervention Project ofDuluth, Minnesota involves a closeworking relationship with law enforcementand the courts. The institutions worktogether as part of a community-wideresponse to hold abusers accountable fortheir violence, to prosecute them for crimi-nal conduct, and to provide them with theopportunity to seek educational groups fortheir abusive behavior. What appears to bechanging their abusive behavior is not just

the participation in the abuser groups, butthe coordinated effort of the community toreinforce the message that batterers areresponsible for their abuse and that abusehas serious, negative, legal and socialconsequences.

For some batterers no treatmentprogram will be effective and incarcerationmay be the only way to protect theirvictims. When making a referral to anoutside agency, it is important to know thatat a minimum the perpetrator programfollows the same guidelines as outlined atthe beginning of the chapter: victim safety,victim integrity and authority to direct herlife, and abuser responsibility for the abuseand for stopping it. Furthermore, it isimportant for the practitioner to tell thepatient directly that the purpose of thereferral is to assist him in stopping hisabusive behavior, and not to useeuphemisms like “anger management” or“family counseling” which masks the truenature of the problem and only plays intothe abuser’s denial of his problem.

F. Establishing a Follow-Up Process

Domestic violence is a pattern ofbehavior that is supported by the victim-blaming tendencies rampant throughoutthe community. Too often the response ofpeers or other community institutionsreinforce the perpetrator’s abusive control.An individual’s abusive conduct does notgo away after one or two short interven-tions. Consequently, it is important thatthe health care practitioner follow up withinquiry about abuse in future contacts withthe patient. The health care practitionercan raise the issue directly by statementssuch as:

“The last time we talked, we weretalking about how you could stop yourabusive behavior. I would like to checkon how you are doing. Since I last sawyou, have you used physical forceagainst person or property in fights in

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4Sheppard, M. (1988). Evaluation of theeducational curriculum — Power and control:Tactics of men who batter. Duluth, MN:Domestic Violence Intervention Project.

the family? Any shoving, pushing, orthrowing things? Any threats ofviolence?”

Also, if referrals were given, ask aboutfollow-through. If the patient claims thateverything is fine, remind him that domes-

tic violence is a problem that does not goaway on its own. Encourage the patient totalk about it. This follow-up provides thepractitioner with the opportunity to re-assess the patient’s abuse pattern, toconfront distortions when found, and toreinforce progress if made.

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CONCLUSION

There is still much evolving concerningappropriate responses to patients who areperpetrators of domestic violence. Whilethis chapter attempts to provide someguidance for approaches, systematic studyis needed to determine which approachesare most effective with which perpetrators.

This chapter is written with an under-standing that no one system alone can stopdomestic violence. Perpetrators maychange over time due to multiple, cumula-tive experiences. Unfortunately, domesticviolence remains embedded in many

community customs and institutions. Theinterventions described in this chapter willbe most effective as they become part of anoverall coordinated community response,which places a priority on victim safety,victim integrity and authority, and perpe-trator responsibility. The interventionsdescribed in this chapter are only one wayto communicate that violence and coercivecontrol are criminal and never justified inintimate relationships. There is no excusefor domestic violence and that message isjust the beginning of change.

CHAPTER 4

ESTABLISHING ANAPPROPRIATERESPONSE TO

DOMESTIC VIOLENCEIN YOUR PRACTICE, INSTITUTION AND

COMMUNITY

BY CAROLE WARSHAW, M.D.

In order for clinicians to develop andsustain an appropriate response to domes-tic violence, they must have the support ofthe institutions in which they practice. Ashealth care professionals attempt to incor-porate routine inquiry about abuse into thestandard of care for all women patients, theneed for a coordinated institutionalresponse to domestic violence becomesincreasingly evident. This chapter addressesstrategies for changing institutions andpractice settings to support and encouragehealth care providers to meet the needs ofvictims of domestic violence.

Providers acting alone simply cannotmeet all of the needs of domestic violencevictims and their children. The optimalresponse to domestic violence requires thecoordinated efforts of all members of thecommunity, including health care providers,

community-based domestic violenceadvocacy groups, child welfare and protec-tive service agencies, and the civil andcriminal justice systems. This chapter willdescribe how to work within clinical practicesettings, health care institutions, and commu-nities to develop such a coordinated response.It will also describe strategies to assure thatbattered women receive appropriate carewithin individual practice settings. The follow-ing issues will be addressed:

■ Creating a practice environment thatenhances rather than discouragesidentification of abuse.

■ Educating health care staff aboutdomestic violence intervention.

■ Developing an integrated response to

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ESTABLISHING AN APPROPRIATERESPONSE TO DOMESTIC

VIOLENCE IN YOUR PRACTICE, INSTITUTION AND COMMUNITY

BY CAROLE WARSHAW, M.D.

INTRODUCTION