Domestic Violence: The Psychiatrist’s Role in Detection and Intervention

President Barack Obama declared this month Domestic Violence Awareness Month, noting that domestic violence (DV) is extremely common in the United States.1 According to the National Coalition Against Domestic Violence, on average, nearly twenty people per minute are physically abused by an intimate partner. During one year, this translates into over 10 million people. One in 3 women and 1 in 4 men have been victims of some form of physical violence by an intimate partner in their lifetime.2

Psychiatrists can play a key role in detecting signs of abuse, determining the level of danger, helping the individual to create a safety plan, making appropriate referrals, providing empathy and emotional support, and providing short- and long-term trauma interventions.3 But “despite widespread recognition of DV as a public health problems, many mental health clinicians still have trouble integrating routine intervention into their day-to-day practice,” observed Carole Warshaw, MD, a psychiatrist who is the director of the National Center on Domestic Violence, Trauma, and Mental Health.

One of the reasons is that “domestic violence is a complex social rather than biomedical problem, and addressing it means asking ourselves to step beyond the traditional medical paradigm and work in partnership with community organizations dedicated to ending domestic violence,” Warshaw told Psychiatry Advisor.

It Begins with Detection

“It should be a routine part of history-taking to inquire about the patient’s home environment,” said Carol A. Bernstein, MD, Associate Professor and Vice Chair, Departments of Psychiatry and Administration, NYU Langone Medical Center, and a past president of the American Psychiatric Association.

She noted that it has become increasingly standard at medical exams or procedures to screen patients for DV, but “psychiatrists will be more sophisticated in how elicit this information,” Bernstein told Psychiatry Advisor.

Begin with general, open-ended questions. “Do you live alone?” “Do you have a significant other?” “How is your relationship going?” “Is your partner supportive?” “What happens when you and your partner disagree?”3 Depending on the answers, you can continue to more targeted questions. (Table 1)

Table 1

Examples of Questions to Ask Patients Who Might be Experiencing Domestic Violence

  • Some people with your physical symptoms experience abuse at home. Is that the case with you?
  • Has your partner ever used issues related to your mental health or use of substances against you?
  • Has your partner ever tried to control your medication or access to treatment?
  • Has your partner ever threatened to take your children away because you are receiving mental health or substance abuse treatment?
  • Has your partner ever threatened to call immigration authorities?
  • Has your partner ever blamed you for his/her abusive treatment by saying that you are the one who is “crazy” or an “addict?”
  • Has your partner done things to make you feel like you are “going crazy?”
  • Have you ever felt humiliated/controlled/ emotionally abused by your partner (or ex-partner?)
  • Have you been physical hurt by your partner?
  • Have you been forced by your partner to engage in sexual activity you did not want?

Source: Howard LM. Adv Psych Treatment. 2012;18:129-136; Carole Warshaw, MD

Warshaw added that it is important to look beyond the patient’s words. Some individuals who have experienced DV have obvious injuries. But others have a more subtle presentation. “Notice body language,” she advised. “Listen for what they may not be telling you if you sense something else may be going on.”