General practitioner management of intimate partner abuse and the whole family: qualitative study
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《英国医生杂志》
1 Centre for the Study of Mothers' and Children's Health, La Trobe University, 251 Faraday Street, Carlton, Vic 3053, Australia, 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 0200, Australia, 3 School of Public Health, Faculty of Health Sciences, La Trobe University, Bundoora, Vic 3086, Australia
Correspondence to: A Taft a.taft@latrobe.edu.au
Abstract
Domestic violence, now commonly called intimate partner abuse, is generally defined to emphasise intimidation, coercion, and control.1 Twice as many patients of general practitioners (5-8%) report partner abuse within the previous 12 months, compared with women in the community (2.4%).2 General practitioners also see men who abuse3 and the children of such couples, whose health is also at risk.4 Most clinical guidance and training for general practitioners focuses on the management of the adult female victim, although one study highlighted that doctors' management decisions may be more influenced by the "dual relationship" with both partners in a couple than by the severity of the violence.5
Health professionals, including doctors, are increasingly being encouraged to screen for partner abuse,6 which is a serious health problem. Primary care is an important early intervention site,7 because general practitioners often have an ongoing therapeutic relationship with the whole family. The limited research on general practitioners' management of partner abuse focuses on perceptions of barriers to screening victims; intervention studies on partner abuse are rare.8
To be effective, guidelines for best practice in management of partner abuse should be informed by how family doctors manage the complexity of seeing all family members. This study explored how general practitioners managed all members of a family in which partner abuse occurred, the impact on doctors themselves, and what further training and support are needed. Our broad objectives were to explore the strength and limitations of continuing medical education on domestic violence, strategies to improve doctors' responses to women from ethnic minorities, the influence of the doctor's gender, the principles and strategies of doctors working with men who use violence, and the need for an integrated continuing medical education curriculum incorporating all family members.
Methods
The samples represented a wide range of forms of partner abuse. Doctors described patterns of partner abuse among their patients that varied from chronic and severe multiple abuses to mutual couple conflict; from what Johnson calls "intimate terrorism" to "common couple violence."16 Some doctors expressed confusion about the boundaries beyond which normal conflict becomes abuse. Legal concepts of physical and sexual assault guided some respondents' awareness of domestic violence (suggested in the quote below), while other doctors, more often from rural areas, included forms of emotional abuse. "In a year, about three or four... There might be a lot more, but it was difficult; at least with the Sri Lankans... and the Vietnamese people, you can see their body, but with the Turkish and Arabic people you can't see their body." (Urban male doctor 1.)
Doctors' perceptions could influence their estimation of the prevalence of partner abuse in their practice, and their identification and management of patients, which suggested that in some practices many victims were being overlooked. All these doctors had sought training. They were attempting to help their patients to manage the violence, yet they experienced many challenges. Limited time and the fee for service system are common restrictions affecting the ability to provide quality care for many Australian general practitioners, but other more specific difficulties existed.
Stress and aversion
Many problems contribute to doctors' aversion to working with partner abuse.17 In this study even those who expressed empathy for patients and wanted to help could find the work unrewarding and financially draining because of long consultations. Doctors could be frustrated because of patients who were "non-compliant" with their advice or who did not return.7 Some were discouraged because they got little positive feedback: "You often don't want to be too good at it because you get too many of them... you might find people start referring them to you." (Rural female doctor 1.) Consequently, these doctors spoke of their own occasional reluctance to acknowledge the problem, even when they had grounds for suspicion.
Responding to victimised women
The doctors described very diverse abused women. Women presented with depression and anxiety, drug or alcohol problems, eating and sleeping disorders, and migraines and injuries as well as with children's ailments.1 Doctors' reactions to their victimised patients ranged from understanding, close identification, and distress to frustration with their inability to engender change. Several doctors were unaware of the barriers inhibiting women's disclosure. They were especially frustrated by women who would not disclose, even when doctors acted on their suspicions and asked directly.7 Most of the urban doctors and a third of the rural doctors believed that the best advice would always be to leave, despite the difficulties women experience.18
Impact of doctors' gender
For some doctors, a lack of professional effectiveness provoked feelings of despair or helplessness. Overall, female doctors believed their gender was advantageous because women would trust them more, they understood women's suffering, and they could identify with women's experiences. They also believed that male patients may find it easier to speak to them about emotional issues. Most male doctors also thought that male patients prefer to discuss their emotional problems with female doctors. However, female doctors said that seeing many patients with psychosocial problems came at some cost.19 Because of their empathy with victims' suffering they expressed more sadness, feelings of frustration, and distress that they had no "magic" remedy. Some consequently felt powerless or demoralised.
Responding to male patients who abuse
Most urban respondents and some rural respondents reported seeing male patients who abused female partners. Twenty men presented to case study doctors with depression, pain, and drug and alcohol abuse, and two presented with mental illness. These seven doctors saw men who attended both in couples and alone, for medical problems, "anger management," or "wife-mandated" behavioural change. The doctors' responses to their male patients could be uncomprehending, hostile, and distancing: "On a dark night I'd run over them," "Some Maltese from St Albans who's beaten the s**t out of his wife."
Men's violence could be variously ascribed to their class, ethnicity, or genetic predisposition. Other doctors spoke of the difficulty accepting that a charming male patient for whom they had long cared was abusing his partner: "It's hard to think of some of the men as abusers if you've been caring for them in other ways and really had no suspicion. I also think there's a tendency to minimise the violence and reassure yourself and the woman that, oh you know, its just bad temper." (Rural female doctor 2.)
Hostile or ambivalent responses to abusive male patients made it difficult for doctors to respond appropriately to the men's violence. When doctors distance themselves from abusive male patients, they place greater responsibility on women to change their situation, irrespective of the women's ability to do so.
Managing couples
Like Ferris et al's (1999) study of Canadian family practitioners, we found that some doctors have difficulty in managing couples, and the severity of the violence did not necessarily guide decisions about management.5 With neither expertise nor practice evidence about managing the "dual relationship," well meaning doctors could violate confidentiality, placing the woman at increased risk.14 One doctor described a Turkish couple, of which the woman eventually disclosed violence. The doctor discussed the husband's anger with him (without his wife's consent) when he next presented. The man realised that his wife had disclosed, and neither ever returned. The doctor sought counselling for her anxiety that she may have caused more abuse. As in overseas studies,20 two other urban doctors revealed that they had done this.
Some case study doctors constructed victims as "deserving," which could affect their management: " not terribly insightful... got a motor mouth, which is thrown into gear before you open the mouth... When Jack is not on drugs or booze he's a very clever man to talk to... I think the quieter Andrea gets , the better the system runs. When she's under control, everything else seems to fit in and go under control." (Urban male doctor 2.)
Some doctors, while meaning well, offered couple counselling: "I usually get them in together first off and just play round with the words and just see whether she will accuse him in front of me... but I usually don't want to accuse a man. Was he guilty of it?" (Urban male doctor 3.) However, this is contraindicated because of the associated risks.7
A few case study doctors did not want to intervene in a couple, and so overlooked the violence. This might occur because the husband's illness required his wife's care (as in the case below), because the doctor-patient relationship was vested in the couple or family as a unit, or because the doctor did not want to lose them as patients. "It doesn't seem right to do it , because he's behaving himself at the moment. And I don't think, why bring up a new critical aspect to his life while he's staying off the grog and looking after his health." (Urban male doctor 2, elderly couple.)
Invisible children
"I had one, just recently, how old was she?... seven. And this mother was saying very clearly, it's not affecting the kid. And yet she was a bed wetter, and she had lots of the classic symptoms... She said, well, I hate it when mummy and daddy fight. And then I said what do you do? I hide in the cupboard, and I take Jack with me. She had this whole behaviour, a way of protecting herself and her brother, who was about two, of getting into cupboards. (Rural female doctor 3.)
With attention firmly on the adult relationships, most doctors (with the exception of the doctor above) overlooked the impact on children. One concern was the potential jeopardising of the doctors' professional relationship with the child's parents: "You get that close to them and how difficult it is then to turn around and accuse them or suggest to them that they're damaging their child." (Rural female doctor 2.)
Some doctors felt that they had no management skills for children's psychosocial issues. Many did not trust child protection services and were unaware of therapeutic services to assist children.
Disclosure, counselling, and referral
When domestic violence is suspected, doctors are advised to ask directly, inform the women of her options, support her, and refer her to specialist agencies.7 Particularly in rural areas, few agencies exist to which general practitioners can refer patients. Furthermore, doctors are often unfamiliar with those agencies relevant to victimised women, men who abuse, and least of all children. The absence of or ignorance about such agencies could sometimes be compounded by distrust of specific services. Some doctors expressed reservations about the benefits of referral, and little published evidence exists about whether intervention is beneficial or harmful to women or children in the longer term.8 Supportive counselling was the most common strategy doctors used. Insufficient time; absence of appropriate training, debriefing, or supervision; and unfamiliarity with or lack of trust in community based agencies all raised doctors' stress levels, which could lead to a reluctance to identify patients: "Sometimes myself I get depressed and frustrated, I don't know what to do... sometimes you ask yourself, did I do the right thing or not? Did I help or did I make it worse?" (Urban female doctor 1.)
Discussion
Eisenstat SA, Bancroft L. Domestic violence. N Eng Med J 1999;341: 886-92.
Hegarty K, Bush R. Prevalence and associations of partner abuse in women attending general practice: a cross sectional survey. Aust NZ J Public Health 2002;26: 437-42.
Oriel KA, Fleming MF. Screening men for partner violence in a primary care setting: a new strategy for detecting domestic violence. J Fam Pract 1998;46: 493-8.
Webb E, Shankleman J, Evans MR, Brooks R. The health of children in refuges for women victims of domestic violence: cross sectional descriptive study. BMJ 2001;323: 210-3.
Ferris LE, Norton P, Dunn EV, Gort EH. Clinical factors affecting physician's management decisions in cases of female partner abuse. Fam Med 1999;31: 415-25.
Richardson J, Coid J, Petruckevich A, Chung WS, Moorey S, Feder G. Women who experience domestic violence and women survivors of childhood sexual abuse: a survey of health professionals' attitudes and clinical practice. Br J Gen Pract 2001;51: 468-70.
Sassetti M. Domestic violence. Primary Care 1993;20: 289-305.
Wathen NC, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289: 589-600.
Yin R. Case study research: design and methods. Second ed. California: Sage, 1994: 171. (Applied Social Methods Series, vol 5.)
Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage Publications, 1990.
American Medical Association diagnostic and treatment guidelines on domestic violence. Arch Fam Med 1992;Sept(1): 39-47.
Adams D. Guidelines for doctors on identifying and helping their patients who batter. J Am Med Womens Assoc 1996;51: 123-6.
Mintz HA, Cornett FW. When your patient is a batterer: what you need to know before treating perpetrators of domestic violence. Postgrad Med 1997;101: 219-28.
Ferris LE, Norton PG, Dunn EV, Gort EH, Degani N. Guidelines for managing domestic abuse when male and female partners are patients of the same physician. JAMA 1997;278: 851-7.
Edleson J. Domestic violence and children. Future Child 1999;9(3).
Johnson MP. Patriarchal violence and common couple violence: two forms of violence against women. J Marriage Fam 1995;57: 283-94.
Hegarty KL, Taft AJ. Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice. Aust NZ J Public Health 2001;25: 433-7.
Gerbert B, Abercrombie P, Caspers N, Love C, Bronstone A. How health care providers help battered women: the survivor's perspective. Women Health 1999;29: 115-35.
Bensing JM, Van Den Brink-Muinen A, De Bakker D. Gender differences in practice style: a Dutch study of general practitioners. Med Care 1993;31: 219-29.
Bowker LH, Maurer L. The medical treatment of battered wives. Women Health 1987;12: 25-45.
Brandt Jr EN. Curricular principles for health professions education about family violence. Acad Med 1997;72(1, suppl): S51-8.
Warshaw C. Intimate partner abuse: developing a framework for change in medical education. Acad Med 1997;72(1, suppl): S26-37.
Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131: 578-84.(Angela Taft, research fel)
Correspondence to: A Taft a.taft@latrobe.edu.au
Abstract
Domestic violence, now commonly called intimate partner abuse, is generally defined to emphasise intimidation, coercion, and control.1 Twice as many patients of general practitioners (5-8%) report partner abuse within the previous 12 months, compared with women in the community (2.4%).2 General practitioners also see men who abuse3 and the children of such couples, whose health is also at risk.4 Most clinical guidance and training for general practitioners focuses on the management of the adult female victim, although one study highlighted that doctors' management decisions may be more influenced by the "dual relationship" with both partners in a couple than by the severity of the violence.5
Health professionals, including doctors, are increasingly being encouraged to screen for partner abuse,6 which is a serious health problem. Primary care is an important early intervention site,7 because general practitioners often have an ongoing therapeutic relationship with the whole family. The limited research on general practitioners' management of partner abuse focuses on perceptions of barriers to screening victims; intervention studies on partner abuse are rare.8
To be effective, guidelines for best practice in management of partner abuse should be informed by how family doctors manage the complexity of seeing all family members. This study explored how general practitioners managed all members of a family in which partner abuse occurred, the impact on doctors themselves, and what further training and support are needed. Our broad objectives were to explore the strength and limitations of continuing medical education on domestic violence, strategies to improve doctors' responses to women from ethnic minorities, the influence of the doctor's gender, the principles and strategies of doctors working with men who use violence, and the need for an integrated continuing medical education curriculum incorporating all family members.
Methods
The samples represented a wide range of forms of partner abuse. Doctors described patterns of partner abuse among their patients that varied from chronic and severe multiple abuses to mutual couple conflict; from what Johnson calls "intimate terrorism" to "common couple violence."16 Some doctors expressed confusion about the boundaries beyond which normal conflict becomes abuse. Legal concepts of physical and sexual assault guided some respondents' awareness of domestic violence (suggested in the quote below), while other doctors, more often from rural areas, included forms of emotional abuse. "In a year, about three or four... There might be a lot more, but it was difficult; at least with the Sri Lankans... and the Vietnamese people, you can see their body, but with the Turkish and Arabic people you can't see their body." (Urban male doctor 1.)
Doctors' perceptions could influence their estimation of the prevalence of partner abuse in their practice, and their identification and management of patients, which suggested that in some practices many victims were being overlooked. All these doctors had sought training. They were attempting to help their patients to manage the violence, yet they experienced many challenges. Limited time and the fee for service system are common restrictions affecting the ability to provide quality care for many Australian general practitioners, but other more specific difficulties existed.
Stress and aversion
Many problems contribute to doctors' aversion to working with partner abuse.17 In this study even those who expressed empathy for patients and wanted to help could find the work unrewarding and financially draining because of long consultations. Doctors could be frustrated because of patients who were "non-compliant" with their advice or who did not return.7 Some were discouraged because they got little positive feedback: "You often don't want to be too good at it because you get too many of them... you might find people start referring them to you." (Rural female doctor 1.) Consequently, these doctors spoke of their own occasional reluctance to acknowledge the problem, even when they had grounds for suspicion.
Responding to victimised women
The doctors described very diverse abused women. Women presented with depression and anxiety, drug or alcohol problems, eating and sleeping disorders, and migraines and injuries as well as with children's ailments.1 Doctors' reactions to their victimised patients ranged from understanding, close identification, and distress to frustration with their inability to engender change. Several doctors were unaware of the barriers inhibiting women's disclosure. They were especially frustrated by women who would not disclose, even when doctors acted on their suspicions and asked directly.7 Most of the urban doctors and a third of the rural doctors believed that the best advice would always be to leave, despite the difficulties women experience.18
Impact of doctors' gender
For some doctors, a lack of professional effectiveness provoked feelings of despair or helplessness. Overall, female doctors believed their gender was advantageous because women would trust them more, they understood women's suffering, and they could identify with women's experiences. They also believed that male patients may find it easier to speak to them about emotional issues. Most male doctors also thought that male patients prefer to discuss their emotional problems with female doctors. However, female doctors said that seeing many patients with psychosocial problems came at some cost.19 Because of their empathy with victims' suffering they expressed more sadness, feelings of frustration, and distress that they had no "magic" remedy. Some consequently felt powerless or demoralised.
Responding to male patients who abuse
Most urban respondents and some rural respondents reported seeing male patients who abused female partners. Twenty men presented to case study doctors with depression, pain, and drug and alcohol abuse, and two presented with mental illness. These seven doctors saw men who attended both in couples and alone, for medical problems, "anger management," or "wife-mandated" behavioural change. The doctors' responses to their male patients could be uncomprehending, hostile, and distancing: "On a dark night I'd run over them," "Some Maltese from St Albans who's beaten the s**t out of his wife."
Men's violence could be variously ascribed to their class, ethnicity, or genetic predisposition. Other doctors spoke of the difficulty accepting that a charming male patient for whom they had long cared was abusing his partner: "It's hard to think of some of the men as abusers if you've been caring for them in other ways and really had no suspicion. I also think there's a tendency to minimise the violence and reassure yourself and the woman that, oh you know, its just bad temper." (Rural female doctor 2.)
Hostile or ambivalent responses to abusive male patients made it difficult for doctors to respond appropriately to the men's violence. When doctors distance themselves from abusive male patients, they place greater responsibility on women to change their situation, irrespective of the women's ability to do so.
Managing couples
Like Ferris et al's (1999) study of Canadian family practitioners, we found that some doctors have difficulty in managing couples, and the severity of the violence did not necessarily guide decisions about management.5 With neither expertise nor practice evidence about managing the "dual relationship," well meaning doctors could violate confidentiality, placing the woman at increased risk.14 One doctor described a Turkish couple, of which the woman eventually disclosed violence. The doctor discussed the husband's anger with him (without his wife's consent) when he next presented. The man realised that his wife had disclosed, and neither ever returned. The doctor sought counselling for her anxiety that she may have caused more abuse. As in overseas studies,20 two other urban doctors revealed that they had done this.
Some case study doctors constructed victims as "deserving," which could affect their management: " not terribly insightful... got a motor mouth, which is thrown into gear before you open the mouth... When Jack is not on drugs or booze he's a very clever man to talk to... I think the quieter Andrea gets , the better the system runs. When she's under control, everything else seems to fit in and go under control." (Urban male doctor 2.)
Some doctors, while meaning well, offered couple counselling: "I usually get them in together first off and just play round with the words and just see whether she will accuse him in front of me... but I usually don't want to accuse a man. Was he guilty of it?" (Urban male doctor 3.) However, this is contraindicated because of the associated risks.7
A few case study doctors did not want to intervene in a couple, and so overlooked the violence. This might occur because the husband's illness required his wife's care (as in the case below), because the doctor-patient relationship was vested in the couple or family as a unit, or because the doctor did not want to lose them as patients. "It doesn't seem right to do it , because he's behaving himself at the moment. And I don't think, why bring up a new critical aspect to his life while he's staying off the grog and looking after his health." (Urban male doctor 2, elderly couple.)
Invisible children
"I had one, just recently, how old was she?... seven. And this mother was saying very clearly, it's not affecting the kid. And yet she was a bed wetter, and she had lots of the classic symptoms... She said, well, I hate it when mummy and daddy fight. And then I said what do you do? I hide in the cupboard, and I take Jack with me. She had this whole behaviour, a way of protecting herself and her brother, who was about two, of getting into cupboards. (Rural female doctor 3.)
With attention firmly on the adult relationships, most doctors (with the exception of the doctor above) overlooked the impact on children. One concern was the potential jeopardising of the doctors' professional relationship with the child's parents: "You get that close to them and how difficult it is then to turn around and accuse them or suggest to them that they're damaging their child." (Rural female doctor 2.)
Some doctors felt that they had no management skills for children's psychosocial issues. Many did not trust child protection services and were unaware of therapeutic services to assist children.
Disclosure, counselling, and referral
When domestic violence is suspected, doctors are advised to ask directly, inform the women of her options, support her, and refer her to specialist agencies.7 Particularly in rural areas, few agencies exist to which general practitioners can refer patients. Furthermore, doctors are often unfamiliar with those agencies relevant to victimised women, men who abuse, and least of all children. The absence of or ignorance about such agencies could sometimes be compounded by distrust of specific services. Some doctors expressed reservations about the benefits of referral, and little published evidence exists about whether intervention is beneficial or harmful to women or children in the longer term.8 Supportive counselling was the most common strategy doctors used. Insufficient time; absence of appropriate training, debriefing, or supervision; and unfamiliarity with or lack of trust in community based agencies all raised doctors' stress levels, which could lead to a reluctance to identify patients: "Sometimes myself I get depressed and frustrated, I don't know what to do... sometimes you ask yourself, did I do the right thing or not? Did I help or did I make it worse?" (Urban female doctor 1.)
Discussion
Eisenstat SA, Bancroft L. Domestic violence. N Eng Med J 1999;341: 886-92.
Hegarty K, Bush R. Prevalence and associations of partner abuse in women attending general practice: a cross sectional survey. Aust NZ J Public Health 2002;26: 437-42.
Oriel KA, Fleming MF. Screening men for partner violence in a primary care setting: a new strategy for detecting domestic violence. J Fam Pract 1998;46: 493-8.
Webb E, Shankleman J, Evans MR, Brooks R. The health of children in refuges for women victims of domestic violence: cross sectional descriptive study. BMJ 2001;323: 210-3.
Ferris LE, Norton P, Dunn EV, Gort EH. Clinical factors affecting physician's management decisions in cases of female partner abuse. Fam Med 1999;31: 415-25.
Richardson J, Coid J, Petruckevich A, Chung WS, Moorey S, Feder G. Women who experience domestic violence and women survivors of childhood sexual abuse: a survey of health professionals' attitudes and clinical practice. Br J Gen Pract 2001;51: 468-70.
Sassetti M. Domestic violence. Primary Care 1993;20: 289-305.
Wathen NC, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289: 589-600.
Yin R. Case study research: design and methods. Second ed. California: Sage, 1994: 171. (Applied Social Methods Series, vol 5.)
Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage Publications, 1990.
American Medical Association diagnostic and treatment guidelines on domestic violence. Arch Fam Med 1992;Sept(1): 39-47.
Adams D. Guidelines for doctors on identifying and helping their patients who batter. J Am Med Womens Assoc 1996;51: 123-6.
Mintz HA, Cornett FW. When your patient is a batterer: what you need to know before treating perpetrators of domestic violence. Postgrad Med 1997;101: 219-28.
Ferris LE, Norton PG, Dunn EV, Gort EH, Degani N. Guidelines for managing domestic abuse when male and female partners are patients of the same physician. JAMA 1997;278: 851-7.
Edleson J. Domestic violence and children. Future Child 1999;9(3).
Johnson MP. Patriarchal violence and common couple violence: two forms of violence against women. J Marriage Fam 1995;57: 283-94.
Hegarty KL, Taft AJ. Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice. Aust NZ J Public Health 2001;25: 433-7.
Gerbert B, Abercrombie P, Caspers N, Love C, Bronstone A. How health care providers help battered women: the survivor's perspective. Women Health 1999;29: 115-35.
Bensing JM, Van Den Brink-Muinen A, De Bakker D. Gender differences in practice style: a Dutch study of general practitioners. Med Care 1993;31: 219-29.
Bowker LH, Maurer L. The medical treatment of battered wives. Women Health 1987;12: 25-45.
Brandt Jr EN. Curricular principles for health professions education about family violence. Acad Med 1997;72(1, suppl): S51-8.
Warshaw C. Intimate partner abuse: developing a framework for change in medical education. Acad Med 1997;72(1, suppl): S26-37.
Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131: 578-84.(Angela Taft, research fel)