Health practitioners' role in alleviating domestic and family violence

Health practitioners hear about — and handle the repercussions of — family and domestic violence more than any other professional, yet many feel they are only modestly equipped to support survivors.

Broadly, healthcare workers know to Listen, Inquire, Validate, Enhance safety, and Support, as per the World Health Organization LIVES model. They also know to give patients Choice and control, Advocate for them, Recognise and understand, and show Emotional empathy (CARE).

However, Professor Kelsey Hegarty, Director at the Centre for Family Violence Prevention at the Royal Women’s Hospital, who helped create the LIVES guidelines, believes current interventions are a “drop in the ocean” and that health workers need more support in tackling this pervasive issue.

Health impacts

Alongside the emotional cost to survivors, the disease burden of family and domestic violence is significant.

For child-bearing women, it is the leading cause of death and disability; and generally, it is a major contributor of PTSD, depression, anxiety and acquired brain injury.

Women are most at risk of being targeted — and of falling prey to health complications. Thirty-six per cent of women aged over 18 have experienced physical or sexual violence since the age of 15; and of those, 22% have been physically assaulted during pregnancy. Women survivors of sexual violence are also less able to protect themselves against sexually transmitted infections.

Alongside immediate health risks, the long-term sequelae of abuse can include chronic conditions like stroke and heart disease, Hegarty said.

“It’s certainly not only black eyes that occur. Imagine what walking on eggshells every day for years and being in an enduring state of fight or flight could do to your health,” she said.

The role of health workers

Given the health repercussions, Hegarty says the role of clinicians in addressing family and domestic violence is clear. However, she believes there may be misconceptions about what exactly that role entails. Too often, the emphasis is on getting a disclosure and not on the quality of the patient–practitioner relationship, she said.

“When we talk to a patient who we suspect might be experiencing family or domestic violence, we shouldn’t do so solely with the purpose of getting a disclosure. Really, it’s about signalling to the patient that family violence is health work; and that the health setting is a good place for them to seek support — even if they don’t disclose on that occasion.”

The right verbal and non-verbal communication is critical to this approach, she added.

“When you enter a conversation about family and domestic violence, you need to be gentle and non-judgmental. The idea is to project that you are someone patients can trust and who genuinely cares about them. This is achieved though body language, tone of voice and choice of words.”

While health workers are often skilled and experienced in handling sensitive topics with patients, conversations around domestic and family violence may require scripting.

“Phrases like, ‘tell me about your relationship — I’m interested because relationships affect your health’, or ‘often in relationships things can happen that make you scared’ are good because they are not too confrontational,” Hegarty said.

Beyond these initial discussions with patients, staff also need to recognise where their own clinical behaviours might be triggering for people with a history of trauma.

Medical gaslighting — where patients’ experiences of physical and mental health problems are minimised — is a prevalent issue, and may be particularly distressing for people with a history of psychological abuse. In intimate relationships, abusers often use gaslighting to downplay their own transgressions.

Systemic conditions

Regardless of how well trauma-informed individual clinicians are, change won’t happen without the right systemic conditions, Hegarty argued.

“If there is a large bullying culture in the workplace, then staff will find this work hard. Or, if staff have their own experiences of domestic and family violence — which many do — they might struggle if not supported,” she said.

With this in mind, healthcare institutions should have clear policies in place for handling domestic and family violence — among both employees and patients.

“A successful program is run at the organisational, staff and patient level. Clinicians who find this work distressing will need to be supported by their employer. There should also be confidential spaces, a positive working culture, and very clear policies and protocols.”

Beyond these measures, a focus on quality assurance is also important. To this end, Hegarty and team have developed an audit to help identify gaps at the system and institution level.

“It’s important to check in and see how your institution is doing in this area. You might be training your staff, but did everyone attend? And of those who did, who actually listened?

“The hallmark of a successful program is where all staff exemplify trauma- and violence-informed care in their daily work,” she concluded.

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