Commentary: The Clinician's Role in Face of Domestic Violence

Article excerpt

Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients' autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.

Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.

Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.

What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual's ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails overrational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.

Domestic violence--which thrives in the secrecy and isolation of the violent couple or family--also can contribute to feelings of shame, embarrassment, denial, and self-blame--all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.

Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. …