NEW ORLEANS ― One in 4 women and 1 in 7 men in the United States have experienced severe physical violence by an intimate partner at some point in their lifetime ― but despite these statistics, a focus on intimate partner violence (IPV) is missing from healthcare, experts say.
IPV is defined by the Centers for Disease Control and Prevention as physical or sexual violence, stalking, or sexual aggression ― including coercive tactics, such as withholding of money and social isolation ― by a current or former intimate partner.
“Something to remember when you’re counseling patients is that intimate partner violence can also be psychological aggression,” Obianuju “Uju” Berry, MD, MPH, instructor of Psychiatry at Columbia University Medical Center in New York City, told delegates attending the Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. “It’s not always just physical violence that can lead to the fear and hyperawareness that most of our victims experience.”
Risk factors for IPV are varied and complex, but lack of social support is a recurring theme among victims, particularly in immigrant communities, owing to social isolation and the absence of an established support system, said Dr Berry.
According to Mayumi Okuda, MD, moderator of the session and psychiatrist at Columbia University Medical Center, many states have found that the main predictor of a woman being able to leave an abusive relationship or being able to bring charges against the perpetrator is the existence of a support network and resources.
Victims of abuse need advocates to help them navigate stressors, such as the need to acquire food, housing, and health insurance. “We’ve found that many of the ways abusive partners control and perpetuate this ongoing abuse is by isolating their partners. The key is to make sure that, first, we’re addressing the issue of support around this person,” she said.
She also emphasized the fact that the the most dangerous time for a woman might be the moment she leaves a violent partner, because the violence can escalate at that point. “It’s also very important for us to keep a humble stance of understanding that, for the most part, many of these women are the experts in their own lives,” said Dr Okuda. “They are managing and finding a way to keep themselves and their families safe.”
Impact on Health
The mental repercussions of IPV can manifest in physical trauma, psychological trauma/stress, and fear/loss of control. “The worst-case scenario is death, but disability occurs first,” said Dr Berry.
Victims are not only at risk for disability from physical injury but also for psychological sequelae, such as posttraumatic stress disorder, anxiety, substance use, self-harm, eating/sleep disorders, depression, and decreased reproductive capacity (caused by loss of control as to the decision to have children or an abortion). Often, multiple mental health disorders coexist in these victims.
“IPV used to be seen as a family concern ― it wasn’t something physicians worried about ― but now, more and more, we’re realizing it’s a public health problem,” she said.
The collective understanding of IPV in a mental health context has been slow, she added. One of the main reasons for this is that IPV training is severely lacking. Healthcare providers do not know how to ask about it. Providers might also fear the consequences of asking, because they may feel they could offend or retraumatize the patient, or they may worry that broaching such a sensitive subject might take too much time.
A 2005 study of IPV screening in healthcare settings found that only 15.5% of physicians reported screening for IPV, and only 35% of recently graduated psychiatrists believed IPV training was relevant to their practice. A 2008 study found that 95% of 243 clinical psychology PhD programs reported no violence-related coursework, and the 5% that did report such coursework did not require it. “But again, 1 in 4 women report physical violence in their lifetime,” she stressed. “These victims are prevalent in our caseloads.”
Client barriers to disclosure often stem from the hidden nature of IPV. Many victims do not even realize they’re being abused, she said. Some fear being retraumatized, shamed, or embarrassed. Others fear violent repercussions from their aggressor, and some are not ready to talk about it.
In addition, Dr Berry noted, “In the current environment, we’re finding that more people are not disclosing domestic violence because of fear of being deported. National policies do have an effect on our clients disclosing and on our ability to help them.” Immigrant and minority women face language barriers and may be unaware of the laws that protect them. They often fear that their partners, if reported, might be incarcerated, deported, or killed.
Doing More for Victims
Regarding IPV, “right now, we’re working in silos,” said Dr Berry. “But what we’re realizing is those silos aren’t working anymore; they’re not helping anyone.” She emphasized the need for integrated teams composed of mental health providers and advocates. “And even if you don’t work in the psychiatry field, it does behoove you to ask your patients if they have been a victim of violence,” she noted. “It could shape how you move forward.”
She and her colleagues developed the Domestic Violence Initiative at Bronx Family Justice Center (BXFJC) in New York City, aimed at providing psychopharmacologic and specific psychological services to IPV victims in a culturally sensitive and trauma-sensitive manner. They provide training for BXFJC staff and partner agencies in mental health topics relevant to IPV populations, with the goal of advancing knowledge of IPV in psychiatry.
“Our domestic violence initiative was able to target a lot of the barriers faced by victims of IPV,” she said. The group champions evidence-based medicine, and all services are provided free of cost. Services include evaluation, consultation with IPV counselors, psychotherapy, and psychopharmacologic treatment.
Their goal is to create a referral network. “These are highly traumatized clients who need longer-term care, but because we’re a very acute service, we can’t provide care for everyone,” she said. She noted that up to 40% of their clients report a prior suicide attempt.
The New York City government supports the program, and through Thrive NYC, a major public health initiative, they have expanded the pilot program to the boroughs of Manhattan, Staten Island, Queens, and Brooklyn.
Dr Berry and her colleagues seek to establish and demonstrate cost-effectiveness to scale up the program even more. “We want to make sure city and federal governments want to take this under their initiative and provide more funding for it,” she said.
Dr Berry and Dr Okuda have disclosed no relevant financial relationships.
Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. Presented October 22, 2017.
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