Recognising and Responding to Partner Abuse

A resource for general practices

Citation: Ministry of Health. 2003. Recognising and Responding to Partner Abuse: A resource for general practices. Wellington: Ministry of Health

Published in June 2003 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand

ISBN 0-478-25659-0 (Book)
ISBN 0-478-25662-0 (Internet)
HP 3642

This document is available on the Ministry of Health’s website:

Foreword

Partner abuse is an important health issue for New Zealanders. It is a significant cause of death and morbidity in our communities and is closely linked with child abuse. To date, addressing partner abuse has mostly concentrated on crisis intervention, however, we know that to make a difference intervention is needed at many levels. General practice can play an important role in identifying abuse early on, and in initiating appropriate help for those in need.

Along with the practical training being provided around New Zealand, this resource will help develop the necessary knowledge and skills for general practices in dealing with partner abuse. The following organisations are pleased to support this resource. It has been developed with input from key stakeholders to ensure it is relevant to general practice.

Acknowledgements

This document has been developed with input by the following:

Margaret Browne–Policy Research Advisor, Women’s Refuge

Dr Faye Clark–GP, Auckland – Doctors for Sexual Abuse Care (DSAC)

Liz Dilger–Practice Nurse, NZ College of Practice Nurses – NZNO

Jo Elvidge–Manager, Family Violence Project, Ministry of Health

Sheryl Hann–Policy Research Advisor, Women’s Refuge

Dr Clare Healy–GP Christchurch, President DSAC

Claire Hurst–Project Manager, DSAC

Terri Lambert–Practice Nurse, NZ College of Practice Nurses – NZNO

Alistair MacDonald–Programme Manager, Injury Prevention, ACC

Dr Lorna Martin–GP Rangiora, Chair Professional Development Committee, RNZCGP

Dr Michael Miller–GP Whangamata

Dr Marion Poore–Public Health Medicine Registrar, GP Dunedin, DSAC

Dr Helen Rodenburg–GP Wellington, President RNZCGP

Lynn Saul–Project Officer, RNZCGP

Developed February 2003, review 2005.

Contents

Foreword

Acknowledgements

Introduction

Key messages

Key facts

Partner Abuse Documentation Form

Risk Assessment

Risk of homicide

Risk of suicide or self-harm

Assessing children’s safety

Protecting children

Referral Agencies

Services for victims of abuse

Child abuse and parent support services

Services for perpetrators

Supporting Mäori Women Experiencing Partner Abuse

Recognition

Response

Referral

Document

Support and Follow-up for Victims of Abuse

Referral

Open door

Ensure there is a safety plan in place

Legal

Responding to Perpetrators of Partner Abuse

Basic principles

Lethality assessment with the perpetrator

Safety Plan: A Resource for Victims of Abuse

Avoiding injury, escaping violence

Preparing for separation – advance arrangements and flight plans

Living safely after separation

Protection Orders and the Domestic Violence Act 1995: Resource for Victims of Abuse

Domestic Violence Act 1995

Power and Control Wheel

Equality Wheel

Excerpts from Relevant Legislation

Crimes Act 1961

Domestic Violence Act 1995

Children, Young Persons, and Their Families Act 1989

Health Act 1956

Health Information Privacy Code 1994

Partner Abuse1

Introduction

Partner abuse, child abuse and elder abuse are collectively termed family violence. Partner abuse is the physical, sexual, verbal and emotional/ psychological abuse of current or past intimate partners, including same sex couples. Partner abuse can happen to either sex and in any socioeconomic, religious or cultural group.

Partner abuse tends to escalate in severity and can result in death. Failure to identify partner abuse early on can also result in multiple health care visits with incorrect diagnosis, costly and inappropriate tests and treatment, and ongoing morbidity.

To effectively reduce partner abuse intervention is needed at many levels. General practices can help victims of abuse because of the opportunities for early intervention that are presented.

To achieve this, those in general practice need:

  • knowledge about the dynamics of abuse and its health effects
  • skill and practice in asking and responding to disclosure
  • skills in safety assessment and documentation
  • knowledge of and ongoing relationships with local referral agencies
  • access to up-to-date patient resources
  • to have systems in place to ensure safety of victims of abuse, themselves and staff.

This resource covers how to ask about partner abuse, provide support, assess risk and discuss options. It is designed for use in conjunction with training that covers these areas.

Working with perpetrators of violence requires special skills and knowledge, and is therefore not covered in this resource. For information on referral services see Appendix 5, and for guidance if a perpetrator brings up abuse during consultation see Appendix 8.

Key messages

  • To identify abuse the first step is to ask questions and then offer help.
  • The aim is not to ‘fix the problem’ but to acknowledge the issue, inform the victim of abuse about options and support their decisions.
  • Family violence is NOT a private matter – it is a health issue that requires a health care response.
  • ‘Domestic violence flourishes because of silence, because the problem stays hidden, and in some subtle but powerful way ... acceptable.’ Esta Soler

Key facts

Studies indicate that:

  • both women and men experience abuse, however, the prevalence is higher for women (Langley et al 1997; Young et al 1997)
  • the majority of women do not object to routine questions about abuse (Ramsay 2002)
  • over a lifetime 15–35 percent of women experience abuse (Young et al 1997)
  • the co-occurrence of partner abuse with child abuse is between 30–60 percent (Ross 1996; Edelson 1999)
  • in 1994 the annual cost to health was estimated at $141,000,000 (Snively 1994; Young et al 1997).

Appendix 1

Partner Abuse Documentation Form

Date...... / Patient NHI......
Patient name...... / FV enquiry
Provider name...... / FV+ (positive)
Patient pregnant? / Yes / No / Due date...... / FV? (suspected)
Children? / Yes / No / Number......
Assess patient safety / Referrals
Yes / No / Is abuser here now? / Family violence agency number given
Yes / No / Is patient afraid of their partner? / Refuge number given
Yes / No / Is patient afraid to go home? / Legal referral made
Yes
Yes / No
No / Has physical violence increased in severity?
Has partner physically abused children? / Police called
In-house referral made
Describe
......
Yes / No / Have children witnessed violence in the home?
Yes / No / Is there a gun in the home?
Yes / No / Threats of homicide / Other referral made
By whom?......
Yes / No / Threats of suicide / Reporting
By whom?...... / CYFS referral
Yes / No / Alcohol or substance abuse / Police
By whom?......
Modified from the Family Violence Prevention Fund and Educational Programs Associates, Inc.

EXAMINATION (continued)

Recording GENERAL EXAMINATION – FRONT OF BODY

Normal (tick) / Abnormal (specify) /
Face
Eyes
Nose
Mouth
Ears
Neck
Shoulders
Breasts
Thorax
Upper arm
Lower arm
Hands
Abdomen
Upper leg
Lower leg
Feet
Measure, describe and show:
Abrasions
Lacerations
Areas of pain and tenderness
Fractures etc.
Sites of trace evidence
Tattoos, scars, birthmarks

EXAMINATION (continued)

Recording GENERAL EXAMINATION – BACK OF BODY

Normal (tick) / Abnormal (specify) /
Scalp
Ears
Neck
Shoulders
Back
Upper arm
Lower arm
Hands
Buttocks
Upper leg
Lower leg
Feet
Measure, describe and show:
Abrasions
Lacerations
Areas of pain and tenderness
Fractures etc.
Sites of trace evidence
Tattoos, scars, birthmarks

APPENDIX 2

Risk Assessment

Risk assessment ascertains the level of immediate risk to the health and safety of a victim of abuse. Health care professionals should conduct a preliminary risk assessment to help identify appropriate referral options. A detailed risk assessment can then be undertaken by agencies that specialise in responding to partner abuse.

This section outlines the primary risks associated with abuse, and how to respond to the risks.

It is best to work as part of a multidisciplinary team so enlist the support of social services or local family violence prevention advocates whenever possible.

Note: the presence of injuries or other evidence of abuse is not necessary before making a referral, particularly if there is risk to children. It is better to refer early to support agencies.

When making a preliminary assessment it is important to reassure the victim of abuse that:

  • you will not do anything to put the victim of abuse or their children in danger
  • there are support networks and services in place that can help them.

Risk of homicide

There is a strong association between prior abuse and later homicide for victims of abuse but no absolute indicators that can determine the level of risk.

An assessment should be made if the victim of abuse is minimising the problem or denying the extent of violence they have experienced. In general, the more factors that are present, the greater the risk.

Is there an immediate risk to health and safety?

  • Is the perpetrator present?
  • Is the victim of abuse afraid of their partner?
  • Is the victim of abuse afraid to go home?

Is there a high risk to health safety?

  • Are there life-threatening injuries?
  • Are children, older people or people with disabilities at risk?
  • Has a threat to kill or a threat with a weapon been made?
  • Has the victim of abuse recently separated from the abusive partner, or is considering separation?
  • Has physical violence increased in severity?
  • Does the perpetrator have access to weapons, particularly firearms?
  • Has there been past assault of strangers, acquaintances, family or animals?

Other factors to consider

  • Have there been threats of homicide?
  • Have there been threats of suicide?
  • Is alcohol or substance abuse involved?

Risk of suicide or self-harm

There is a strong association between partner abuse and suicide or self-harm. Signs associated with high risk of suicide include:

  • previous suicide attempts
  • stated intent to die or an attempt to kill oneself
  • a well-developed concrete suicide plan
  • access to the method to implement their plan
  • planning for suicide (for example, putting affairs in order).

Other factors that are frequently associated with the risk of suicide or self-harm may themselves be symptoms of abuse. These include depression, extreme anxiety, agitation or enraged behaviour, excessive drug and/or alcohol use or abuse. Ask directly if the victim of abuse is thinking about committing suicide, or has attempted suicide in the past. For example:

  • You sound really depressed. Are you thinking about killing yourself?
  • Have you hurt yourself before?
  • What were you thinking about doing to hurt/kill yourself?
  • Do you have access to (a gun, poison, etc)?

If the risk is high, refer to the appropriate mental health service and to a specialist family violence agency.

The most helpful way to reduce suicide risk may be to help make the victim of abuse safe from the abuse.

Note: Use caution when prescribing tranquillisers or antidepressants to victims of abuse. Some studies have indicated that these drugs are over prescribed to victims of abuse, and may place them at increased risk of more serious abuse. Treatment for any identified mental health disorders for victims of partner abuse should include:

  • addressing the abuse as a central part of treatment
  • identifying abuse is as a causative factor in their mental health problems.

Assessing children’s safety

If either partner abuse or child abuse is identified or suspected it is necessary to conduct a risk assessment to other family members because of the high co-occurrence of multiple types of violence within families. The emphasis is on keeping the child safe, and enabling the victim of abuse to get real and appropriate help. The following questions will help in making an assessment.

  • Does the perpetrator have access to the child(ren)?
  • Has the perpetrator ever hurt or threatened to hurt or kill the child(ren)?
  • Has the perpetrator ever removed or threatened to remove the child(ren) from the victim of abuse’s care?
  • Have the child(ren) ever witnessed partner abuse (physical or verbal) occurring?
  • Has the perpetrator hit the child(ren) with belts, straps, or other objects that have left marks, bruises, welts, or other injuries?
  • Has the perpetrator ever touched or spoken to the child(ren) in a sexual way?
  • Have the child(ren) tried to intervene to protect the victim of abuse from the perpetrator?
  • Were the child(ren) injured as a result?

You also need to assess the risk the victim of abuse may pose to the children. Ask the following questions.

  • When women are experiencing the sort of abuse you have described to me, it can affect their ability to parent in the way they would if they were free from abuse. Is this true for you?
  • Are you ever afraid that you might hurt your children?
  • Have you ever hurt your children?
  • Do you know what practical help there is to assist you?

This will provide some information about the child’s safety, but further information from other sources (eg, grandparents, other family members or Child, Youth and Family) may be needed. Always document what you have been told and consult with experienced colleagues if you have concerns about child safety.

Protecting children

Any concerns about the safety of children should be discussed with the victim of abuse by following these principles.

  • Broach the topic sensitively.
  • Help the parents/caregiver feel supported, and able to share any concerns they have with you.
  • Help them understand that you want to help keep the child safe, and support them in their care of the child.
  • Keep the parents informed at all stages of the process.
  • Where options exist, support the parents/caregivers to make their own decisions.
  • Involve extended family/whänau and other people who are important to them.
  • Be sensitive to, and discuss the patient or caregiver’s fears about approaching other agencies such as police, social services, hospital staff, social workers and other agencies.

If available, consult with social services or specialist child protection team.

Do not discuss child safety if this places either the child or you, the health care provider, in danger. The family may close ranks and reduce the possibility of being able to help a child. The family may seek to avoid child protective agency staff.

Your role is to keep the child safe. You can consult with Child, Youth and Family at anytime and do not need to seek permission. If you or your colleagues decide to make a report to Child, Youth and Family, the victim of abuse should be informed.

Actions taken to protect the child may place the victim of abuse at risk. Always refer the victim of abuse to specialist family violence support services, and inform Child, Youth and Family about the presence of partner abuse as well as child abuse.

  • Ask the victim of abuse how they think the perpetrator will respond.
  • Ask if a child protection report has been made in the past, and what the perpetrator’s reaction was.
  • If the perpetrator is present in the health care facility, ask the victim of abuse whom they would like to tell the perpetrator about the report. For example, would they like the health care provider to do it? Does the abused partner want to be present when the abuser is told? Do they want to do it?
  • Make sure the victim of abuse has information on how to contact support agencies (for example, the police, Women’s Refuge, Child, Youth and Family).

Refer to Ministry of Health 2001, Recommended Referral Process for General Practitioners: Suspected child abuse and neglect for further information on dealing with suspected child abuse.

APPENDIX 3

Referral Agencies

External referral agencies are vital in providing support to identified or suspected victims of family violence. It is strongly recommended that you or your agency meet and develop referral relationships with local staff from the organisations listed here, before using this guideline.

It is vital that health care providers have knowledge of the people and groups within their local community who possess the necessary knowledge and skills for working with Mäori women and children who are victims of violence. This includes Mäori family violence prevention advocates and services.

Services for victims of abuse

Women’s Refuge

The National Collective of Independent Women’s Refuges is a network of 51refuges covering all urban and rural areas across New Zealand. Women’s Refuge is one of the key services for women and children, as it provides 24-hour access to emergency and longer-term safe housing for women and children and runs a 24-hour crisis line. In addition to shelter, refuge workers can offer counselling to women, and can put them in touch with other support agencies, including women’s support programmes, explain legal rights, help them apply for emergency funds, and go with them to a lawyer, police, or court for support. These services are available to any woman who is fearful of her partner or other family member. Women do not have to have experienced physical abuse before a refuge will help them.

Local telephone books will provide contact details under the Personal Help section at the front or under ‘Women’s Refuge’. In an emergency, Women’s Refuge can be contacted through the police.

Comprehensive information about Women’s Refuge services, legal and social services, and understanding the dynamics of family violence is available from the Women’s Refuge website

Culturally matched services

Women’s Refuge runs Mäori refuges parallel with general refuges. In Auckland there are Pasifika refuges and an Asian and Migrant Women’s Refuge which provides a 24-hour phone line with Refuge advocates who speak Asian, Middle Eastern and African languages (0800 SHAKTI/ 0800 742 584 from anywhere in New Zealand or 636 8512 within Auckland). Check for culturally matched services in your area.

Doctors for Sexual Abuse Care (DSAC)

DSAC is a national organisation of doctors, formed in 1988, to advance knowledge and improve standards for medical care of the sexually abused. DSAC doctors are specially trained in the sensitive treatment of sexually abused patients, and in the collection of forensic evidence, if required. Ph:(09)3761422.