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Understanding and identifying domestic abuse

Abuse within the home can take many forms and is often hidden from outsiders. Nurses in primary care have an important role in supporting the vulnerable

On 14th June 2013, Charles Saatchi, art collector and former advertising executive, sat at a table outside a restaurant in Mayfair with his wife Nigella Lawson, celebrity cook and food writer. Unknown to them, they were being watched by a photographer who was hidden from their view. The resulting pictures appeared to capture an assault by Saatchi on his wife and provoked a media storm. The sight of Lawson's distress as her husband held her by her throat provoked horror and outrage. Overnight the domestic goddess became a symbol for victims of domestic violence. Saatchi subsequently accepted a police caution for assault, his wife left the family home with her children, and in the ensuing divorce proceedings cited her husband's “continuing unreasonable behaviour” as the grounds on which she sought to end her marriage.

While speculation about Saatchi and Lawson was rife, charities supporting victims of domestic violence and abuse reported increased contact both through their helplines and in traffic to their websites. The extensive media coverage served to raise public awareness of some significant issues relating to domestic violence:

 - It is life-threatening: on average, two women are killed each week, and one man every 17 days.1

 - It is rarely confined to a single incident: women are assaulted around 35 times before seeking help.2

 - It can affect anyone, regardless of socio-economic background, class or professional status.

 - It occurs among people of all ethnicities, whatever their religious beliefs, age, gender, sexuality or ability.

 - It involves controlling and/or coercive behaviour which may result in physical, psychological, emotional, sexual and/or financial abuse.

 - It may coexist with, or be a risk factor for, child abuse or elder abuse within a family.

The government recently implemented an updated definition of domestic abuse, defining it as: 'Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality'. Controlling behaviour is defined as 'A range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape, and regulating their everyday behaviour'. Coercive behaviour is defined as: 'An act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim'. The definition includes culturally-motivated violence such as female genital mutilation and forced marriage.3

This extended definition is significant as it recognises: 

 - The range of abuse to which victims may be subjected.

- The fact that domestic abuse is a serious issue in teenage relationships.1

Domestic violence and abuse represent a major health and social care issue that can have a devastating impact on the lives of those affected. Consequences to health and wellbeing include:

- Physical injuries, which may be severe and result in disability or death.

- Mental illness and psychological disorders, including addictions and substance misuse, and increased risk of suicide.

- Complications in pregnancy with risks to the unborn child such as miscarriage, low birth weight, fetal injury or death.

- Serious impairment of a mother's parenting ability and attachment to her baby.

- Significant risk of actual physical, psychological and/or developmental harm to children who experience or witness abuse.

Nurses working in primary care are among those health professionals who have a crucial role in identifying and, where possible, preventing domestic abuse. Early intervention and appropriate support are key to reducing the risks of ongoing harm within the families affected. This can only be achieved if screening for domestic abuse is integral to any assessment of risk factors within a family and begins at the earliest opportunity. Midwives are among those who routinely raise this issue with expectant mothers, usually at the booking appointment. However, a lack of awareness by health professionals, including nurses, is a critical obstacle to providing help and support where it is most needed.4 In order to be effective, nurses must have appropriate training to develop the skills and confidence to: 

- Recognise potential physical or psychological signs of abuse; for example, unexplained injuries at different stages of healing, persistent anxiety, or self-harming behaviour.5

 - Ask questions sensitively.

- Respond appropriately to any disclosure, from perpetrators as well as victims.

- Identify when urgent action is required to safeguard children and/or adults.

- Share information with relevant personnel and agencies, recognising the limits of patient confidentiality when adults or children are at significant risk of harm.6

You should be familiar with relevant procedures and resources, including your local Multi-Agency Risk Assessment Conference (MARAC). The MARAC toolkit for health visitors, school nurses and community midwives includes a checklist to identify high risk adults and/or children for referral.7 Checklists are not infallible: your professional judgement is crucial in determining the extent of risk to your patient, as is the victim's own perception of their risk. 

Most abuse goes on, unreported, behind closed doors but there may be signs that one partner is exerting control over the other's actions and activities even when they are not physically present. The perpetrator may isolate the victim from friends and family, take control over finances, and prevent them from working. They may also be reluctant to let their partner see a health professional on their own. Wherever possible you should create an opportunity to be alone with a suspected victim, and in the case of people who do not speak English, ensure that a suitably trained and independent interpreter is able to assist you. Do not rely solely on family members to interpret for you. Even after disclosing abuse, many victims either do not wish to leave the abusive relationship, or find it hard to do so. Reasons include: 

- The profoundly low self-esteem induced in victims, which generates a lack of confidence in their ability to seek and sustain an alternative life.

 - Belief in threats that they or their children will be hurt or killed.

 - Lack of confidence in the ability of the police to protect them.

 - Concern about how they will survive financially. 

 - Women who abuse their male partners may prevent them from leaving by threatening to expose real or fabricated sexual preferences or orientation, or threaten to prevent them having access to their children by denouncing them as abusive. 

Providing victims with expert advice and support is the remit of a trained Independent Domestic Violence Advocate (IDVA), but if you are the first person abuse is disclosed to, it is essential to have a good understanding of how a victim can be supported if they leave their abusive partner. Local details vary, but in general victims who intend to leave their abuser need:

 - An immediate physical refuge at a protected address. 

- Arrangements for their children; for example, new schools or childcare.

- Access to emergency financial support and state benefits.

- Healthcare, including management of any mental health problems. 

- Legal advice.

- Options for rehousing.

- Empowerment, so that they can take control of their lives and make decisions about their future.

In families where domestic abuse is suspected, the safety of any children must be paramount. Death or serious injury may occur if appropriate intervention is not timely. 

The behaviour of children exposed to domestic violence varies according to the age of the child but in babies and young children may result in:

- Excessive crying.

- Poor sleep.

- Irritability.

- Fear.

- Failure to thrive.

In older children problems include:

- Poor educational attainment.

- Involvement in juvenile crime.

- Anxiety, depression and low self-esteem.

- Substance misuse.

- Self-harming.

- Aggressive behaviour.8

Experiencing domestic abuse in childhood may have lifelong consequences, resulting in victims enduring abusive relationships as adults or becoming perpetrators themselves. You can help to break this downward spiral. Through early recognition and prompt action nurses can make a significant difference to the lives of those affected by, or at risk from, domestic violence and abuse.

 

Resources

Women's Aid - directory of services for each region of the UK

National Domestic Violence Helpline for assistance with refuge

accommodation and advice 

0808 200 0247

Men's advice line 

0808 801 0327

'Honour' Helpline - forced marriage and 'honour' based violence 

0800 599 9247

Rape and Sexual Abuse Support Centre 

0808 802 9999

Broken Rainbow - lesbian, gay, bisexual and transgender victims 

0845 260 4460

'Respect' phone line for people who are abusive or violent towards their partners 

0808 802 4040

Department of Health. Improving Safety, Reducing Harm: Children, young people and domestic violence. A practical toolkit for front-line professionals. London: Department of Health, 2012.

HM Government. Multi-Agency Practice Guidelines: Female Genital Mutilation. Crown Copyright, 2011.

 

References

1. Crime Survey for England and Wales (formerly British Crime Survey)

2. Yearnshire S. Analysis of cohort. In: Bewley S, Friend J, Mezey G. Violence against women. London: RCOG press; 1997.

3. Home Office. Domestic violence and abuse: new definition.

4. Richardson J, Coid J, Petruckevitch A, et al. Identifying domestic violence: cross sectional study in primary care. BMJ 2002;324:274-9.

5. Riggs DS, Caulfield MB, Street AE. Risk for Domestic Violence: Factors Associated with Perpetration and Victimization. Journal of Clinical Psychology 2000;56:1289-316.

6. United Kingdom Council of Caldicott Guardians. “Striking The Balance”: Practical Guidance on the application of Caldicott Guardian principles to Domestic Violence and MARACS. London: Department of Health; 2012

7. CAADA (Coordinated Action Against Domestic Abuse). MARAC toolkit. 

8. Abell S. Domestic Violence: Its Impact on Children. Clinical Pediatrics 2008;47:413-415.