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II. Victim Profile
III. Clinical Findings
IV. When to Suspect Spousal Abuse
V. Cycle of Violence
There are multiple names for spousal abuse placed within the realm of intimate partner violence. According to Martin (1988) the definition of battering which is part of spousal abuse is the affliction of injury or physical pain intended to cause harm from punching, slapping, biting, and hair pulling. More serious assaults may include choking, kicking, breaking bones, stabbing, shooting, or forcible restraints. Campbell and Humphreys (1993) also define battering as repeated physical and/or sexual assault of an intimate partner within the context of coercive control. Gelles and Straus (1988) point out that most women who hit men do so in self-defense, while most physical abuse is initiated by men. Women, due to their smaller size and lesser strength, are more prone to serious injury and death as a result of male-initiated violence (Browne and Herbert 1997). Sadock (1989) describes spousal abuse as the mistreatment or abuse of one spouse by another. She describes injuries ranging from shoving and pushing to choking and severe battering. These victims may suffer from broken limbs, fractured ribs, internal bleeding, and brain damage. Injuries may also be inflicted on the face, breast, and, if the woman is pregnant, the abdomen. A woman is battered every fifteen seconds, and battering in the United States is the leading cause of injury to women between the ages of fifteen and forty-four. An epidemic of spousal abuse is occurring in the United States due to the frequency of battering among spouses or significant others.
Dickstein and Nadelson (1989) describe battered women as representing all age, racial, educational, religious, and social/economic groups. They may be married or single, business executives or housewives. Walker (1979) points out that women who are battered tend to have low self-esteem, commonly adhere to feminine sex role stereotypes, and frequently accept blame for batterers’ actions. They commonly exhibit feelings of fear, anger, shame, and guilt and may be isolated from family and support systems. Many of these victims grew up in abusive homes, and may have left those homes and even married at a very young age in order to escape the abuse. Other symptoms of abuse may include withdrawal from socializing, self-blame, denial of abuse, and making excuses for the abuser. These abused individuals may also wonder, ‘‘What did I do to make him react so violently?’’ and their families may reinforce this self-questioning.
According to Campbell et al. (2003), most women will stay with their male abusers because of children, financial problems, fear of living alone, emotional dependence on the abusers, a belief that divorce is shameful, and/or a fear of reprisals from the abusers.
Most battered victims view their relationships as male dominated; and as the battering continues, a victim’s ability to recognize the options available to her and to make decisions regarding her life (and possibly the lives of her children) develops into a phenomenon of learned helplessness. This phenomenon occurs when an individual fails to understand that regardless of his/her behavior, there is usually an undesirable and/or unpredictable outcome. According to Barnett (2001), women will mainly stay in fear for their lives or their children’s lives as the batterer gains more power and control with the use of intimidation (i.e., making threats such as ‘‘I’ll kill you and the kids if you don’t do as I say’’). As they continue, these threats compound the victim’s low self-esteem and she sees no way out of her situation. She may try to leave, only to return and be confronted by her abuser and the psychological power he holds over her, or murdered when attempting to leave or after having left. Other authors, such as Moss (1991), cite three more reasons for a woman staying in the marriage: a lack of a support network for leaving, religious beliefs, and a lack of financial independence to support herself and her children.
Health care providers see a panoply of behaviors from abused women. The clinical picture of these victims will include physical, emotional, and psychological injuries. Most victims are treated in the emergency room for physical injuries. Assessment for intimate partner abuse should be mandatory and take place in whatever setting the victim chooses to seek help. When no injuries are obvious, assessment for abuse is best handled with a history about the victim’s intimate partner relationship. Several themes expressed by victims who have been in spousal abusive relationships have been identified by Hall (2003) and Smith (2003). These include relational authenticity deficits, immobility, emptiness, and disconnection. Answers to questions about these types of relationships should be assessed for feelings of being controlled or needing to control. A relationship is more likely to be violent when it is characterized by a partner’s excessive jealousy, emotional immaturity, neediness, strong feelings of inadequacy, low self-esteem, and/or poor problem-solving and social skills (Hattendorf and Tollerud 1997).
The victim may be asked about how the couple solves their problems; if one partner needs to have the final say or uses forceful verbal aggression, this partner can also be considered abusive and possibly dangerous. Another approach would be to ask the individual whether the couple’s arguments involve ‘‘pushing or shoving.’’ As the interview continues, questions about violence within the relationship help to normalize the patient’s experience and lessen the stigma of disclosure. If the patient hesitates, looks away, or displays similar nonverbal behavior, or reveals risk factors for abuse, he/she may be asked again later in the interview about physical violence (Poirier 2000). A number of clinics, hospitals, and doctors’ offices ask women about safety issues as part of the overall health history or intake interview.
Due to the delicate and sensitive nature of the topic, and with many abused women being embarrassed about admitting to a problem, health care workers must be careful with their questioning approach. One technique used is the SAFE (Stress/ Safety, Afraid/Abused, Friends/Family, and Emergency Plan) technique. The first two categories (Stress/Safety, Afraid/Abused) are designed to detect abuse. If abuse is present, questions in the other two categories are asked of the patient. Ashur (1993) notes that the usefulness of these questions allows the health care provider to paraphrase or edit them as needed for any given situation. If abuse is revealed from questioning, the health care provider’s first response is critical. An abused woman should realize that she is not alone and should not be afraid to reveal the frequency of the abuse. Careful recording is essential in order to identify the extent and type of abuse, along with documentation using a body map to identify the location of contusions, bruises, or cuts for potential legal actions related to the violence. Other recordings of old and new injuries must be documented, and obtaining the patient’s permission to take x-rays as well as photographs is essential. The health care provider must also obtain the abuser’s name and how the abuser injured the patient, taking direct quotes from her. Inclusive with this is educating the patient about abuse and giving her referrals to social services, as well as reassuring her that confidentiality will be maintained (Berlinger 2004).
Janssen, Holt, and Sugg (2002) indicate that the health care provider has an ethical duty to diagnose and treat domestic violence victims, pointing out that some health care providers have been held liable in the past for failure to ask about abuse. Introducing the concept of domestic violence is an overlooked health issue and has been compared to ‘‘opening Pandora’s box.’’ Unlike other health risks for which providers order routine screening, exposure to spousal abuse is known to be often avoided due to exposure to embarrassing situations. The excuse often given is that the health care provider does not feel competent in dealing with abuse once it is identified (Sugg 1992). Battering during pregnancy often leads to miscarriage and stillbirth, as well as future psychological and physical problems for the woman (Mattson and Rodriquez 1999; Scobie andMcGuire 1999).Because of this likelihood, assessment forms for abuse screening are often included in patient charts and initiated on the arrival of the patient to the postpartum unit from the delivery suite.
When to Suspect Spousal Abuse
The health care provider should suspect spousal abuse in any patient with the following characteristics:
- Presents with unexplained bruises, lacerations, burns, fractures, or multiple injuries in various stages of healing (particularly in areas normally covered by clothing).
- Delays seeking treatment for an injury.
- Appears embarrassed, evasive, anxious, or depressed.
- Has a partner who is reluctant to leave the victim alone and is domineering and uncooperative, or insists on answering all of the questions for the patient (though one should also keep in mind that some abusers are excessively solicitous of the victim).
- Says her partner has a psychiatric history or problems with alcohol or drugs.
- Has injuries that do not reflect the nature of her ‘‘accident.’’
- Expresses fear about returning home or fear for her children’s safety.
- Talks about harming herself.
The health care provider interviewing a patient in a case of suspected abuse should trust his or her instincts even when these characteristics are not present. It is important for the safety and care of the patient that she is given assurance of confidentiality and that the abuser will not be made aware of any information shared with the provider. The heath care provider should keep in mind his or her own nonverbal behavior, including facial expressions that reflect sincerity. It is important to ask open-ended questions of the patient in an empathetic, nonjudgmental manner. One of the key attributes of the provider is being a good listener. The provider should offer written materials on the phases and progression of abuse, characteristics of victims and abusers, and the reasons victims stay. It is important for the victim to devise a safety plan and discuss with her provider the effects of abuse on the children in the home (Berlinger 2004).
Cycle of Violence
Battery may include violent sexual assault as well as physical violence. It may go on for days, after which the abuser may be extremely apologetic, promising to never do it again. This pattern is endemic of the cycle of violence. According to Walker (1979), the cycle of violence has three phases. The first phase is the tension-building phase, in which the woman senses an exacerbation of the man’s frustration. He becomes angry with little provocation, but after lashing out at her may be quick to apologize. At this point the victim may become very compliant and nurturing, trying to anticipate his every whim in order to prevent his anger from escalating. Minor battering incidents may occur during this phase, and in a desperate attempt to avoid more serious confrontations, the woman accepts the abuse as being legitimately directed toward her. Her ability to reason is impaired when she assumes the guilt for the abuse. The battering incidents continue to escalate as the tension mounts and the woman waits for the inevitable explosion. This first phase might last from a few weeks to even years. As the phase intensifies, the victim becomes greatly impaired by not recognizing that the abuser’s jealousy and possessiveness has increased along with threats of abuse and brutality to maintain control and captivity of her.
During the second phase of the cycle of violence, the battering phase, the most violent behavior occurs, lasting for the shortest duration. A triggering event occurs, and violence most often begins with the batterer justifying his behavior to himself, though in reality he has lost control. It might begin with the batterer wanting to ‘‘teach her a lesson’’ or the woman intentionally provoking the behavior of the abuser. The woman will often initiate the battering phase when the situation has become unbearable, knowing that once it is over, things will be better. During this phase the beatings are severe, and physical damage will occur. Drugs and alcohol may be involved with this phase of the cycle of violence. The victim survives by dissociating from her body despite the severity of the abuse. Help for the victim is usually sought only if the injury is severe or the woman fears for the lives of herself and her children.
The apologetic phase, the third and final phase of the cycle of violence, is actually the so-called honeymoon phase, during which the batterer becomes extremely loving and contrite. The abuser makes apologies and promises in order to win the forgiveness of the victim, changes his behavior, and exhibits every bit of charm he can muster. The batterer believes he can now control his behavior, and since he has taught his victim a ‘‘lesson,’’ he believes she will not act up again. The victim’s feelings are played on by the abuser and she desperately wants to believe that she can change his behavior. Magical thinking is used by the victim, who focuses on the loving phase of the relationship and hopes against hope that the previous battering phase will not be repeated. This third phase may last briefly and may be almost undetectable—in most incidences the cycle all too soon begins again.
Women and men need to understand this cycle of violence and be willing to leave if abused, or have the abusive spouse seek help. Lore and Shultz (1993) conclude that there is evidence to suggest that social pressure may be used on abusers to help them control their behavior. Overall, the health care professional must be aware of the signs of abuse through careful observation of the individual and her spouse, since many victims overuse the health care system with multiple pre-hypochondriacal complaints. Many of the symptoms of emotional and physical abuse include atypical chest pain, asthma, recurrent headaches, somatic complaints with no identifiable cause, eating disorders and other gastrointestinal complaints, anxiety/panic attacks, depression, drug overdose, forgetfulness, hopelessness/suicide attempts, guilt, low self-esteem, sleep disturbances, and an inability to make decisions.
Although spousal abuse is considered a crime in the United States, there may be the need for the victim to obtain a restraining order from her county of residence that legally prohibits the abuser from contacting or approaching her; however, a restraining order provides only limited protection. Holt et al. (2002) found that permanent protection orders were less likely to be violated, while the likelihood of abuse increased with temporary restraining orders, even when relationships had ended. Mullen and colleagues (1999) report that stalking or other attempts at communication may follow the issuance of a restraining order. Many times the victimized spouse will move into a shelter, though most shelters have a waiting list and provide only a temporary respite.
Thus, for the overall safety of the abused victim, the importance of recognition, assessment, and implementation of action by health care providers cannot be overemphasized. Asking the correct questions, doing careful observation, and following the right reporting and recording procedures may mean the difference between life and death for these victims.
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