Working With Perpetrators of Intimate Partner Violence

In addition to its toll on physical health and economic well-being, the pandemic has exposed the often overlooked crisis of intimate partner violence (IPV). The critical public health directives used for slowing the spread of the novel SARS-CoV-2 virus by means of social distancing, lockdowns, quarantines, and stay-at-home orders are the same actions that often put those who experience IPV at greatest risk, demonstrating that home is not a place of refuge for many. Rates of IPV, including the use or threat of physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse have risen significantly during the pandemic worldwide.

In an earlier CLOSLER piece, colleagues and I shared five ways healthcare professionals can help address IPV among patients , including asking patients directly about IPV experiences and screening for safety during telehealth appointments. Screening for IPV experiences is an important start and is consistent with Institute of Medicine and U.S. Preventive Services Task Force recommendations. Although screening patients for IPV experiences is essential for providing necessary support and follow up care, on its own, it’s insufficient to prevent IPV as it doesn’t address the act of violence, only the consequences.

To prevent IPV, screening and resources for IPV perpetration are crucial. Rather than solely identifying survivors of IPV, complementary efforts are needed to detect those at risk of perpetrating IPV, and those who have perpetrated, to prevent future incidents. In addition, IPV cessation efforts must focus on developing and implementing effective and acceptable IPV perpetration treatment.

Healthcare professionals are in a unique position to identify IPV perpetration. Annual physicals and the capacity to follow patients’ care over time allows for comprehensive evaluation of varying physical and mental health concerns. Many of the same strategies useful for screening patients for other sensitive issues like suicidal ideation, can be adapted to assess for violence perpetration.

1. Be direct and use behaviorally specific examples.

Ask patients about recent relationship stressors and escalations in conflict in their relationship. Ask direct questions with behavioral examples. For instance, assess whether they have screamed or cursed at their partner, threatened their partner with harm, physically or sexually hurt their partner, or used coercive control to monitor or restrict their partner. Using behaviorally specific examples shifts the conversation from labels, “Have you been physically abusive?” to behaviors that can be assessed and discussed, “have you pushed, slapped, grabbed, or punched your partner?”.

2. Communicate support and nonjudgement.

Responses to disclosures of IPV perpetration should be supportive, nonjudgmental, and knowledgeable. Using a nondirective and empathic style can increase rapport, openness, and patients’ willingness to disclose socially undesirable behavior, such as IPV perpetration.

3. Know your state laws and reporting guidelines.

In most states, disclosed or suspected IPV doesn’t constitute mandatory reporting (except when a vulnerable adult, minor, or animal are involved). Healthcare professionals should be aware of, and adhere to, their state and facility policies and procedures for reporting IPV. Additionally, clinicians should always discuss their mandated reporting responsibilities with patients prior to screening for IPV, including the limits of confidentiality.

4. Have a plan for responding to positive disclosures.

Make sure you have information, resources, and referrals available for patients who disclose IPV perpetration. If your workplace doesn’t offer related services, it helps to be aware of resources in the greater community. Most states offer abuse intervention programs, although the names of these programs vary. If you’re used to developing safety plans with patients for suicidal ideation, consider adapting the plan for IPV perpetration by assessing danger of lethality and identifying warning signs, coping strategies, emergency contacts, and reasons for not engaging in violence.

5. Document appropriately and ethically.

Document these clinical encounters like you would any other: clearly, factually, and without judgement. Use patient-centered, non-stigmatizing language (for example, writing “patient stated,” instead of “patient alleged”), and document outcomes of any assessments, interventions, or referrals.