Domestic Violence, Natural Disasters, and Health Care Providers

by Dr. Raymond B. Flannery Jr. on March 30, 2021 10:45 am

“Home is where the heart is” is a common expression that connotes caring and support. However in some homes it means heartache, medical injury, psychological terror, and even death. Not all family values are good, prosocial values; some are violent and destructive.

Domestic violence (DV) refers to the physical, sexual, verbal/oral, and nonverbal acts of violence inflicted on a family member by any other family member. These potential assailants include grandparents, parents, children, aunts, uncles, live-in au pairs and servants (including trafficked servants), and any other member who regularly lives in the home.

There are at least two forms of DV situations. The first is the troubled family wherein DV has been an ongoing problem. The second is the new DV situations in previously nonviolent families secondary to being confined to home in natural disasters, such as in the COVID-19 pandemic.

For example, the New York City Police Department saw a 15-to-20 percent increase in the first few weeks of this pandemic in 2020. A natural disaster makes both of these types of DV worse. Nonviolent families must now cope with newly emerging violence, and ongoing DV families with continuous violence have nowhere to escape and no one to tell during a national disaster that restricts movement.

This basic review outlines several of the major dynamics in these families, and then it lists some of the basic interventions needed by health-care providers that assist these troubled families.

Domestic Violent Homes

It is true that every family is unique in its own way, but there is enough published research to identify at least the two types of ongoing DV families. Although the research for the DV in previously nonviolent families is limited, the literature suggests that these previously nonviolent families may come to resemble ongoing DV families, unless the reason for confinement is resolved or passes on its own.

The two types of DV are the cycle of violence and the family incest pattern.

The first type of ongoing DV family is characterized by abuse that follows a pattern, known as the cycle of violence [1] and is usually associated with physical and verbal/oral abuse of any type. The first component of the cycle is the tension-building phase. The assailant becomes angrier over time. The family tension builds and everyone in the household knows that violence will soon follow. These assaults have different temporal patterns: sometimes each week, sometimes each month, sometimes every six months. The pattern occurs like clockwork.

The second component is the inevitable outburst. Herein the assailant strikes out with physical violence that may medically injure and psychologically terrify. When this phase is over, the assailant begins the third contrition phase. He tells the victim that it will never happen again, sends flowers/candy, and pleads to be forgiven as it will never happen again. The victim usually relents and the cycle starts again. Over time these violent episodes will increase in intensity up to, and including, spousal murder.

This second well-researched family pattern has to do with familial incest [2]. Usually the father is the assailant. He is most likely a victim of untreated posttraumatic stress disorder (PTSD), is entitled, is depressed, wants to be taken care of, and is more than likely abusing substances. His wife or partner is also likely a victim of untreated PTSD. During her childhood, her own mother was, likely a victim of incest, became overwhelmed with marriage and the children, and withdrew emotionally from the family. The eldest daughter became “the parent” and had to look after her father and siblings. Her father began to approach her, groom her, and over time became involved in incestuous behavior. As a teenage young adult she is drawn to men who need to be cared for, and she marries the type of male assailant outlined above. The marriage proceeds until the wife is overwhelmed with domestic and child-rearing stressors. At that point, she withdraws as her mother did. The husband reaches out to the oldest daughter and the cycle starts again.

These assailants are deficient in problem-solving resources and verbal conflict-resolution skills. But many victims remain in these DV situations because of their children and/or because they are economically dependent. Others stay because they have been brainwashed into believing that they are in fact responsible for the abuse, and many correctly fear being stalked, and even murdered, if they leave.

Often overlooked in these homes are the nonviolent children of all ages, who are witnessing this mayhem. Research has demonstrated that two-thirds of children who witness violence growing up will themselves inflict violence in time in their own marriages. This is known as the intergenerational transfer of violence [3] and remains a major risk factor for subsequent violence.

Domestic Violence Interventions

Addressing the many issues raised by domestic violence is a complicated process that entails several health-care provider skills and interventions. A general three-step approach may prove helpful. The three stops include ensuring safety, assessing the risk of recurring violence and other needed assessments, and fielding a treatment plan that reduces risk of subsequent family turmoil. These materials are covered in greater detail in other formats [4, 5].

Insuring Safety

Obviously, safety is a paramount consideration for the assailant, the family members, and all first responders. If your agency receives a DV call, obtain the name of the caller and the site of the disturbance. Forward this information immediately to the police. If your agency is to respond as well (e.g., medical triage), go to the site, stay in contact with your assigned police car, and do as the police instruct. If you are removing the victim from the home for transport to the hospital, be aware that any other family member could potentially erupt in violence toward you as you leave. For example: the father has been arrested, you are transporting the mother, and the children are afraid of being alone, should the assailant father return. As you leave, remain in contact with your assigned police car.

If you are making a non-emergent call on a DV family, can you assume that violence will not erupt? In questionable cases, practice scene surveillance. Medical and mental-health workers are not often trained in surveillance, but police are and can teach the provider the basics. Essentially, drive on the street behind the DV family home. Check out the backyard for signs of the assailant or an angry unleashed animal. Pull down to the next right, view the end of the house, again looking for signs of disturbance. Then, drive past the front of the house, pull up so you can see the front and other end of the house. Again look for any signs of distress. Can you account for everyone on the street? Is anyone hiding behind a fire hydrant or large tree trunk? If it seems clear, approach the house carefully and listen for any signs of a violent struggle. Do not walk up the front sidewalk. Rather approach from the side of the front door, and open the door from the side to avoid someone shooting when the door opens. Enter quickly, stand with your back to the wall, and keep looking for anything that could be used as a weapon. Provide whatever services that are necessary and survey the family as you leave. Keep in touch with your cop car. (See Krebs [6] for a more detailed account.)

When indicated, transport the victim to the nearest emergency room (ER) for care. Make sure safety is assured in the hospital, even if the victim must be hidden somewhere else in the building. If it is at all possible, create a holding environment that provides safety, caring support, confidentiality, and privacy.

Care providers need to assess for any medical injuries and in sexual abuse cases for venereal disease, AIDS, and possible pregnancy. A semen-specimen kit should be completed. Next, the ER ought to consider the need for any legal counsel and for safe housing after discharge.

Can the victim return home? Is a battered women’s shelter indicated? Safety, remains the guiding principle.

Assessing Risk of Reoccurrence and other Needed Assessments

Reducing the risk of recurrence and assessing what supports the family will need to obtain this goal are complicated. The common sources of stress that lead to violence in many homes are severe financial difficulties, unemployment, substance abuse, and lack of housing/health insurance for family members. This is complicated by any pathologies found in the household members. Here again, personal financial debt, substance abuse, and interpersonal-skills deficiencies can increase the probability of recurrence. Often overlooked is a past history of untreated PTSD in both assailant and victim. Clinical depression is often present in many, if not all, family members.

The care provider may want to begin with a history of violence assessment [7]. A sound history of past violence, episodes of anger and the like are important information for assessing the present level of risk. Next the various treatment needs for each family member have to be put in place. Removal of weapons from the home, any necessary treatments for substance abuse, untreated PTSD, depression-and-anger-management classes need to be established and implemented before a formal treatment plan can be put in place.

The Treatment Plan

When all of these assessments have been completed and individual treatments are completed or underway, the treatment plan will need to begin by including what the victim and other nonvictim family members can tolerate. Should the assailant remain out of the house? Can he or she visit for a meal? Determine what is possible and proceed in small, manageable steps.

Next, the care provider(s) need(s) to educate the family about the cycle of violence [1, 2] and the intergenerational transfer of violence [3]. Couples’ counseling may be indicated, even if the parties are still apart. The focus would be in part correcting interpersonal-skills deficiencies, with the assailant learning verbal conflict-resolution skills and the victim learning to be assertive.

When the various treatments and skills’ trainings are in place and when the risk of new violence considered to be low, a detailed safety plan is drawn up. It includes a strategy for restitution and amends; a review of socially acceptable coping skills for thoughts, feelings, and behaviors; and a clear plan about how to summon help.

The plan is then implemented. Monitoring continues intensely at first and then continues for as long as needed.

Preventing violence and instilling or restoring more normal family functioning is a complicated and time-consuming task but it insures a better quality of life for every family member and, given the intergenerational transfer of violence, a better quality of life for those yet to be born.

References

1. Walker, L. E. A. The Battered Woman Syndrome, New York, NY: Springer, 1984.
2. Gelinas, D. J. “The Persisting Negative Effects of Incest.” Psychiatry, 1983, 46: 312-32.
3. Widom, C. S. “Does Violence Beget Violence? A Critical Examination of the Literature.” Psychological Bulletin, 1989, 106: 3-28.
4. Flannery, R. B. Jr. The Violent Person: Professional Risk Management Strategies for Safety and Care. Riverdale, NY: American Mental Health Foundation, 2009.
5. Flannery, R. B. Jr. Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery, second edition. Riverdale, NY: American Mental Health Foundation, 2012.
6. Krebs, D. When Violence Erupts: A Survival Guide for Emergency Responders. Sudbury, MA: Jones and Bartlett, 2003.
7. Bourn, R, Swartz M., and Swanson, J. “Assessing and Managing Violence Risks in Clinical Practice.” Journal of Practical Psychology and Behavioral Health, July 1996, 205-15.

Raymond B. Flannery Jr., Ph.D., FACLP, a licensed clinical psychologist, is Associate Professor of Psychology (Part Time), Department of Psychiatry, Harvard Medical School, as well as Adjunct Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School and Adjunct Professor of Psychology (Part-Time), the Woods College of Advancing Studies, Boston College. He is an internationally recognized and award-winning scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, for all types and sizes of groups, and may be reached at The American Mental Health Foundation.