Opportunities for preventive violence counseling and crisis intervention in the primary care setting are often missed. Providers may lack sufficient knowledge or may have values, biases, or experiences that leave them lacking in the confidence to explore violence-related issues with their patients. Moreover, some providers have experienced violence themselves, provoking feelings of guilt or inadequacy about handling these issues and rendering them unable to aid their patients.

By the same token, patients who are either targets or perpetrators of violent behavior are often ashamed and hide their histories from health care providers. A person abused by violence may present with focal, unrelated symptoms, such as gastrointestinal distress, pelvic pain, or diffuse, chronic symptoms that defy a clear diagnosis. Perpetrators, on the other hand, may exhibit uncontrolled anger or threatening behavior or may appear inappropriately solicitous toward the provider.

Anticipation of the relationship between these presentations and violence may lead a provider to explore nonverbal clues, despite the seemingly unrelated symptoms bringing a patient for care. Eliciting a history of violence may reveal other related illnesses, such as underlying depression or substance abuse.

Besides patients’ reticence to disclose their history, the sensitivity of issues related to violence may impede successful intervention. Although primary care providers have grown accustomed to addressing other confidential behaviors such as sexual practices, eating disorders, or drug use, patients may still feel threatened, frightened, or intruded on by frank, pointed questions. This is one reason why suggestions for behavior modification are often met with little enthusiasm.

For some patients, the wish to engage in a romantic relationship, parent a child, or own a gun without interference is akin to the democratic notion of a right. Strong feelings concerning the intrusion of government or cultural mores may impede a working relationship between the patient and the provider. This dilemma is compounded by legal requirements that, in cases such as suspected child abuse, compel the provider to set aside the wishes of the patient and comply with legislative mandates.

Balancing the needs of the patient and legislative mandates presents a challenge for practitioners of relationship-centered care. At times, a provider will learn information that will lead to removal of children from a patient’s home or will provoke the break-up of a romantic relationship. A provider may be conflicted as to what constitutes an appropriate response to information elicited, especially within a relationship ostensibly inspired by trust.

There are two factors to consider in this unique dilemma. First, adult patients who are not yet ready to confront the impact of their violent behavior will not respond honestly to pointed questions, no matter how skillful the interviewer. Those who are willing to change violent behavior patterns often have anticipated the personal risks involved. Second, the patient may experience a sense of relief after making the decision to seek help, allowing the provider to be a source of continued support and guidance.

In cases of child abuse, the role of the provider is more complicated and may create a dilemma, especially if a situation arises where the needs of a child and an adult conflict—for instance, if both are patients of the same provider. But because children are physically and emotionally vulnerable to adults and cannot protect or advocate for themselves within the social service agencies or medical or school arenas where the violence is likely to be discovered, a child’s needs must prevail. An important exception is suspected abuse between adult children and elderly parents, in which case the elder is the more vulnerable and most often the victim.

Regardless of initial impediments, violence screening becomes more effective after acquiring four skills:

Domestic violence has been defined as a pattern of assault or coercion used by an adult or adolescent to force a partner to comply with the other partner’s wishes (Neufeld, 1996). Although abuse of men by women is known, women are overwhelmingly the targets of violence by men. Reports estimate between 2 and 4 million women are beaten by a male intimate every year, accounting for 85% to 90% of all cases of partner abuse.

Homicide is the greatest danger in battering relationships. Among all women homicide victims, Bailey et al (1997) reported that 82% were slain by someone they knew, most often by firearms. The mere presence of a gun in the home is strongly associated with domestic violence and is a predictor that violence will result in the homicide of a woman. A woman’s chances of becoming a homicide victim in a domestic dispute are also increased if she lives alone, abuses illicit drugs or alcohol (although violence is most strongly associated with alcohol abuse by the batterer), has a history of prior domestic violence, or lives with someone with a record of arrest.

Pregnant woman are at special risk for violence. An unplanned or unwanted pregnancy can renew or escalate an existing battering relationship (Gazmararian et al, 1995). Furthermore, women assaulted during pregnancy are twice as likely to have preterm labor and are at increased risk for chorioamnionitis as well (Berenson et al, 1995).

Violence within lesbian and gay relationships is compounded by a number of factors. Many gay men and lesbians forego police intervention for fear of harassment or ridicule from insensitive law enforcers. Even when police have been called, gay and lesbian partnerships have not been seen as families by many official agencies and therefore have been omitted from reporting mechanisms documenting heterosexual abuse. The extent of underreporting of gay and lesbian domestic violence is not known. The inability to define the extent of the problem has left a void in the identification of the particular risk factors and interventions within these communities. This problem is compounded by a reluctance among some health care workers to address the problem honestly, excluding gay and lesbian patients from the majority of health education efforts.

Screening for child abuse is infrequently performed by providers caring for adults. However, primary care providers may have reason for concern about the battering potential of adult patients toward their children. Intervention may be sought as a result of either an observed interaction between a patient and child, or historical factors elicited in an examination.

A history of violence in the home of origin is closely tied with adult battering behavior. Women who experienced violence as children or witnessed domestic abuse between their parents are more likely to become subject to violence in their adult lives. Further, they are at greater risk for physically abusing their children, especially if they were abused as children themselves. Asking patients if they are concerned about the way they discipline their children, or if they feel they use undue force, may be a way to begin a dialogue on this sensitive subject.

Violence between parents is a strong predictor of child abuse by the abusive parent. There is a direct relation between the
severity of spousal violence and the likelihood of child abuse. If only one act of spousal abuse occurs, there is a 5% chance that a child will be battered. If more than 50 incidences between adults occur, there is a 30% likelihood of child abuse when a woman is abusive, and abuse is nearly certain if the batterer is a man (Ross, 1996). Identification of domestic violence within a household necessitates careful screening of all children who live there.

A more difficult problem exists when an adult physically or emotionally abuses a child in the midst of an examination. Responding to the act without losing the trust of the patient can take great skill. Reprimanding, counseling, or advising in these situations is likely to be fruitless, especially if there is a cultural difference between the provider and the patient. Cultures vary widely on what constitutes sufficient discipline. Providers, however, are bound to a standard of acceptable behavior set forth by regulatory agencies. Mandated courses on child abuse, as well as special offices established in many hospitals, should provide the boundaries needed for emergency intervention.