Can Your Idea of Happily Ever After Interfere With IPV Patient Care?

Jennifer Ayres, PhD

Jennifer Ayres, PhD

As a trauma psychologist, I find that my greatest challenge in working with survivors of Intimate Partner Violence (IPV) is contending with my automatic bias that the “happily ever after” includes my patient leaving his or her perpetrator. When my bias arises, I reflect on three truths I learned from my undergraduate employment at a battered women’s shelter.

  • Most people go back.
  • If he or she goes back, and you made it clear that you thought it wasn’t a good decision, the patient can’t return to you the next time.
  • It will happen again.

And there are a couple truths I’ve learned since I worked at the shelter.

  • Basic decisions become complicated when you consider all the repercussions.
  • Leaving might not be the best decision.
  • If he or she does leave, the resources often aren’t available, and there is no referral for “make someone feel safe and free.”

These last three are challenging because I am much more comfortable with the patient who decides to flee the abusive situation or engage in the legal fight.

However, frozen indecision is the common response. Patients will arrive in our exam rooms stuck between two basic truths: (1) I love this person and (2) This person is no longer safe. And the second truth typically has an attachment of “but he or she has the capability of becoming safe again with the appropriate help and support.”

So what do we do as health care providers when our patients approach us in this place of conflict?

Use motivational interviewing skills.

Validate the emotional conflict of making such a difficult decision. Identify barriers. Understand that pre-contemplation, contemplation, and relapse are important stages of the change process and meet the patient where he or she is. Ensure that a tacit message isn’t sent that our support is contingent on his or her being at the “correct” stage of the change process.

Identify the psychosocial needs that will appear if the decision is to leave.

The shelter, the ER, legal aid…those are the easy ones. The tougher ones are trauma-focused counselors for adults and children, immediate needs for housing, food assistance, low-cost utilities, finding employment, and financial assistance for clothing to look for jobs. Remember that most IPV survivors are accustomed to hiding their abuse to avoid retaliation by the perpetrator and potential rejection by family members, friends, and people in the larger community. Make sure that an in-house referral to a case manager is not inadvertently distancing or socially isolating by emphasizing the benefits of seeking interdisciplinary support (eg, “I want to be certain that we are supporting you to the highest degree possible. Our case manager knows much more about resources than I do. Is it okay if I go get him or her to help us?”).

Reflect on what this patient’s trauma elicits in us.

Gently push up against automatic responses of “poor thing” or “I would never allow my partner to treat me like that” or fantasies of what we would do in the same situation. Recognize these automatic responses and fantasies as what they are—defenses. These stories, particularly those uttered by people who are perceived as similar others, elicit vulnerability in all of us. They make us feel helpless and unsafe, and we are highly motivated to resolve those feelings.

Once we’ve done self-reflection and given ourselves permission to feel what his or her helplessness elicits in us, we’re ready to reach out in authenticity with compassion instead of pity.

“I’d be scared too. I don’t know all the answers to your questions, but I’m going to help you however I can.” Or “I don’t know what you should do or even what I’d do in your situation. What I know is that it would be one of, if not the, hardest decision I’d ever have to make, and I’d want a lot of support. And I’d like to be one person on your support team.”

Remember that the answers aren’t ours to find.

We are allies and trusted advisers on our patients’ life journeys, not the decision makers.

When we listen to their stories and respond with respect, we send silent messages to the survivors: You have worth. You have a right to feel safe. You are not alone. I believe you.

We do not know the impact of those silent messages. They may be discarded because they do not fit a negative self-image or are inconsistent with survival mode thinking. It is also possible that they will provide the survivor with comfort during the scary moments, including the moment when he or she steps from the contemplation to the action phase of the change process.

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