Slides and Notes Pages were developed by:

Patricia J. Bland, M.A. CCDC, Trainer, Providence Health System

Family Violence Program at Medalia HealthCare
Leigh Nachman Hofheimer, M.A., Education Coordinator, Washington
State Coalition Against Domestic Violence
Ramoncita Maestas, M.D., Faculty Family Physician at the Providence
Family Practice Residency Program and Clinical Associate
Professor, U.W. School of Medicine, Department of Family
Medicine
Roy G. Farrell, M.D., Chair, Violence Prevention Committee,
Washington State Medical Association; Immediate Past President,
Washington Physicians for Social Responsibility.
Kristine Stewart, MSW, ACSW, Perinatal Social Worker, Swedish
Medical Center Division of Perinatal Medicine
Note: This program may be freely used, copied and distributed as long as this
cover page is included. Significant portions of slides & notes
originally adapted from the publication entitled, Improving the
Health Care System s Response to Domestic Violence: A resource
Manual for Health Care Providers, produced by the Family
Violence Prevention Fund in collaboration with the Pennsylvania
Coalition Against Domestic Violence. Written by Carole Warshaw,
M.D. and Anne L. Ganley, Ph.D, with contributions by Patricia R.
Salber M.D. Other sources cited also. Special thanks to the following for
technical assistance: Mary Pontarolo, Executive Director, Washington
State Coalition Against Domestic Violence; Lois Loontjens, Executive
Director, New Beginnings for Battered Women and their Children;
Ann Forbes, Director, Alcohol Drug Help Line; Margaret Hobart,

 Domestic violence is about power and control. It is about one

person in an intimate relationship, exerting power and control over
a partner. Domestic violence perpetrators are clearly definable
primary aggressors who intentionally use any tactic necessary to
exert power and control in their intimate relationships. Domestic
violence is not a single incident of abuse. Rather, it is a repeated
pattern of unpredictable abusive behavior. Attempts by a victim to
resist this pattern of abuse generally result in retaliation by the
batterer. Without intervention, the violence may increase in intensity
(it gets more severe), and in frequency (it happens more often).
Some Key Elements of Domestic Violence (Ganley, 1995):
a pattern of assaultive and coercive behaviors that includes
psychological attacks as well as economic coercion.
a pattern of behaviors including a variety of tactics, some physically
injurious and some not, some criminal and some not, carried out in
multiple, sometimes daily episodes.
a pattern of purposeful behavior, directed at achieving compliance
from or control over the victim.
a combination of physical attacks, terrorizing acts and controlling
tactics used by perpetrators that result in fear as well as physical
and psychological harm to victims and their children.1(pp. 16).
Reference
1. Ganley, A. (1995). Understanding Domestic Violence. In
Improving the Health Care Response to Domestic Violence: A
Resource Manual for Health Care Providers,
produced by The Family Violence Prevention Fund in

DOMESTIC VIOLENCE
Barriers to Detection
1) Lack of knowledge
2) Lack of Confidence
in Intervention
3) Lack of time

Who are
the

VICTIMS ?

 Adolescent dating violence is frequently over-looked; however,

girls as young as 12 are often found in violent relationships. By the
age of 20, one-third of all young women will experience dating
violence (Metropolitan King County Council, 1996). 1
Domestic violence occurs in a relationship where the perpetrator
and victim are known to each other. The relationship may be of
short or long duration. The partners or former partners may or may
not have children together. The intimate context of the violence is
important to understanding the nature of the problem and in
developing effective interventions.
DV victims experience trauma similar to that of victims of stranger
violence. Unfortunately, the intimate context often leads others to
negate the seriousness of the violence. DV occurs in an
unpredictable pattern that is recognizable when power and control
dynamics are understood.
Abusive partners have on-going access to victims, know daily
routines, vulnerabilities, etc. and can continue to have considerable
control over their partners lives. Family ties, social sanctions and
other social barriers complicate the situation and create additional
barriers to strategies for self-protection. (Ganley,1995). 2
References
1. Metropolitan King County Council (1996). Domestic and dating
violence: An information handbook (pp.12). Seattle, WA.
2. See Ganley, A. Understanding DV (pp. 17-18) on earlier
notes page for full citation.

 Though not meant to detract from those cases where the victim is
male, the majority of domestic violence victims are female. The
U.S. Dept. of Justice estimates that 95% of reported assaults on
spouses or ex-spouses are committed by men against women
(Douglas, 1991) There are no prevalence figures for domestic
violence in gay and lesbian relationships, but experts (Lobel, 1986;
Renzetti, 1992; Letelier, 1994) indicate that DV is a significant
problem in same-sex relationships as well, (Family Violence
Prevention Fund, 1995). 1
The invisibility of violent behaviors directed towards intimate
partners tends to be greatest for victims on either end of the
economic continuum. Both very poor and very wealthy women are
victims of domestic violence. Women on public assistance
responding to Washington State PRAMS survey questions were 5
times more likely to report injury from a husband or partner. 2 All
women, regardless of their socio-economic status must be routinely
screened for domestic violence in the health care setting.

References - ( Slide)
1. This figure comes from FBI Statistics, which are probably
conservative estimates.
2. Schulman, M.A., A Survey of Spousal Violence Against Women in
Kentucky. Washington, DC: US. Government Printing
Office, 1979.
References - (Notes page)
1. Ganley, A. Understanding Domestic Violence, pp. 17. ( See
earlier notes page for full citation).

THE VICTIMS
When people meet me, and find out
that I ve been in an abusive
relationship
they just can t believe it.

Stacy
First American woman to summit
Mount Everest

THE VICTIMS
Women represent 95% of adult victims
Between 1 and 4 million women abused per year
Lifetime risk for women is about 20%

Looking at me, with all the things

I ve done in my life..
They think, how could I have been in
a relationship like that?

THE VICTIMS

Domestic violence is the leading cause of

injury to women ages 15-44 in the United
States

 It is important to realize that we are not talking about us and

them. Domestic violence touches us all.
Whenever training on DV in a health care setting it is important to
acknowledge the many staff and providers present who may have
experienced DV themselves, or have known a friend, family
member or co-worker who has.
Domestic Violence training can be difficult or upsetting for some
individuals. Old memories can be triggered as well as current
concerns about one s own (or a friend s co-worker s, neighbor s or
relative s) relationship. Be sure to include Employee Assistance
Program (EAP) participation when training, either on-site or as a
resource, whenever possible. Handouts should always include local
DV program resources for staff as well as for the patients they serve.
Like many other public health problems, domestic violence is
frequently chronic, often progressive and can be lethal. Staff we are
training may currently be involved in an abusive relationship and
have not known where to turn. Establishing a relationship with
your local DV victims service providers empowers both patients
and providers.
Reference

11

References for above slide

1. JAMA, 1990
2. Colorado DV Coalition, DV for Health Care Providers, 3rd Edition,
1991.
3. Salber, P. and Taliaferro, R., The Physician s Guide to Domestic
Violence (pp. 27). California: Volcano Press, 1995.
Note: In Washington State and King County:
*In Washington there were 65 domestic violence related
deaths in 1995. 52% of these involved firearms. King County
reported 5,576 domestic violence related incidents in 1995, up 4.4%
from 1994. All other categories of crimes, including gang related
and hate crimes went down (King County Department of Public
Safety, 1995).
*Each year, in King County, more than 11,000 women and
children fleeing violent homes are turned away from shelters
because of lack of space (Domestic Violence Public Education Plan:
Revised. Love Shouldn t Hurt. Washington: 1/13/94).
*In Bellevue, Washington, the number of DV calls since
1990 has nearly doubled (Bellevue Police Department, 1996).
*From 1990-95, client calls (crisis line and follow-up calls)
to Eastside Domestic Violence Program increased from 2,287 to
9,494, 315%. For every woman seeking shelter, 12 or more are turned

12

DYNAMICS OF
DOMESTIC VIOLENCE

POWER
AND

CONTROL

THE DYNAMICS OF
DOMESTIC VIOLENCE
A pattern of assaultive and
coercive behavior
Physical
Sexual
Psychological
u
u
u
u

threats
intimidation
emotional abuse
isolation

Economic

DYNAMICS OF
DOMESTIC VIOLENCE
Either dinner wasn t exactly what he
wanted,
the house wasn t immaculate,
I didn t look presentable enough
any excuse at all, really
and it was always my fault.
It was very debilitating,
I ended up walking on eggshells.
I began questioning my own competence
to do anything.

THE DYNAMICS OF
DOMESTIC VIOLENCE
It started out slowly. At first he just wanted to know
where I was going all the time. Then he wanted to tell
me where I was going all the time. By the end, I
wasn t allowed to go anywhere.
If I went out with my girlfriends, I knew I would
come back to find the house trashed he would
always break something he knew I really cared
about.

 Though not meant to detract from those cases where the victim is
male, the majority of domestic violence victims are female. The
U.S. Dept. of Justice estimates that 95% of reported assaults on
spouses or ex-spouses are committed by men against women
(Douglas, 1991) There are no prevalence figures for domestic
violence in gay and lesbian relationships, but experts (Lobel, 1986;
Renzetti, 1992; Letelier, 1994) indicate that DV is a significant
problem in same-sex relationships as well, (Family Violence
Prevention Fund, 1995). 1
The invisibility of violent behaviors directed towards intimate
partners tends to be greatest for victims on either end of the
economic continuum. Both very poor and very wealthy women are
victims of domestic violence. Women on public assistance
responding to Washington State PRAMS survey questions were 5
times more likely to report injury from a husband or partner. 2 All
women, regardless of their socio-economic status must be routinely
screened for domestic violence in the health care setting.

References - ( Slide)
1. This figure comes from FBI Statistics, which are probably
conservative estimates.
2. Schulman, M.A., A Survey of Spousal Violence Against Women in
Kentucky. Washington, DC: US. Government Printing
Office, 1979.
References - (Notes page)
1. Ganley, A. Understanding Domestic Violence, pp. 17. ( See
earlier notes page for full citation).

19

20

 Domestic Violence is learned behavior. It is learned through

observation, experience and reinforcement. Batterer s learn the
benefits of exerting power within the family, (and also from societal
institutions where power and control dynamics are emphasized).
Rarely is abuse caused by perpetrator illness or disease.
Alcohol and other drugs: Use by victims may be a consequence of
violence and not the cause. Perpetrators may use alcohol or other
drugs as an excuse for the battering. Batterers who are misusing
alcohol or other drugs must get treatment for both problems.
Treatment for substance abuse alone does not mean battering
behavior will cease. And, treatment by a WA state certified batterers
program cannot ensure safety; especially, if substance misuse goes
undetected. Substance abuse by a batterer, victim or both, while not
the cause, is often associated with greater severity of injuries and
increased lethality rates. Chemically affected victims of violence
often believe their use of a substance means violence against them is
warranted. Always affirm no one has the right to hurt them and
that violence directed against them is never their fault under any
circumstance.
Stress: Violence is a choice; it is one of many behavioral options
when stress occurs. While stress may be experienced in varying
degrees of intensity, each individual can choose an alternative to
violence in response to stress. People choose ways to reduce stress
according to what they have learned about strategies that have
worked for them in the past. It is important to hold individuals
accountable for the choices they make to reduce stress especially
when those choices involve violence or other illegal
behaviors, (Ganley, 1995).

21

 Batterers use isolation to prevent victims from using support

systems among friends or family. Frequently, batterers do not allow
their partners to have friends or contact with anyone they perceive
as a threat or supportive to their victims. Jealousy is often used as
an excuse by batterers for this as well as for other tactics of abuse
they use when choosing to get their own way.
Isolation limits a victim to one point of view: the batterer s. This
tactic makes a batterer seem omnipotent. Tactics such as isolation,
humiliation, enforcement of trivial demands and intermittent reenforcement may be perceived not solely as tactics of violence, but
also as tools designed to maintain control and prevent escape.
Batterers issue threats of retaliation to cultivate fear and despair.
They induce debility by denying sleep, medications and food.
Batterers also monitor and monopolize all a victim s time
(NiCarthy, 1984). They make the rules in a relationship. They
enforce the rules in a relationship. They change the rules in a
relationship.
DV is often perceived as a private matter. Don t get involved in
family business, is a cultural norm for many, as are religious
beliefs such as, Marriage is for life, or, Children need two
parents.
Many professionals don t understand the dynamics of DV or are
frightened of intruding. Potential helpers may worry they too
could be targeted by an abuser. Clergy have told victims to pray for
change or to be a better wife. Historically battered women have
been prescribed psychotropic meds (e.g., sedatives) making victims
vulnerable to addiction and less capable of protecting themselves.
Therapists have told couples to work on communication and have

22

THE CHILDREN
Perpetrators of domestic violence traumatize children

THE CHILDREN
Effect on Children:

(1) Physical injuries

- intentional
- unintentional

(2) Psychological injuries

- witnessing violence

In 85% of police calls for domestic violence, children

had witnessed the violence
Witnessing parental violence is a risk factor for:
Males- to physically abuse
Females- to become victims of abuse

DOMESTIC VIOLENCE
Entry into the health care system
represents an opportunity for detection
of domestic violence and referral to
appropriate community resources

DOMESTIC VIOLENCE
and the Emergency Department
30% of all female trauma patients
22-35% of all females presenting to the
Emergency Department
most are repeat ED patients
u
u

20% 11 or more abuse related visits

23% 6-10 abuse related visits

DOMESTIC VIOLENCE
SEQUELAE
In the 12 month period following violence:
Victims use health care services twice as
often as non-victims
Healthcare costs were 2.5 times higher for victims

Victimization was the single best predictor of total

yearly physician visits and of outpatient health
care costs

FAILURE TO DIAGNOSE
DOMESTIC VIOLENCE
Inappropriate treatment
Increase victim s sense of helplessness and
entrapment
Lost opportunity to refer to appropriate
community resources
Increase danger to the patient

Why don t they just leave?

FEAR
LOW SELF ESTEEM
ISOLATION
LACK OF RESOURCES
PROMISES TO CHANGE

 The greatest consequence battered women face when leaving an

abusive relationship is death. Again, health care providers are not
responsible for curing DV. Leaving an abusive relationship is a
process and on any given day, a provider may meet a victim at the
beginning, middle or end of the process.
It is important to define success not as, Getting her to leave, or
making decisions for a battered woman; but as breaking the
isolation and giving the message, You are not alone.
Battered women understand the complex constraints their abuser
forces upon them. They recognize the unique features of their
abusive relationships as well as the dangers that exist.
Women experiencing DV benefit most from supportive statements
such as: This must be very hard for you. Anyone could find
themselves in this situation. I m sure when you met your partner
neither you nor anyone else could have guessed this would happen.
It must be painful when someone you love can be frightening. It s
not your fault. What can I do to support you today?
Providing a referral to local DV shelter or community advocacy
programs is the single best step you can take in addition to
providing any needed medical treatment. Advocates are your allies
and experts at safety planning which is a complicated and lengthy
process.
Remember, most battered women do not routinely self-identify as
victims. Many will never consider shelter as an option. However,
they may be comfortable talking to someone. Many battered women
say they want the violence to stop rather than their relationships to
end.

31

FEAR

LOW SELF ESTEEM

Everyone seems to think that what you

need to do is to just leave the relationship
and then everything will be fine.

I thought that I was worthless, that I

couldn t do anything right.

That s the myth. The reality is that the

violence escalates if you try to get away.

I thought I was ugly, just a horrible

individual no one would ever love
me and I myself was incapable of
love.

I knew that not only did I have to leave, I

had to DISAPPEAR.

LEAVING IS A PROCESS
I think I left 12 times before I finally stayed gone.
When I look back on it now, I realize I was practicing. It was a process
it took time, I had to learn how to leave and I had to learn how to stay gone.

Stacy
First American Woman to summit
Mount Everest

Promises to Change
I don t really know
why I kept going back...
He begged me to, swore
he d never do it again.
And, I wanted to hear it.
I was overweight, I felt
unloved

LACK OF RESOURCES

After years of violence, I was completely

bewildered. I didn t know how to get away!
There has to be a place to go to, its not just a
matter of leaving from someone. And, for many
victims of domestic violence that place either
doesn t exist or they don t know that it exists.

 Leaving is a process and is often dangerous for a victim. As a

society we need to begin reframing our questions, asking , Why are
batterers allowed to harm their partners? rather than, Why don t
victims leave? Batterers must be held accountable for their actions
and the choices they make. When we as a society say NO to
intimate partner abuse and MEAN it, our need for battered
women s advocates may decrease sharply.
Separation violence clearly is a safety issue. A victim can say,
Goodbye, but the perpetrator s response may be to stalk, harass
at work, threaten retaliation such as harm to children, pets or
property. The list of tactics used by batterers is daunting. DV
victims are often isolated from friends and family by their abusers.
Yet, DV victims actively develop survival strategies to keep
themselves and their children safe.
Many factors shape a woman s repeated attempts to live violence
free. These factors may include (but are not limited to): a lack of
housing; limited (or no) access to economic resources; threats of
retaliation and hopes that a batterer will change or stop the violence.
Many battered women make repeated efforts to achieve safety;
often, struggling alone rather than revealing their situation to
others. It is not unusual for a battered woman to fear telling anyone
about her situation until it is safe for her to do so. Believing the
victim and letting her know, You are not alone, is an intervention
in and of itself. You may be the first person who believes her story
and offers support without question. This may be the first of many
conversations creating a climate of safety, and respect for this
woman. Your local DV advocates are always available to offer
education, resources and safety planning assistance.

37

 Leaving is a process. Remember, batterers are extremely controlling,

manipulative and directive. Interventions perceived by the battered
woman as authoritarian or overly directive are not as successful as
those designed to acknowledge her unique survival strategies.
Survivors of domestic violence do leave. They leave when they are
ready. They leave when they believe it is safe to do so.
Success can be defined very simply. Did you break her isolation,
provide a referral, ask about safety? Offer options and avoid
pushing your own opinion or time-frame agenda. Victims leave
when they are ready. Think of yourself as one who sows seeds .
An medical response that affirms a battered woman s story and
decision-making process is essential because there are so many
societal sanctions that perpetuate violence. To illustrate this point
during training, ask the group to quickly brainstorm songs that glorify or
endorse violence against women. TV shows, movies and newspaper
articles also provide examples of cultural messages about domestic violence.
Ask group members to examine their own beliefs about violence and
challenge them to move away from asking why, someone stays to why
batterers are allowed to continue abusing.
We all need to acknowledge victims of violence don t like abuse,
don t cause abuse, and may need time to realize they can t change
an abuser s behavior. Providers, Social Workers, Nurses, Medical
Assistants, Nutritionists, Security, Patient Service Repsall who
come in contact with victims of violence, play a part within our
state s coordinated community response to end domestic violence.

38

THE VICTIMS

THE CHILDREN

Domestic violence is the leading cause of

injury to women ages 15-44 in the United
States

Probably the most important contribution to

ending abuse and protecting the health of its
victims is to identify and acknowledge the
abuse
Council on Ethical and Judicial Affairs, American
Medical Association