Case study
Your patient
James has been attending your surgery since the birth of his now 5 year old son. Helen, his wife, is expecting to give birth again in the next month; she is also your patient. You've always liked James, have talked on occasions about golf and joked about the rapid expansion of his I.T company.
Helen has recently disclosed to you that James held her up against a wall by her throat the other night. James comes to see you stating that he's really stressed at work and he needs medication to help him sleep as he gets no peace at home.
How would you handle this?
Most male perpetrators of domestic violence accessing help from their GPs will state that they have problems with stress, anger, depression or alcohol. Rarely will they admit they are abusive without sensitive but direct exploration.
Safety is paramount
In this scenario, the safety of Helen, her son and her unborn baby are priority. If you let on to James that you are aware of Helen's disclosure you could be putting them at risk so you cannot challenge him directly with this. James is not freely disclosing his violence but you can ask him to talk more about the concerns he has and what specifically he is like at times when he is ‘stressed'. If you can get him talking about any arguments they are having, you can ask him how these go. If he is vague, you can ask for details about a specific argument and ask if he has concerns about how he handles himself. You may need to press for specifics or make suggestions, eg. Do you shout lots/swear/put her down/call her names? Have you ever laid your hands on her? How? Ask if his partner has ever been anxious or scared or felt controlled in some way. Sometimes it is easier for a man to answer if you ask how his partner would describe him in an argument.
Blaming and minimising
Most abusive men blame their partners for their own behaviour. He may tell you that ‘she winds him up', ‘she pushes his buttons', ‘she nags him' or generally paint a very negative picture of his partner. You will probably need to refocus him on his behaviour, as this is all he has control over.
He may try to get you to collude with him (‘you know what women are like', ‘all couples argue') or play down what he is doing (presenting the above scenario for example as ‘we had a fight', ‘I only pushed her once', ‘she bruises easily').
This avoidance may be because he is ashamed to face up to the responsibility of what he is doing. He may want to avoid the consequences of his actions.
He may also blame alcohol or drugs. These do not ‘cause' violence as such - many people (including perpetrators) drink alcohol, even to excess, and are not violent. Many victims of domestic violence say that they also experience abuse when a partner is sober. Alcohol or drug use may mean however that any violence is more serious. If James gets more aggressive when he has a drink and he continues to drink, he is making a choice to put his family at risk. He may need help addressing both his alcohol use as well as his violence - addressing his alcohol use alone is not sufficient to stop his violence.
Responsibility
It is important to remember that there are no excuses for domestic violence. However angry or upset James is, he has choices about how he handles himself and he is 100% responsible for what he does.
Whilst he may feel like he ‘lost control', most abusive men set limits on what they do. In this scenario, James at some point, stops himself from strangling Helen until she cannot breathe. Whilst James may say he experiences overwhelming feelings of stress or anger, it's likely that he would not dare speak to a work colleague (and certainly not his boss!) the way he speaks to Helen at times. It's also unlikely that he would have used the violence that he did to Helen if adult family members were present (he may or may not stop himself behaving abusively when his son is present). Therefore, it is not simply that he has problems managing stressful, anxious or angry feelings and so medication alone (e.g anti-depressants) is not the solution to stopping his violence. Domestic violence is not a medical condition that medication can ‘fix' - the Respect Phoneline hears from a number of men that have been prescribed anti-depressants or similar medication and are still looking for help because they have been violent again. Similarly, anger management, individual or couples counselling are inappropriate and potentially dangerous interventions where there is domestic violence.
Rather than being about ‘losing control', domestic violence is a pattern of behaviours of which the violence is one element which is instrumental in the perpetrator having control over their partner. In this scenario, James' violence may have been to close Helen down, avoid hearing things he didn't want to hear from her or frighten her into doing something she didn't want to do. The violence ‘works' in that Helen is likely to be nervous about raising the issue again with James. A specialist perpetrator programme would address these issues.
Child protection
In addition to the physical and emotional risks to Helen, there is a young son and an unborn baby that need protecting in this scenario.
Sign-posting
Helen can get support to prioritise her and her children's safety by calling either the 24 hour National Domestic Violence Helpline on 0808 2000 247 or your local domestic violence women's service.
James needs to get help and attend a domestic violence perpetrator programme. If he admits he has a problem and wants help, he can find out if there is one in his area by calling the Respect Phoneline on freephone number 0808 802 4040 (free from landlines and mobile phones). These programmes are designed to help clients change their abusive behaviours by addressing the underpinning attitudes and beliefs and to develop respectful, non-abusive relationships. They generally take place in a group-work setting on a weekly basis for at least six months. The Respect Phoneline also offers information and advice to practitioners who have contact with people who are being abusive and are looking for help on how to safely manage this.
Domestic violence is unacceptable. It isn't a private matter between two people, it is against the law and it is everybody's business.
This particular scenario focuses on violence from a man to his female partner. Domestic violence also occurs in same sex relationships and from women to their male partners. In Respect's experience, the majority of domestic violence is committed by men against women.
