Domestic matters

The treatment of women injured by domestic
violence would be much improved, says Emma Williamson, by better
joint working between health care practitioners and social care
professionals, an approach that would reduce the work burden for
medics and social workers alike.

Only recently have health practitioners, and
medics in particular, begun to address the issue of domestic
violence. This is of concern to social workers, because when health
practitioners are unsure of the response they should give to
patients presenting with injuries resulting from domestic violence,
such clients will seek help and assistance elsewhere – and that
might just be in your office and at your desk.

A growing number of social workers have
acknowledged the impact that domestic violence has on their
clients. A number of reports now exist which have identified how
domestic violence can affect families and children, in relation to
child protection, work with abused children, and through the court
welfare system.

Articles exist which have addressed this issue
in relation to social workers, but how does the response of the
health sector affect social work provision?

As one doctor interviewed for my study
Domestic Violence and Health: The Response of the Medical
Profession¹ puts it: “Social services and GPs are
at each other’s throats, there’s this pure confrontational
relationship. There’s no defined position as to where the
boundaries between NHS and social workers should be – the higher up
they are managerially the more they try to pass it over to the
other side. At ground level it usually becomes a scrap.”

This illustrates how the poor working
relationships between professionals can increase frustrations and
limit professional choices.

In relation to domestic violence, a survey of
all health practitioners in one county found that 36.8 per cent of
health practitioners believed that social services have principle
responsibility for domestic violence, compared with 9.4 per cent
who named the police.²

Unfortunately, social workers are likely to
find dealing with this issue as stressful as their health
counterparts do.

“I honestly wouldn’t be able to tell you where
the nearest refuge is,” says a medic. “I would ring up, if I’d got
a situation. If a crisis had developed and I was worried about
somebody’s physical and mental health and I thought that if they
needed emergency care I’d ring the social services duty officer,
who is always available, but not always helpful.”

This is an important point as a duty social
worker may, understandably, be unhelpful when being asked to
provide information that a GP is capable of accessing elsewhere.
This does, however, illustrate a continuing problem about how
health practitioners perceive the roles and responsibilities of
other social care professionals. It challenges the feasibility of
inter-agency working and highlights the frustration that such
ignorance causes.

It is within this context that the medical
profession’s response to domestic violence is relevant to social
work practice and policy.

Both social and health practitioners have been
encouraged since 1995 to work in an inter-agency context in order
to address the needs of patients or clients who experience domestic
violence.³ This has taken place alongside the police,
refuge providers, legal representatives, and voluntary
organisations.

Only in March 2000 did the Department of
Health produce a comprehensive resource manual for health
practitioners that outlines how health services can practically
address the issue of domestic violence within a clinical
context^.4

The manual was compiled from the
recommendations of various professional bodies, including the
British Medical Association, the Royal College of Obstetrics and
Gynaecology, the Royal College of General Practice, and the British
Association of Accident and Emergency Medicine. It was also
produced three years after the World Health Organisation stated:
“Women and girls are most at risk of violence from men they know,
particularly in the family. Rape and sexual torture are used as
weapons of war. Violence against women has serious mental, physical
and sexual health consequences. Violence against women is a public
health problem. It can be prevented.”⁵

The DoH manual also comes two years after a
report evaluating the costs of domestic violence stated that the
estimated financial yearly cost of domestic violence for Greater
London alone was £278 million.⁶

This resource manual reiterates the importance
of inter-agency working in order to reduce professional isolation
and frustration and to offer more appropriate services to clients.
However, this raises the question of how to ensure the guidance is
implemented when health practitioners have not, on the whole,
heeded such calls in the past.

The Women’s Aid Federation of England is
currently evaluating the implementation of this resource manual,
and findings will help. But increasingly it will be those engaged
already in domestic violence inter-agency initiatives, from health
as well as other professions, who will be left with the burden of
encouraging their medical colleagues to engage in the inter-agency
process.

My study looks at the health impact of
domestic violence, as well as the response of health and other
professionals. Views of health practitioners help us understand
more clearly how domestic violence impacts on the health
professional’s daily role and suggestions for training health
professionals may be a valuable resource for anyone faced with an
empty health chair round the inter-agency forum table.

The study also details a number of key
findings:

– Women present to healthcare professionals
for the validation of their experiences.

– There was a clear differentiation made
between the identification, documentation and treatment of physical
and non-physical injuries.

– Healthcare professionals use cultural myths
and stereotypes about women who experience domestic violence, which
perpetuate their professional frustrations relating to the
treatment of domestic violence-related injuries.

– The existence of a medical hierarchy
undermines the potential of non-medical health professionals to
interact positively with women who have domestic violence-related
injuries.

– Domestic violence, in and of itself, has not
undergone medicalisation and is unlikely to.

What is clear from health care professionals
is that when they do engage in inter-agency initiatives it
helps.

One says: “Realising that there are other
people out there too, through the multi-disciplinary training,
people who struggle within their own professions with this problem
and have the same difficulties, helps. I think if you know faces,
even vaguely, you’re much happier to phone them up and ask: ‘What
should I do about ….’, or, ‘this situation I’m in, where could I
direct this woman?’. You are much more likely to ask for help and
advice if you’ve met somebody.”

And another comments: “I’ve had pre-meetings,
social workers have phoned up and said ‘I’m just about to go and
what’s your angle on it’ and we’ve had a sort of quick network
meeting on it. When that works, it works really well. When it
doesn’t work then you end up with numerous agencies working in
different directions.”

What is not evident, however, is a realisation
that by not working alongside other professional groups, health
practitioners are perpetuating the frustrations which they feel
when dealing with the issue of domestic violence. As one
practitioner commented, “You say ‘next’, and this woman comes in
and your heart sinks and you think, ‘oh no, it’s one of
those’.”

Perhaps professionals across the board should
realise that patients and clients will continue to present with
domestic violence-related injuries until they receive an adequate
response appropriate to their needs. Providing an inadequate
response through a lack of understanding and knowledge about the
issue, exacerbated by a lack of inter-agency collaboration,
ultimately results in professionals being at least partly
responsible for the frustration they currently feel.

¹ E Wilson, Domestic
Violence and Health: The response of the medical profession,
Policy Press, 2000.

² P Abbott and E
Williamson, “Women, health and domestic violence”,
Journal of Gender Studies, 8 (1), pp 83-102,
1999.

³ Home Office,
Inter-Agency Circular: Inter-Agency Co-ordination to Tackle
Domestic Violence, London, Home Office, 1995.

⁴ Department of Health,
Domestic Violence: A Resource Manual for Health Care
Professionals, DoH, 2000.

⁵ World Health
Organisation, Violence Against Women: A Priority Health
Issue, Geneva, WHO, 1997.

⁶ E A Stanko, D Crisp, C
Hale, H Lucraft. Counting the Costs: Estimating the Impact of
Domestic Violence in the London Borough of Hackney, Swindon:
Crime Concern, 1998.

Domestic Violence and Health
is available from www.policypress.org.uk
and Domestic Violence: A Resource Manual for Health Care
Professionals is available at www.doh.gov.uk/pdfs/domestic.pdf

Dr Emma Williamson is a Wellcome Trust
Research Fellow, based in the centre for ethics in medicine,
University of Bristol.