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I made him hit me! Strategies for Spousal/Partner Abuse
I made him hit me! Strategies for Spousal/Partner Abuse

Section 15
Spousal or Partner Abuse Assessment

Question 15 | Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Spousal or Partner Abuse Assessment: Intimate Partner Violence
Intimate partner violence is a pattern of assaultive and coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent, and are aimed at establishing control by one partner over the other.

Preparing Your Practice - Create a Safe Environment for Assessment and Disclosure
There are several important steps you can take to create a safe and supportive environment for asking patients about IPV and reproductive and sexual coercion. These steps include:
1. Having a written policy and providing training on IPV and reproductive and sexual coercion including the appropriate steps to inform patients about confidentiality and reporting requirements
2. Having a private place to interview patients alone where conversations cannot be overheard or interrupted
3. Displaying educational posters addressing IPV, reproductive and sexual coercion, and healthy relationships that are multicultural and multilingual in bathrooms, waiting rooms, exam rooms, hallways, and other highly visible areas
4. Having information including hotline numbers, safety cards, and resource cards on display in common areas and in private locations for patients such as bathrooms and exam rooms

Develop Referral Lists and Partner with Local/Regional Resources
There is a range of referrals and resources available for victims of abuse in many communities. Contact the following entities to find out contact information for a referral list and to have resources available at your facility:
1. The domestic violence coalition in your state (for a listing go to: nnedv .org/resources/coalitions .html)
2. Meet with local domestic and sexual violence program professionals to understand the services they provide. Arrangements can often be made so that staff can call a domestic violence advocate for advice and discuss a scenario hypothetically, if needed, to understand how to best meet the needs of a patient who is experiencing abuse
3. The violence prevention program in your state health department

Training on IPV and Reproductive Coercion
Core training on IPV and on reproductive and sexual coercion will be most effective if all clinic staff that has contact with patients are trained. When possible, training should include staff from domestic violence and sexual assault programs.

Assessment, Harm Reduction and Intervention
Getting Started: Always Discuss the Limits of Confidentiality Prior to Assessment
Mandatory reporting requirements are different in each state and territory. Consider contacting the following organizations for information and resources specific to your state/region:
1. Child protection/child welfare services in your state for information about reporting requirements for minors experiencing and/or exposed to violence
2. The domestic violence coalition and sexual assault coalition in your state may have legal advocates or other experts that provide information and training on reporting requirements for IPV. For a complete list
go to www.nnedv.org/resources/coalitions.html
3. Many forms of reproductive and sexual coercion described in this guide are not included in most legal definitions of IPV. Some forms, however, such as forced sex, may be included the legal definition of IPV. In addition to IPV laws, teen dating violence can also raise questions about mandatory child abuse reporting requirements and statutory rape laws.

In addition, providers need to be familiar with relevant state privacy laws and federal regulations regarding the confidentiality of health information. Make sure that you have accurate and up-to-date information about mandatory reporting laws for your state. Always disclose limits of confidentiality prior to doing any assessment with patients. The script below is an example of how to disclose limits of confidentiality with a patient before doing assessment for IPV and reproductive coercion.

Sample Script to Inform Client about Limits of Confidentiality:
"I’m really glad you came in today (fill in the blank for visit type). Before we get started I want you to know that everything you share with me is confidential, unless (fill in state law here—likely this script will look very different for an adolescent than an adult) you have been injured by a weapon, forced to have sex by someone, or are suicidal—those things I would have to report, ok?"

Verbal Assessment is Essential
While assessment questions for IPV may be embedded in self-administered medical history forms, asking questions about IPV and reproductive and sexual coercion also needs to be part of the face-to-face assessment between the provider and the patient.

The patient’s responses to these questions will help inform the provider about the best way to proceed relative to the treatment plan, potential complications, compliance considerations, other health risks, and safety concerns. This informed approach will ultimately save time and enhance the quality of care and reproductive health outcomes. Ongoing training opportunities should be available for new hires and staff who want to repeat the training. Refresher training is important to introduce advances in the field and offer opportunities for staff to discuss progress, challenges, and opportunities.

Four Surveys for Spousal or Partner Abuse Assessment

Partner Violence Screen (PVS)
1. Have you been hit, kicked, punched, or otherwise hurt by someone
within the past year? If so, by whom?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?
A "yes" response on any question is considered positive for partner violence.

The Hurt, Insult, Threaten, and Scream Scale (HITS)
The HITS scale is a paper-and-pencil instrument that is comprised of the following four items:
"How often does your partner: physically Hurt you, Insult you or talk down to you, Threaten you with harm, and Scream or curse you?"

Patients responded to each of these items with a 5-point frequency format: never, rarely, sometimes, fairly often, and frequently. Score values could range from a minimum of 4 to a maximum of 20.

The Partner Abuse Interview
"Many people, at one time or another, get physical with their partner when they’re angry. For example, some people threaten to hurt their partners, some push or shove, and some slap or hit. I’m going to ask you about a variety of common behaviors, and I’d like you to tell me if your partner did these during the past year."

For each behavior answered no, put a "zero" in the appropriate box and ask if patient was bruised or injured in any other way. If answer is yes, code "1" for no injury, "2" for possible injury, and "3" for injury.

Has your partner… Yes/No Injury Codes
1. Thrown something at you ( ) 1 2 3
2. Pushed, grabbed, or shoved you ( ) 1 2 3
3. Slapped you ( ) 1 2 3
4. Kicked, bit, hit you with a fist ( ) 1 2 3
5. Hit or tried to hit you with an object ( ) 1 2 3
6. Beat you up ( ) 1 2 3
7. Threatened you with a gun or knife ( ) 1 2 3
8. Used a gun or knife ( ) 1 2 3
9. Forced you to have sex when you didn’t want to ( ) 1 2 3
10. Other ( ) 1 2 3

Ask the following questions if the answer to any of the above questions is anything other than "zero"
11. "Some people are afraid that their partners will physically hurt them if they argue with their partners or do something their partners don’t like. How much would you say you are afraid of this happening to you?"
( ) Not at all (1)
( ) A little (2)
( ) Quite a bit/Very afraid (3)

Domestic Violence Screening Tool
1. Have you ever been threatened, hit, punched, slapped, or injured by a husband, boyfriend, or significant other you had at any point in the past?
2. Have you ever been hurt or frightened so badly by a husband, boyfriend, or significant other that you were in fear for your life?
3. Have you been hit, punched, slapped, or injured by a husband, boyfriend, or significant other within the last month?
4. Are you currently involved in a close relationship with a husband, boyfriend, or significant other?
5. Are you here today for injuries received from your husband, boyfriend, or significant other?
6. Do you often feel stressed due to fear of threats or violent behavior from your current husband, boyfriend, or significant other?
7. Has your current husband, boyfriend, or significant other ever hit, punched, slapped, or injured you?
8. Do you think it is likely that your husband, boyfriend, or significant other will hit, slap, punch, kick, or otherwise hurt you in the future?
9. Do you think you will be safe if you go back home to your husband, boyfriend, or significant other at this time?

A "yes" response to any question is considered positive for partner violence.

Sources:
Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of three brief
screening questions for detecting partner violence in the emergency department. JAMA 1997;277(17): 1357-
1361.

Sherin KM, Sinacore JM, Li X, Zitter RE, and Shakil A. HITS: a short domestic violence screening tool for use
in a family practice setting. Family Medicine 1998;30(7):508-12.

Pan HS, Ehrensaft MK, Heyman RE, O’Leary KD, Schwartz R. Evaluating domestic partner abuse in a family
practice clinic. Family Medicine 1997;29(7):492-5.

Furbee, PM, Sikora, R, Williams, JM, and Derk, SJ. Annals of Emergency Medicine 1998; 31(4):495-498.

Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings, Second Edition
Linda Chamberlain, PhD., MPH and Rebecca Levenson, MA

Personal Reflection Exercise #6
The preceding section was about spousal and partner abuse assessment. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
What four items comprise the HITS scale?
To select and enter your answer go to Answer Booklet.

 
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