Q&A: A Clinical Social Worker in the Emergency Department Reflects on Her Experiences with Patient Victims of Domestic Violence and their Children

Clinical social workers in healthcare settings are critical in providing a key point of entry to safety and services for victims of domestic violence (DV). Rates of DV among patients in healthcare settings are high, especially in the emergency department (Campbell, 2002). When asked, DV-exposed patients often consider healthcare professionals those they can most trust to disclose the abuse (Feder, Hutson, Ramsay, & Taket, 2006; Zeitler et al., 2006); however, patients are unlikely to disclose unless directly asked (Taket, Nurse, & Smith, 2003) – thus, formalized screening in healthcare settings is essential. Even when screening is successfully implemented, there is so much that goes into connecting victims and their children to services, including how knowledgeable a professional is about services available, effectiveness in motivating a patient to seek help, and ability to develop a working relationship with victims during what are often described as chaotic and highly stressful situations. As such, there are a number of barriers faced. This blog piece offers a Q&A with a licensed clinical social worker with several years of experience working in a hospital emergency department.

What is your role at the hospital and how often do you come across patients who you suspect or determine are victims of domestic violence?

I work as a licensed clinical social worker in the hospital, with my primary focus in emergency medicine.  As a Licensed Clinical Social Worker (LCSW) in the hospital I provide intervention and treatment to hospital patients for various concerns; patient advocacy, child abuse/neglect/exploitation, chronic disease, conservator/health care representative, coping issues for patient and/or family, crisis intervention, elder abuse/neglect/exploitation, end of life and bereavement issues, family/interpersonal violence family mediation, lengthy hospitalizations, and substance abuse assessments.

It is hard to quantify how often I come across patients who I suspect or determine are victims of interpersonal violence, but I would say during my work week I myself may see an average of 3-4 patients who are confirmed victims of IPV.  I am only one of over 25 social workers in the hospital, so hospital-wide, that weekly number is likely higher.

What is hospital procedure for addressing suspected domestic violence, and how does the presence of children change how you might handle a situation?

We follow the JACHO healthcare standards for care in the identification of victims of domestic violence.  This involves a universal screening policy for all female patients and a list of indicators for male or female patients that would trigger further inquiry.

If a patient screens positive for IPV, or there is a concern for IPV with a negative screen, a referral to social work is placed.  As the LCSW, I would then conduct a biopsychosocial assessment, along with safety and danger assessments, safety planning and appropriate referrals.

When children are present with the victim, if the child is old enough to sit outside of the room for a few minutes, I would request to speak to the victim alone.  If younger children are with a victim, I will discuss with them how they would like to go about our meeting.  Often the children are witnesses to the assault, which may have brought the patient to us, which means I may have to make a report to DCF.

Are there any patient experiences you’ve had that really stand out to you with regards to domestic violence?

Yes, there are a few experiences over the years that stand out to me.  One experience involved a patient who was an amazingly strong woman, who had broken world records in her specialty, but also had been in a marriage in which she suffered over 10 years of violence by her husband. I was the first person she had told her story to. This woman’s achievements despite having been chronically victimized really struck me and spoke to her resilience. Being the first one to hear her story highlighted for me the important work we do as social workers and how we conduct our interactions may influence who decides to seek support and who doesn’t.

Another encounter that sticks with me involved a mother who came in with her children and a few packed bags while her spouse was out of the home. We worked to get her and her children into a safe place. Another experience involved a patient whose perpetrator had come in with her and was in the waiting room while she was in a treatment room. After discharge, I walked her out a side exit to an awaiting cab to get her to safety. As you can see, so many of these situations are urgent and require strategic timing for victims to achieve safety and to get connected with services.

There are so many stories, each one of them as important as the other.  And then, of course, there are those times when someone plans to return to their home and their abusive partner, and you have to remind yourself that people have the right to self-determination – and trust that they know what it best for their situation and circumstances at that time.

What barriers have you faced in identifying victims and connecting them to the help they need, and are there things that you think the hospital could do to improve identification of victims and connect them to services?

One of the challenges to identifying victims is making sure that everyone is screened for safety. To do that effectively you have to ask the hard questions and you need to ask them without others present.  I think sometimes these questions are just glazed over or people don’t feel comfortable asking someone to step out of the room while they talk to the patient.  I also believe that when someone comes in for something repeatedly, especially if it is a vague complaint, and within a short period of time, that repeated screening is critical. As we know, it may not be until the 5th, 10th or later visit before they will open up about domestic violence.

One of biggest barriers my patients face is a lack of space in shelters that are local to where they reside if they need to leave their home.  Often, if there is shelter space, it is in a town that is so far away from where their lives are centered: children’s schools, medical providers, employment, etc.  Especially if they do not have a vehicle, it makes it very challenging to go out of town for shelter services.  Finally, a number of patients with known or suspected domestic violence decline resources and are not ready to even make a phone call to consider services. I can only hope that by meeting with them and giving them an idea of what is available, they will have this knowledge for when they are ready to finally reach out for help.

References Cited:
Campbell JC. Violence against women and health consequences. The Lancet. 2002 2002;359(9314):1331Q1336.

Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence: Expectations and experiences when they encounter health care professionals: a metaQanalysis of qualitative studies. Archives of Internal Medicine. 2006/01/09/ 2006;166(1):22Q37.

Taket A, Nurse J, Smith K, et al. Routinely asking women about domestic violence in health settings. BMJ : British Medical Journal. 2003/09/20/ 2003;327(7416):673Q 676.

Zeitler MS, Paine AD, Breitbart V, et al. Attitudes About Intimate Partner Violence Screening Among an Ethnically Diverse Sample of Young Women. Journal of Adolescent Health. 2006/07// 2006;39(1):119.e111Q119.e118.