What are the primary considerations for managing trauma in a patient who has experienced domestic violence?

Trauma Management in Domestic Violence Patients

When managing trauma in patients who have experienced domestic violence, immediately assess physical injuries while simultaneously screening for safety concerns, providing trauma-informed psychological support, and coordinating comprehensive follow-up care—all while maintaining a supportive, nonjudgmental environment that prioritizes the patient's immediate safety and long-term recovery.

Immediate Safety Assessment

• Directly ask whether the patient has safety concerns related to the perpetrator, the perpetrator's friends, or others, and assess whether the patient has been threatened, is afraid of anyone, or if the perpetrator has a history of violence or access to weapons 1
• Determine if the patient is safe to discharge from medical care, as this is a critical decision point that cannot be deferred 2, 1
• Evaluate for signs of domestic violence in children, partners and spouses, the elderly, those with intellectual and developmental disabilities, and other vulnerable populations, as implementation of social distancing and home-based self-quarantine could increase those risks 2

Physical Trauma Management

• Treat all physical injuries immediately, providing proper documentation of the incident and physical findings through photographs and body maps 2, 1
• Be alert to physical examination findings suggestive of abuse and neglect, such as burns, bruises, and repeated suspicious traumatic injury 2
• Women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner compared to men, requiring heightened clinical vigilance 2

Psychological and Mental Health Screening

• Screen immediately for suicidal ideation, self-harm behaviors, and homicidal ideation, as sexual assault survivors have significantly elevated rates of depression and self-harm 3, 1
• If any suicidal or homicidal ideation is present, refer urgently to an experienced mental health professional—this cannot be delayed 3
• Recognize that harmful outcomes of family violence include not only repercussions of acute trauma, including death or unwanted pregnancy, but also long-term physical problems and psychiatric disorders, such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse 2

Trauma-Informed Care Approach

• Initiate direct trauma-focused cognitive behavioral therapy (TF-CBT) immediately without a stabilization phase, as current evidence demonstrates that trauma-focused treatment is safe and effective with large effect size reductions in symptoms and low attrition rates (18%) 3
• Provide a supportive nonjudgmental environment that reflects an understanding of trauma and its many effects on health and behavior 2, 1
• Address both physical and psychological safety concerns using a culturally informed strengths-based approach 2
• Use trauma-informed practices to help illuminate the nature and effects of abuse on survivors' everyday experience and provide opportunities for clients to regain control over their lives 2

Screening and Detection Methods

• Use simple direct questioning in a supportive environment, as this is effective in facilitating disclosure and detecting cases of abuse 4
• Consider validated screening instruments such as the HITS (Hurt, Insulted, Threatened, Screamed at) instrument, the Partner Abuse Interview, or the Women's Experience with Battering (WEB) Scale for intimate partner violence 2
• Be aware that self-administered questionnaires elicit more positive responses than interviewer-administered questionnaires 2
• Recognize that at least 6% of emergency department patients have experienced domestic violence in the previous 12 months, though actual prevalence rates are probably higher 4

Comprehensive Medical Interventions

• Provide empirical treatment for sexually transmitted infections, such as Chlamydia, gonorrhea, and trichomoniasis when sexual assault is involved 1
• Offer emergency contraception within 120 hours of sexual assault 1
• Initiate or complete hepatitis B virus and HPV immunization series as indicated 1
• Arrange for skilled counseling by a mental health professional 2

Follow-Up Care Coordination

• Schedule a visit within 1-2 weeks of initial presentation to assess injuries, medication adherence, mental health functioning, and need for additional psychological counseling 1
• Provide written instructions for later reference, as many patients will not recall everything said during the initial evaluation 1
• Establish a coordinated care team including relevant specialists, trauma-specialized mental health providers, and primary care 3
• Provide telephone numbers of local crisis centers, shelters, and protective service agencies 2

Evidence-Based Interventions for Recovery

• The most promising results have been from nurse home visiting advocacy programmes, mother-child psychotherapeutic interventions, and specific psychological treatments including Cognitive Behaviour Therapy, Trauma informed Cognitive Behaviour Therapy, and for sexual assault, Exposure and Eye Movement Desensitization and Reprocessing Interventions 5
• Patients with supportive networks have reduced adverse mental health outcomes 4
• Access to community resources is increased if patients receive education and information 4

Special Considerations for Children

• Children who witness intimate partner violence are at risk for developmental delay, school failure, violent behavior, and a variety of psychiatric disorders, including depression and oppositional defiant disorder 2
• If a child or adolescent is considered to be at imminent risk for harm, this is a child protection emergency, and authorities (child protective services and law enforcement) must be contacted immediately 2
• The child or adolescent should remain under medical staff supervision until the contacted authorities have established a plan for further care 2

Legal and Financial Resources

• Inform patients that they are eligible for reimbursement of medical expenses through the U.S. Department of Justice Victim's Compensation Program when the sexual assault is reported to police 2, 1
• Be aware of state-specific mandatory reporting requirements for domestic violence and sexual assault, which vary by jurisdiction 2, 1
• Familiarize yourself with state and local reporting requirements, as laws vary from one jurisdiction to another with differences in definitions, whom and what should be reported, who should report, and to whom 2

Critical Pitfalls to Avoid

• Do not delay trauma processing or require prolonged stabilization phases, as the outdated phase-based approach is contradicted by current evidence showing that patients can safely engage in focused trauma work immediately 3
• Do not minimize or fail to identify abuse, as women will have negative perceptions of emergency care if their abuse is minimalized or not identified 4
• Do not accept avoidant coping, as avoidant coping is associated with greater distress and potentially higher risk of adverse outcomes 3
• Avoid routine opioid use as first-line analgesia due to complications in vulnerable populations 6

Ongoing Support and Monitoring

• Remain caring and supportive of the patient as they work through these crises, even if they choose to follow advice or courses of action other than leaving the relationship 7
• Monitor for long-term mental health sequelae, as approximately 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year in the United States, with 31% of all women reporting abuse at some point in their lifetimes 2
• Ensure that staff have access to appropriate training on trauma-informed practices, as those who managed complaints should be trained in the nature and consequences of interpersonal violence 2