Responding to Domestic Abuse - Guidelines for Health Care Workers in NHSScotland

Guidelines for Health Care Workers in NHS Scotland in responding to domestic abuse


RESPONDING TO DOMESTIC ABUSE - GUIDELINES FOR HEALTH CARE WORKERS IN NHSSCOTLAND

PART 2: IDENTIFYING AND ADDRESSING DOMESTIC ABUSE - THE ROLE OF THE HEALTH CARE WORKER

This section provides information about the impact of domestic abuse and advice on how to approach the difficult task of talking about abuse. It outlines potential signs and indicators of domestic abuse and principles to inform effective practice. It provides guidance effective support.

Domestic abuse may result in physical injury, chronic physical ill health and ongoing emotional and mental health difficulties. It can lead to acute and chronic physical disability, miscarriage, loss of hearing or vision, physical disfigurement, and psychological injury leading to depression, drug and alcohol problems and sometimes suicide or attempted suicide. At the extreme end of the continuum, some women are murdered by their partners or ex-partners.

Violence not only has severe health consequences for the person directly affected. Children suffer the consequences of abuse too. They may show a number of the following symptoms: failure to thrive, development of anxiety and depression, withdrawal, asthma, eczema, disability caused by abuse of the mother during and after pregnancy, bedwetting and attempted suicide. Death from murder or suicide can also occur.

Barriers to accessing health service provision

Helping women tell others about abuse and obtain the help they need is not always easy. Patients may not disclose, or may not receive, the support they require, either through lack of information about available services, or because the service they seek help from lacks the skills or knowledge to provide an appropriate and effective response. NHS Scotland should offer a safe system and comprehensive support to which an abused individual can turn with confidence. This will require clear care pathways for women, well known to staff.

Women and children who have experienced abuse may not disclose what has happened to them because:

  • they may not perceive what is happening as abuse;

  • they may be ashamed and embarrassed about what has happened to them;

  • they fear reprisals and serious escalation of abuse from their partner if outsiders get involved;

  • they think they may receive an unsympathetic response or not be believed, particularly if the abuse is psychological or there are no physical symptoms;

  • they fear that their children will be taken into care;

  • they don't know what help might be obtained from health professionals;

  • they are afraid of the police and other authorities, and fear deportation if a refugee, asylum seeker, or woman who has entered the country to get married;

  • they feel trapped, degraded or humiliated; lacking self-esteem;

  • they may be depressed and unable to make even basic decisions;

  • they fear of insecurity, including financial;

  • they do not realise that abuse is something they should not have to tolerate;

  • children fear their mother will be blamed;

  • of emotional dependence;

  • of stigma of being without a partner;

  • of lack of support from family & friends;

  • they hope that their partner's behaviour will change.

Although it is important not to make assumptions about women based on their personal or social background, capabilities or living situations, certain circumstances may impact on a woman's ability to disclose abuse and create barriers to accessing services. The instances of these are even higher when the victim is from an ethnic minority group, male or homosexual. See table 2:

Health care settings should present information in ways that let women know that abuse is a subject that can be raised with their health care worker. Relevant addresses and telephone numbers should be made easily accessible to enable women to get help with or without the support or knowledge of health care staff. 4 Displays, posters and information leaflets in reception and public waiting areas, consulting rooms, public and staff toilets and staff offices, may encourage some women to disclose.

Staff should be aware however that written material alone is not sufficient, as women may have difficulties with literacy or her first language may not be English, or it may simply not be noticed or read. In these cases the health care worker must be proactive in providing information.

DOMESTIC ABUSE - GOOD PRACTICE IN SCOTLAND

An information sticker offering advice on domestic abuse issues was developed and distributed throughout public toilets within the Forth Valley NHS Board area.

Table 2 Potential barriers to accessing provision

Common issues that create barriers to accessing provision

Women from minority ethnic/rural/travelling communities

Elderly/People with learning difficulties

Men/same sex couples and others

poverty

homelessness

isolation

fear/mistrust of authority

religious values

literacy problems

advocacy

fear of institutionalisation

mental health depression

illness

previous childhood abuse

confidentiality

access to information

finance

self esteem

reliance on abuser

young person

alcohol problem

drug misuse

stigma

language barriers

immigration status

racial or religious

discrimination

cultural values

lack of interpreter

threats of deportation (from family members)

threats of separation from children

isolation from own relatives or friends

family pressure

unaware of the level

of support and services available

ethnic and rural communities tend to be male dominated

travelling lifestyle

distance from services

lack of transport

residency rights

prevailing sense of being helpless

deafness

blindness

mobility problems

physical access

self harm

dependence on abuser who may also be care giver

weak memory and/or

alzheimers disease

learning disability

embarrassment

cultural expectations - men stronger than women

women are the 'typical' victims of domestic abuse

men are expected to be able to look after themselves

fear of not being taken seriously

lack of service

provision

homophobia

fear of 'coming out'

limited legal representation afforded to gay couples

perpetrators

persuading their partner that their behaviour is an expression of masculinity rather than domestic abuse

prostitution

self blame

The Scottish Executive document on public involvement Patient Focus and Public Involvement (2001) states that appropriate interpreters should be made available where necessary. In domestic abuse cases, where interpreter facilities are required, female interpreters should be available where possible and family members should not be used as interpreters. Health care staff should be aware that the abusive partner might also be the carer, advocate or usual interpreter.

Providing the right environment

Health care workers should be sensitive to cues and warning signs, which might suggest domestic abuse. Women may approach a range of health services directly or indirectly when they experience abuse. Continuity of care, with women seeing the same professional at subsequent appointments, may be helpful in giving them confidence to discuss problems. Many health care contacts may take place in a private setting such as the home or surgery. Where health care professionals are approached in a public setting such as an outpatients' clinic, a quiet private space should be found where confidentiality can be assured. If time or private space is not available immediately, staff should arrange a further appointment for more detailed discussion as soon as possible afterwards.

If the woman is not alone, suitable arrangements should be made to offer privacy. If she has children with her, wherever possible, arrangements should be made for another member of staff to look after the children safely. Health care workers working with children and young people who are experiencing domestic abuse will also need to be sensitive to their needs.

Partners should generally be made welcome where women bring them along to health care appointments. Nevertheless if a woman is accompanied by her partner (or any person) at every appointment, an arrangement should be made to see the woman on her own at least once. If the appointment relates to physical injury, staff should seek an opportunity to see the woman alone to ask for information directly. This should be done tactfully, for example when obtaining a urine sample. During antenatal appointments, women should be seen first and the accompanying person invited in afterwards.

Recognising the signs

Women experiencing domestic abuse may often seek help for other complaints but be unable to disclose domestic abuse. In these instances, health care workers need to be able to recognise potential indicators of abuse and respond appropriately and supportively. It should be borne in mind that indicators of abuse are not sufficiently sensitive or specific to be used as definitive markers. These may also be attributable to other causes. Women experiencing abuse may show no signs or indications.

Many women try to conceal their abuse for their own survival. Where any suspicion exists in the mind of the health care worker, they must act either by broaching the subject directly with the woman, or by seeking advice from a senior colleague about what to do next.

Physical and emotional indicators

The following physical factors should raise the question of possible abuse in the mind of the health care worker and prompt further enquiry:

Table 3 Physical and emotional indicators

  • The woman reports chronic pain, or there is pain due to diffused trauma, without physical evidence. Bruising may be present where the explanation does not fit with the description of the injury.

  • Repeated or chronic injuries. Injuries that are untended and of several different ages, especially to the head, neck, breasts, abdomen and genitals.

  • The woman minimises injuries and/or repeatedly gives the same explanation.

  • The woman exhibits physical symptoms related to stress, other anxiety disorders or depression, such as panic attacks, feelings of isolation and inability to cope, suicide attempts or gestures of deliberate self-harm.

  • There is frequent use of prescribed tranquillisers, anti-depressants or pain medications.

  • There are gynaecological problems such as frequent vaginal and urinary tract infections, dyspareunia and pelvic pain.

  • There is evidence of rape or sexual assault, such as injury to genitals.

  • Dental emergencies and instances of facio-maxillary trauma occur.

  • There is evidence of alcohol problems and/or substance misuse.

Behavioural indicators

Whether or not physical indicators are present, certain behavioural patterns may be a clue to the presence of abuse:

Table 4 Behavioural indicators

  • The woman misses appointments and/or does not comply with treatment regimens.

  • There are frequent admissions/appointments for apparently minor complaints e.g. backache, headache etc.

  • The woman appears unable to communicate independently. The partner may accompany the woman at all times, and insist on staying close and answering all questions directed to her. He may undermine, mock or belittle her. She may appear frightened, ashamed, evasive, embarrassed or be reluctant to speak or disagree in front of her partner.

  • The woman reports, or the partner expresses, intense irrational jealousy or possessiveness or conversely may appear overly concerned.

  • The woman or her partner denies or minimises abuse. The woman exhibits an exaggerated sense of personal responsibility for the relationship, including self-blame for the partner's violence.

The Confidential Enquiries into Maternal Deaths in the UK (CEMD) estimates that over a third of domestic abuse incidents start during pregnancy. Pregnancy may trigger or exacerbate male abuse in the home. Pregnancy may indeed be a consequence of abuse and an indication that the pregnant woman is in a coercive relationship, and health care staff should be particularly alert to this possibility where she is under 18. To investigate the possibility of abuse, the health worker should talk to the young woman about how she feels about her pregnancy. In the case of admission for abortion, gynaecological staff should never assume that the teenager or older woman has consented to unprotected intercourse.

There are strong links between domestic abuse and adverse pregnancy outcomes and maternity services should be particularly alert to the possibility of abuse and proactive in its detection and management. Service providers should consider routinely printing on the bottom of hand held records and co-operation cards, local information on services, emergency helplines and sources of help concerning domestic abuse.

The woman should have the opportunity to establish a good relationship with a midwife or doctor. Midwives in particular during assessment and antenatal care, may have the opportunity to support and empower the woman to escape abuse (See part 2).

Table 5 Indicators related to pregnancy

  • Late booking.

  • Unplanned or unwanted pregnancy.

  • General unhappiness about the birth of the baby.

  • Frequent visits with vague complaints or symptoms 'of an unknown clinical cause' and without evidence of physiological abnormality.

  • Recurring admissions usually for reduced fetal movements/abdominal pain/investigation of UTI (although these are common in pregnancy).

  • A high incidence of stillbirth, miscarriage and termination of pregnancies.

  • Fetal injury and fetal deaths.

  • Intrauterine growth retardation/low birth weight.

  • Pre-term labour/prematurity.

  • Evidence, or a history, of Postnatal depression

  • Post-natally, removal of perennial sutures.

Research and practice has identified both the need for routine enquiry during maternity care and to see every woman on her own at least once during the antenatal period, to enable disclosure (RCOG (1997) and Confidential Enquiries into Maternal Deaths in the UK (2001)). Women who have disclosed domestic abuse are poor clinic attendees and there is a need for active outreach services.

DOMESTIC ABUSE - GOOD PRACTICE IN SCOTLAND

  • Midwives at Forth Park Maternity Hospital are encouraged to ask women whether they are experiencing abuse at home.

  • Aberdeen Maternity Hospital has established a group to address domestic abuse issues relating to midwifery.

Introducing the subject

Having had cause to suspect possible abuse, the health care worker must be prepared to broach the subject with the woman. Research evidence indicates that a substantial number of women do not tell agencies about abuse, but want the agency to enquire or prompt discussions. With training, staff should be aware of their responsibility to give women permission to speak out about their experience.

Challenging fears and concerns

Health care workers may be reluctant to confront a woman about the possibility that she is being abused, or acknowledge that it is a feature of a particular case, for a number of reasons. These include:

  • concern about being seen to be intrusive or causing offence;

  • concern that there may not be adequate time or resources to deal with the issue;

  • belief that this is not the province of the NHS;

  • belief that other local services will deal with abuse;

  • fear of not knowing what to do next;

  • fear of making things worse;

  • fear of 'taking the lid off' something which will get out of control;

  • fear of personal attack;

  • personal identification with abuse, either as someone who is experiencing abuse or as a perpetrator;

  • fear of involvement (i.e. as a witness).

It is important to be direct but tactful. No form of abuse can be considered acceptable or insignificant.

Asking questions

Discussing domestic abuse can be difficult and embarrassing. It is important to introduce the subject with open-ended, non-threatening questions so that the woman has a choice about how to respond and therefore remains in control of the interview. An abused woman's circumstances are almost certainly too complex to reduce to YES/NO responses. More open questions may include:

  • How are things at home?

  • How are you feeling generally?

  • How are things with your partner?

If responses to open questions suggest that all is not well, the worker should ask more probing questions.

  • What kinds of things are going wrong at home?

  • What sorts of things are bothering you?

  • Has anyone ever done anything to you to hurt you...is that happening now?

It may be helpful to say that it is important to ask such questions as in some cases women have mentioned problems. This will indicate that, where the woman is experiencing abuse, she is not alone. It should also reduce the likelihood of offence to those who are not experiencing problems in their relationships. Staff should not assume that women will be hostile or offended at being asked. If she is angry, that does not mean that the subject should not have been raised. The woman may come back later and want to discuss it when she is more able to do so. NHS Boards and Trusts should consider arranging training for key staff in counselling

More detailed prompt questions are included in Annex D.

Perpetrators as patients

An abused woman and the perpetrator of the abuse may be registered at the same medical practice. The GP, nurse or other health care worker may be aware that domestic abuse is occurring and may have discussed it with the woman. However, it is not likely that a woman who has made a disclosure will wish the issue of domestic abuse to be raised with her partner: fear of the perpetrator finding out is a common reason for women not disclosing. For example a GP discussing domestic abuse with a perpetrator may breach medical confidentiality and could be dangerous.

The perpetrator may also be in need of counselling and medical care in the same way as any other patient. The medical practice must ensure that the appropriate medical care is available. However, the health of the perpetrator, mental or otherwise, is not an excuse for abuse. Health care workers must guard against collusion, particularly if they know the perpetrator personally and find it difficult to accept the potential for abuse. It should always be made clear that abuse is unacceptable regardless of the other problems that the perpetrator might have.

Staff should also be ready to deal with the topic of abuse should disclosure occur, but should not put themselves in danger. Fear of violence towards members of the primary health care team may be justified. Managers of GP practices or LHCCs should assess the risk presented by any individual and ensure that staff are adequately protected. Removal of the alleged perpetrator from the doctor's list without robust evidence that the patient represents a real threat to staff at the surgery, or to other patients, is unacceptable. GPs may need to discuss this with the General Medical Council, the British Medical Association or Medical Defence Unions (see part 5).

Responding effectively

The subject of domestic abuse having been opened up, it is important that the health care worker manage the ensuing discussion appropriately. The following table gives guidance for staff on conducting interviews with women regarding the domestic abuse they are experiencing. Employers should provide appropriate training to support this guidance.

There are basic principles involved in talking with women experiencing abuse:

Table 6 Talking with women

  • Listen carefully. The woman may talk around the subject before getting to the point. Often requests for help are veiled or oblique and must be identified and amplified. If necessary, clarify that you have understood she is talking about domestic abuse.

  • Believe her and say so.

  • Reassure her that she was right to disclose. Be careful not to make her feel inadequate for not having sought help sooner: remember, she may have sought help and been rebuffed. Reaffirm that she is a valuable person and that her needs are as important as anyone else's.

  • Affirm the strength the woman has shown in enduring continued abuse, and the courage she has displayed in asking for help. Acknowledge her experience and accept her evaluation of the danger of her current situation. Stress that she does not have to continue in her situation and that you want to help.

  • Be honest and sympathetic. Explain why questions are being asked so that the woman has a concrete focus, and avoid making her feel judged or defensive. At this stage it is useful to ask direct questions that require direct answers. Under no circumstances should the woman be led to believe that she is in some way to blame for what has happened.

  • Let her control the discussion. Talking about abuse may be very difficult, so allow her to go at her own pace. She may only reveal a proportion of the abuse she has experienced.

  • Respect confidentiality. Remind the woman that anything she chooses to tell you will be confidential, but also explain the limitations of your confidentiality, for example if there are children involved who may be at risk from the abuser. (See section 2.7)

  • Be constructive. In addition to being supported and believed, the woman may need accurate information on the law, benefits, local resources and local support groups, and the worker should have these to hand. Be realistic about what help can be offered and be aware that giving inaccurate information such as wrong telephone numbers, addresses or times of opening could further discourage or endanger the woman.

  • Be prepared to deal with the disclosure over several contacts.

  • Avoid saying 'why don't you?' - it's never that simple.

  • Don't try to solve everything. Every woman has the right to make her own decisions. She should be allowed to ignore the advice of health care workers if she wishes, or cease contact, without being judged. Women whose lives have been controlled by abusive men need time and space to learn to take control of their own lives again.

  • Make sure she knows she can approach NHS staff again in future.

Health care workers can help and provide support by listening sympathetically. It is not always necessary to do something to be helpful. However, local arrangements should be in place for any referral on to specialist services or support.

Documenting and recording abuse, confidentiality and sharing information with others

Any member of staff within the health service may have cause to treat women, children and young people who have been abused. All may be asked to provide evidence to support legal actions. Careful recording and documentation is crucial.

Documenting injuries

In 1994 the British Association of Accident and Emergency Medicine issued guidelines on domestic violence to A&E Departments in the UK, recommending that attending staff be thorough in their examination of injuries, stressing that injuries should be documented meticulously and legibly, and highlighting that the presenting complaint may be only part of the picture.

Documenting disclosure of abuse

It is important that health care workers discuss with the woman as early as possible that:

  • it will be necessary to record accurately all information given

  • that it may be necessary to share this information with other agencies such as social work and police if staff fear that there is a risk to life

They should seek the woman's consent to document the disclosure of abuse in her patient record, and the woman should see and have the opportunity to correct if necessary any information written about her. The woman should be informed of the importance and possible benefits of abuse being properly documented. Increasingly, a woman seeking legal help is likely to be asked to prove that she has been abused and medical evidence can be a most useful way to strengthen her case, especially in court. It can also help in applications for an Interdict, Exclusion Order, Non-Harassment Order or for child custody purposes.

If there is objection to staff documenting the disclosure then they cannot care for the patient properly and this should be explained sensitively and carefully to the patient. If there is any information which the patient does not want to be readily accessible in her case notes, then she can request that this information is stored in a sealed envelope, only available to specified staff, except in an emergency. Staff should record these arrangements in the notes.

If an individual, especially a child may be at risk of significant harm, this will override a professional or agency requirement to keep information confidential. All health care workers have a responsibility to act in a manner which ensures the safety and welfare of an individual, especially children. This should be explained to the patient.

It should also be noted that under the Data Protection Act, the perpetrator may also have the right to see any information held which refers to him or her in the victim's casenotes. However in practice, the perpetrator might not be allowed to exercise this right if this might be harmful to others. Clinicians and other health care staff should consult with their agency's adviser on domestic abuse (see part 4) and their local Caldicott Guardian before deciding to disclose any information to an alleged perpetrator.

Sharing information

Medical and other health care professionals should provide written reports of their findings when asked to do so by the police, the local authority or the Reporter, as these agencies may need to take action on the basis of medical findings. Medical reports should normally be provided with the patient's consent unless there are special circumstances which require disclosure without the patient's consent, for example a Court orders disclosure, or disclosure is required to protect a child or other vulnerable person.

Staff should keep up-to-date case records of their involvement in any domestic abuse case, especially when child protection issues are involved. Records should include:

  • details of any concerns about the woman, child and family;

  • details of any contact or involvement with the family and any other agencies;

  • the findings of any assessment;

  • any decisions made about the case within each agency or in discussions with other agencies;

  • a note of information shared with other agencies, with whom and when;

  • a statement that the woman has been asked about sharing information and has given or withheld consent.

Recording referrals and disclosures

Any information about or alleging domestic abuse in a referral or disclosure should be written down accurately and in detail, either at the time or immediately afterwards with the woman's consent. Records should note the date and time that any incident occurred and the date when the record was made. They must also be signed.

Any documentation of disclosure of domestic abuse must clearly and accurately record the woman's history. These records must be maintained in strict confidence and never in her hand held notes. An agreed plan of action, which can be followed up by the health care worker at a later date, may also be useful. If the woman does not keep to the agreed action, the health worker needs to document this in the records and ask her about this in a non-challenging way. If the woman feels she will be judged negatively because of failure to follow the plan, she may default on further appointments. If there is no follow up, the woman may feel that she has not been listened to.

Documenting domestic abuse can be difficult and time consuming, but health care workers should endeavour to offer a supportive service, which may or may not need the intervention of others. Any child protection concerns should be shared with the social work Department and the police in line with local child protection guidance, without delay.

Recording systems should meet the requirements of legislation on access to files and data protection. Storage arrangements should be adequately secure and protect client confidentiality.

Guidance for the retention and destruction of Health Records is set out in NHS MEL (1993) 152, Appendix A, paragraph 6 and Appendix B, 1b.

"Children's and Young Adults' Records (persons aged less than 16 on date of admission) shall be retained for a minimum until the person reaches 25 or 3 years after death if this is earlier. At the conclusion of the period, the records may be destroyed, but there is no obligation to do so".

Confidentiality of personal health information is the cornerstone of the patient/health professional relationship. In Scotland, guidance on handling personal health information rests on the Code of Practice on Confidentiality of Personal Health Information, issued to the NHS in 1990. The Code, which is due for revision in 2002, sets out the main principles that have to be followed by all NHS staff. The overriding principle of the Code is that information about the health and welfare of a patient is confidential in respect of that patient and such information should not be disclosed to other persons without the consent of the patient, except in certain well defined circumstances, for example where a child is at risk.

It is a matter for the health professional with overall responsibility for clinical care to determine whether the wider public interest outweighs the rights of a patient to confidentiality and warrants the disclosure of information. In reaching a decision, all relevant circumstances should be taken into account including the need to protect the public and any rights of the patient to have confidentiality of personal information about him or her protected.

Doctors' professional accountability

The General Medical Council's advice to doctors is that where they believe a patient to be experiencing neglect, or physical or sexual abuse, and that patient cannot give or withhold consent to disclosure, information should be disclosed to the appropriate responsible person or agency where it is felt to be in the patient's best interests. This has particular implications for those women who may be recognised by the Incapacity (Scotland) Act (2001). Where such circumstances arise in relation to children, concerns about abuse need to be shared with other agencies such as social work services. It will usually, but not necessarily, be appropriate for those with parental responsibility to be informed.

Nurses' and midwives' professional accountability

All nurses and midwives should be familiar with the Nursing and Midwifery Council's Code of Professional Conduct, which came into effect on 1 June 2002. The designated, named or senior nurse/midwife should encourage staff to refer to the document and ensure that the Code is covered in in-service training. The Code of Professional Conduct makes sure that nurses, health visitors and midwives promote the interests of their patients and clients, respect the client's autonomy and are accountable for their own practice.

Caldicott Report on Review of Patient-identifiable Information

Each NHS Board and NHS Trust has appointed a 'Caldicott Guardian' who is responsible for the way that the organisation handles and protects patient-identifiable information. The Caldicott Guardian is a senior health professional, most usually the Director of Public Health at NHS Board level and the Medical or Nursing Director within NHS Trusts. Any queries about the disclosure of personal health information should be referred to the Guardian.

Safety assessments

Once any response to the patient's immediate needs has been made, it is important to make an assessment of safety. Conducting a safety assessment with the woman may help her to think through her situation and make decisions about what she needs to do.

It should be determined whether the woman is afraid to go home and if necessary she should be referred to the local Scottish Women's Aid or other agencies (see Part 4) where experienced help and support is available.

A full safety assessment should address:

  • The history of abuse of the woman and her children, considering any escalation in frequency, intensity or severity.

  • Whether the abuser is:

  • Making verbal threats

  • Physically violent

  • Threatening to harm or abduct the children

  • Physically harming the children

  • Frightening/disturbing/threatening friends and neighbours

  • Frequently intoxicated on drugs/alcohol and more abusive in this state

  • The woman's current fear of the situation and her beliefs about her immediate danger.

  • Self-harm or suicide threats/attempt by the woman.

  • The woman's attempts to get help - from police, courts or Women's Aid groups during the past 12 months.

  • The availability of emotional support and practical support from friends and family.

A decision to leave

If the woman is returning to a living situation that may expose her to abuse in the future, the health care worker should provide information about services and offer practical advice. Preparing a safety bag to keep hidden in a secure place, such as a friend's house should be recommended. Practical advice about what should be contained in the safety bag is available from local Women's Aid groups.

Where possible the woman should arrange alternative accommodation before leaving, by contacting for example local Scottish Women's Aid or a friend. However, the most dangerous time for a woman and children is when she is planning to leave her abuser, as her partner may escalate the intensity of the abuse if he becomes aware of her intention. Her first priority is get herself and the children away from danger and to a safe place where she can call for help and advice. This may require the assistance of the police (see part 1).

A decision to stay

It is important to understand that leaving an abuser is not a single act but a process. It should be remembered that many women face multiple obstacles in escaping abuse, often the same obstacles that make disclosure difficult (see part 2).

Women stay for many reasons ranging from love for the abusive partner (though not the abuse), fear of reprisals against her or her children and lack of money. Leaving and staying both require strength and resourcefulness. A woman may hope that her partner will change and that the family can stay together. An abusive partner may exhibit periods of loving behaviour and express remorse. Support services for women fleeing domestic abuse vary widely around the country. Well resourced in some areas, in others options may be more limited. Difficulties with housing and money, as well as a range of emotional pressures, may force a woman to return to an abusive partner.

The decision to leave or stay rests with the woman. The health care worker must respect and support her, regardless of the decision she makes. However, when children are exposed to risk, health care workers will need to notify agencies with statutory responsibility for child protection (see Part 3).

Referral to other specialist services

Women who are experiencing, or have experienced, domestic abuse or child abuse may experience severe psychological consequences resulting in depression, drug misuse and alcohol problems and sometimes suicide or attempted suicide. Women with learning difficulties or mental health problems may require referral to psychological or psychiatric services.

All staff should have access to information about alcohol/substance misuse and treatment services. Antenatal staff should routinely ask for information at booking about alcohol and drug use, problems in relation to substance misuse, psychiatric history, and be aware of the links between these problems and domestic abuse.

Psychological interventions should be delivered by skilled personnel trained specifically in domestic abuse, in an appropriate professional context, with regular supervision. Many patients will need long term help and support.

Advocacy

Some women may benefit from an advocacy service to ensure their needs are understood and are clearly and sensitively expressed, so that they can contribute to the decision making. The Adults with Incapacity (Scotland) Act 2000 must also be considered in terms of decision making and consideration of the person's future.

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