Editorials - December 1, 1999 - American Academy of Family Physicians

Editorials

Reframing Our Approach to Domestic Violence: The Cyclic Batterer Syndrome

JODEAN NICOLETTE, M.D.
JIM NUOVO, M.D.
University of California, Davis, School of Medicine
Sacramento, California

See article in this issue.

In this issue of American Family Physician, Eyler and Cohen¹ provide two illustrative cases of domestic violence and intervention techniques, but they transcend the paradigm of this major public health issue by presenting a case in which the patient is the perpetrator.

Domestic violence statistics are ubiquitous and staggering: one third of women are assaulted by a male partner during their lifetime, millions of women per year receive severe or life-threatening injuries from their male partner, and the majority of women killed in the United States die at the hands of someone they know.

Faced with the prevalence of domestic violence, physicians have struggled to understand and characterize violence between partners and to develop and implement effective interventions that include prevention.^2-4 For many reasons, most of these interventions have focused on treating the victims of domestic violence, rather than on treating the perpetrators. Understandably, priority has been placed on the immediate safety and security of the victims of intimidation and assault. Other possible reasons for placing emphasis on identifying and treating victims include more frequent interaction with the health care system, overdiagnosis of the victim because of poor understanding of the emotional and psychologic effects of the cycle of violence, and the erroneous belief that violence is innate and, hence, untreatable. A final important reason why therapy is focused on the victim, rather than on the perpetrator, is the possible internalization by health care providers of the social acceptance of the victimization of women.

The authors provide a discussion not only on identifying batterers, but on intervention techniques as well. This discussion appropriately includes the "funneling technique"⁵ questions, mandatory reporting to appropriate agencies and referral for behavioral therapy, social learning therapy and cognitive therapy with a therapist trained to work with batterers.

Programs specifically designed for batterers are increasing in number, and physicians should be aware of such resources in the same way that they learn about other community services. Many states have now instituted certification standards for batterer-treatment programs. Ideally, these programs are designed to help the batterer break the cycle of violence, yet never excuse the abusive behavior. Safe and effective programs use a group approach, last at least 24 weeks, provide a psycho-education approach rather than one involving psychotherapy, avoid couples' counseling and have consistent procedures for assessing danger and protecting victims.⁶

Besides appropriate referral for therapy, the perpetrator may benefit from direct interaction with the physician about the physical and psychologic risks a batterer faces outside the obvious risk to the abused partner and the long-term risks to any children involved in the cycle of violence. The physician should alert the batterer to less obvious repercussions, such as the potential loss of personal freedom from incarceration and the financial costs to the family if legal fees and court costs are entailed. As physicians, we have a responsibility to the perpetrator as well as to the partner and children to diagnose, educate and intervene.

The most important point is that the perpetrator has a serious problem that needs attention. In order to interrupt and prevent further violence, the health care system can and should intervene. Attempts have been made to assign associated and even causal conditions to the behavior of the batterer that include substance abuse and depression, as well as certain personality disorders. In truth, while violence can be worsened by these factors, most perpetrators of the cycle of violence do not carry any of the currently defined major psychiatric diagnoses.⁷ For this reason, perhaps perpetuation of the cycle of violence warrants characterization of a new syndrome. A well-defined and recognized condition is more likely to receive significant attention, as well as provide resources for research and treatment.

In 1984, Lenore Walker published her pioneering book about domestic violence, entitled (coining the phrase) The Battered Woman Syndrome.⁸ Almost two decades later, with more data and a better understanding of our complex society, we can reframe our existing knowledge and perhaps describe the "cyclic batterer syndrome." Only by recognizing and addressing the multifactorial roots of violence in our society can we move closer to living in peace.

Dr. Nuovo is an associate professor in the Department of Family and Community Medicine, University of California, Davis, Sacramento. Dr. Nicolette is senior resident in the Department of Family and Community Medicine, University of California, Davis.

Address correspondence to Jim Nuovo, M.D., Department of Family and Community Medicine, University of CaliforniaDavis, 2221 Stockton Blvd., Sacramento, CA 95017.

REFERENCES

Eyler AE, Cohen M. Case studies in partner violence. Am Fam Physician 1999;60:2569-77.

Saltzman LE, Johnson D. CDC's family and intimate violence prevention team: basing programs on science. J Am Med Womens Assoc 1996;51:83-6.

Warshaw C. Identification, assessment, and intervention with victims of domestic violence. In: Ganley AL, Salber PR. Improving the health care response to domestic violence: a resource manual for health care providers. 2nd ed. Family Violence Prevention Fund, San Francisco: Family Violence Prevention Fund, 1996.

Warshaw C. Domestic violence: changing theory, changing practice. J Am Med Womens Assoc 1996;51:87-91.

Ambuel B, Brownell EE, Lahti T, Hamberger LK. Community as a context for teaching about prevention of family violence. The Fourteenth Forum for Behavioral Science Education in Family Medicine, Chicago: 1993.

Adams D. Guidelines for doctors on identifying and helping their patients who batter. J Am Med Womens Assoc 1996;51:126.

Tolman RM, Bennett LW. A review of quantitative research on men who batter. Journal of Interpersonal Violence, March 1990;5:87-118.

Walker LE. The battered woman syndrome. Vol. 2. New York: Harper & Row, 1984.

We Repeat, 30 Years Later: ORT for Acute Diarrheal Disease Is "In"

MARY ELLEN AVERY, M.D.
Harvard Medical School
Boston, Massachusetts

See article in this issue.

Many of today's experienced clinicians grew up with the belief that clear liquids by mouth are appropriate in the treatment of vomiting and diarrhea. We have recommended a variety of liquids, such as tea, cola syrup from the local soda fountain diluted in water, chicken broth, consommé and apple juice. Thus, when the United Nations International Children's Emergency Fund (UNICEF) adopted the use of oral rehydration therapy (ORT) in a major campaign to treat this leading cause of death in infants and children of developing countries, we tended to say "What else is new?" Moreover, U.S. physicians have often admitted dehydrated infants to the hospital for intravenous therapy with saline and glucose mixtures.

What we missed was what was really new, that is, new back in 1968--the critical discovery, occurring in the early 1960s, of coupled transport of sodium and glucose in a 1:1 molar ratio in the intestine.¹ This discovery formed the scientific basis of ORT. In 1968, Hirschhorn and colleagues² described a "decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions."² In 1985, Santosham and associates³ went a step further, demonstrating the efficacy of oral rehydration in a double-blind comparison of four different solutions. Meanwhile, many clinical trials of carbohydrate and sodium salts mixed in a 1:1.4 ratio (World Health Organization) and a 2:1 ratio (American Academy of Pediatrics) established the safety and efficacy of these mixtures.

However, 30 years later, oral rehydration with appropriate solutions is still not universally used. The reasons may be multiple and include lack of knowledge of the appropriate concentration of sodium, potassium and glucose and, importantly, the proper technique for administration. In developing countries, ORT is administered by giving a teaspoon of solution every few minutes over a period of hours. In the United States, although oral rehydration solutions are readily available, they often fail because thirsty and hungry infants who are given a bottle are likely to consume too much too fast, with swallowed air, and then will promptly vomit. Parents then complain that their child is not able to keep down the fluid. And even if properly instructed, many parents are unwilling to provide oral feeds slowly--to say nothing of nurses and doctors in a busy emergency department or office--when the alternative is 30 minutes of intravenous rehydration.

Despite its attraction, a few arguments for avoiding intravenous therapy in favor of ORT (except in patients with shock) are awareness that the child's thirst protects against overhydration with oral therapy, and ORT is less expensive. Yes, it is counterintuitive to state that a less expensive treatment is more effective than a complicated technology.⁴ However, here are the words of Charles Carpenter, published in the New England Journal of Medicine in 1982:

"We physicians all presumably accept the 'primum non nocere' principle. On the basis of . . . studies . . . this principle would dictate that oral rehydration be accepted not only as an equal, but perhaps as the superior, means of treating acute diarrheal illnesses in the sophisticated and sanitized medical centers of the Western world as well as in rural Bangladesh."⁵

It is now more than 30 years since oral rehydration therapy was first advocated for routine use in the treatment of dehydration caused by acute diarrheal disease. In this issue of AFP, Burkhart⁶ does a good job of reminding us why and how to do it right.

Dr. Avery is a Thomas Morgan Rotch Distinguished Professor of Pediatrics at Harvard Medical School and Physician-in-Chief Emeritus at the Children's Hospital, both in Boston.

Address correspondence to Mary Ellen Avery, M.D., Children's Hospital, 300 Longwood Ave., Hunnewell 4, Boston MA 02115; e-mail address: Avery_M@A1. tch.harvard.edu.

REFERENCES

Curran PF. Na, Cl, and water transport by rat ileum in vitro. J Gen Physiol 1960;43:1137-48.

Hirschhorn N. The treatment of acute diarrhea in children. An historical and physiological perspective. Am J Clin Nutr 1980;33:637-63.

Santosham M, Burns B, Nadkarni V, Foster S, Garrett S, Croll L, et al. Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double-blind comparison of four different solutions. Pediatrics 1985;76:159-66.

Carpenter CC. Oral rehydration: is it as good as parenteral therapy? [Editorial]. N Engl J Med 1982; 306:1103-04.

Avery ME, Snyder JD. Oral therapy for acute diarrhea. The underused simple solution. N Engl J Med 1990;323:891-4.

Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician 1999;60:2555-66.

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