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.