Training needs of psychiatry residents in handling Intimate Partner Violence (IPV) in clinical situations-A survey.

Dear Editor,

Intimate Partner Violence (IPV) is a global public health issue. Nearly one-third of women in India and across the world experience at least one form of IPV during their lifetime (“WHO | WHO multi-country study on women’s health and domestic violence against women”, 2020; National Family Health Survey (NFHS-4) 2015-16, 2017).

IPV refers to any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship (“WHO | WHO multi-country study on women’s health and domestic violence against women”, 2020). IPV and mental health issues share a bidirectional relationship, where women subjected to violence seek mental health care more often than non-abused women. Also, women mental health service users are at a higher risk of experiencing IPV (Oram et al., 2013; Trevillion et al., 2012b). IPV is also associated with increased vulnerability towards developing mental health problems such as post-traumatic stress disorder (PTSD), depression, anxiety, sexual problems, suicide, self-harm, chronic pain and substance abuse (Howard et al., 2013; Stewart and Chandra, 2017).

Healthcare providers are likely to be the first point of contact for women facing IPV and health settings have been considered to be the most appropriate setting to ask about IPV and provide interventions or direct victims to appropriate resources. However, there are numerous barriers both to disclosure and to the enquiry, which may be responsible for low rates of detection. The most common reasons for non-disclosure have been reported to be- embarrassment, shame, fear of threats and further violence or confinement from the perpetrator; re-traumatization; hopelessness; inability to recognize violence (particularly emotional), the stigma associated with one’s mental illness, and lack of privacy (Stewart and Chandra, 2017; Vranda et al., 2018). Mental health professionals may also be reluctant to ask about IPV and common barriers identified include personal discomfort, therapeutic nihilism, fear of offending, causing re-traumatization and time constraints (Stewart and Chandra, 2017; Trevillion et al., 2012a).

Mental health professionals should ideally play an important role in identification, triage, and providing interventions for women who have mental health problems and report IPV. The problem of IPV has become particularly relevant during the COVID-19 pandemic as there has been an increase in the number of callers on DV helplines worldwide, particularly during the lockdown (Bradbury‐Jones and Isham, 2020).

This survey was conducted among 137 junior and senior residents in psychiatry at an academic psychiatry centre in India which saw a footfall of 1,55,077 patients in the year 2019, of which 61,449 (39.6 %) were women. The survey was conducted as part of a teaching seminar on IPV in mental health during the period of the COVID-19 pandemic. This survey aimed to examine awareness about IPV and perceived barriers in assessing and providing interventions. Of the 137 residents approached, 94 (68.61 %) residents responded to the survey. The survey consisted of 8 items with responses rated on a Likert scale, dispersed through an online survey form. The anonymity of responses was maintained. Details of their responses are presented in Table 1 . Responses with more than one option marked, rendering them ambiguous, were excluded.

Table 1

Survey Details and Results.

Survey Questions [overall responses = 94]	Often / Very Often [n (%)]	Occasionally [n (%)]	Not at all [n (%)]
1. “How frequently have women spontaneously disclosed IPV to you without asking?” (n = 91)	15(16.5 %)	62 (68.1 %)	14 (15.4 %)
2. “How often do you check for IPV as a part of routine care while assessing a woman in the OPD?” (n = 92)	27(29.4 %)	58(63.0 %)	7 (7.6 %)
3. “How frequently have you wanted to intervene when IPV was disclosed but have not known what to say?” (n = 91)	69(75.8 %)	17 (18.7 %)	5 (5.5 %)
4. “How frequently have you experienced the following barriers in assessment or intervention for IPV?”
i Lack of training and supervision(n = 94)	67(71.3 %)	24 (25.5 %)	3 (3.2 %)
ii Concerns about victim’s safety (n = 94)	71(75.5 %)	21 (22.3 %)	2 (2.2 %)
iii Lack of privacy (n = 94)	52(55.3 %)	39 (41.5 %)	3 (3.2 %)
iv Lack of knowledge about available resources (n = 94)	76(80.8 %)	17 (18.1 %)	1 (1.1 %)
v Concerns about medicolegal issues (n = 94)	72(76.6 %)	18 (19.2 %)	4 (4.2 %)
vi Therapeutic nihilism or helplessness (n = 94)	60(63.8 %)	26 (27.7 %)	8 (8.5 %)
5. “How often have you asked for IPV in the following situations?”
i The woman has bruises (n = 94)	85(90.4 %)	6 (6.4 %)	3 (3.2 %)
ii The woman reports somatic symptoms (n = 94)	32(34.0 %)	48 (51.1 %)	14 (14.9 %)
iii The woman presents with self-harm (n = 94)	57(60.6 %)	28 (29.8 %)	9 (9.6 %)
iv iv. The woman’s partner has alcohol dependence (n = 94)	79(84.0 %)	14 (14.9 %)	1 (1.1 %)
6. “How often have there been instances in your clinical experience where IPV was disclosed but not addressed?” (n = 92)	46(50.0 %)	35 (38.0 %)	11 (12.0 %)
7. “How confident are you in asking questions about the following?”	Very/ Quite	Somewhat	Not at all
i Emotional violence (n = 94)	65(69.2 %)	28 (29.8 %)	1 (1.1 %)
ii Physical violence (n = 94)	81(86.2 %)	11 (11.7 %)	2 (2.1 %)
iii Sexual violence(n = 94)	37(39.4 %)	44 (46.8 %)	13 (13.8 %)
8. “Have you received any formal training or inputs (workshops/CME/clinical teaching) on how to detect or respond to IPV?” (n = 91)	Yes -12 (13.2 %)
	No – 79 (86.8 %)

The results indicate fairly low rates of spontaneous disclosure of IPV by women approaching mental health services as well as low rates of routine clinical assessment of IPV by residents (Table 1). The majority of the residents perceived difficulties in responding to IPV or asking about it and mentioned lack of knowledge, comfort, safety concerns and concerns about medicolegal issues as prominent reasons. Nearly 71 % of residents reported not receiving formal training as being a barrier. Currently, training on IPV as part of clinical rotations is varied and depends on the individual consultants’ emphasis on gender issues rather than it being part of the curriculum.

These findings are similar to that of a UK-based study among 131 mental health professionals (psychiatrists and psychiatric nurses) where the majority of participants (60 %) felt that they lacked adequate knowledge of support services, and 27 % noticed that their workplace did not have sufficient referral resources for domestic violence (Nyame et al., 2013).

An Australian study that assessed psychiatrists’ and trainees’ preparedness in dealing with IPV, found that comfort and skill levels were directly correlated with the number of hours of training they had received. The training programme included assessment techniques, safety planning, knowledge about existing resources and referral pathways (Forsdike et al., 2019).

Based on the findings of this survey, and the available literature, we conclude that residents may benefit from training in responding to IPV in clinical settings as part of their residency program. This would include improving assessment skills, how to triage, being alert to clinical conditions that could indicate IPV, as well as training in addressing IPV once disclosed, knowledge about access to services, and ensuring safety. The World Psychiatric Association (WPA) has developed a competency-based curriculum (Stewart and Chandra, 2017) for training and describes the skills and knowledge that psychiatry trainees should have when dealing with IPV.

How formal training about IPV for psychiatry trainees improves comfort and skill as well as service user satisfaction, and how much it is sustained over time, is an important area of study.

Centre where study conducted

National Institute of Mental Health and NeuroSciences (NIMHANS) Bangalore, India.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors report no declarations of interest.