When I conceptualized this talk, my intention was to offer folx a lens into my lived experience as a survivor of child abuse, domestic violence and alcoholism. In some ways, the chaos of my upbringing is exactly what prepared me to be an emergency physician. I connect differently with my patients who present in the Emergency Department with any of these three separate problems. I would venture to guess that the same is true for any of my colleagues who have similar life stories. This topic is difficult to fully dissect in a simple blogpost or 12 minute talk, however, hopefully this provides food for thought.

There may be times your patient who presents with complications of alcoholism, intimate partner violence or child abuse is remarkably difficult and may even be labeled as such. Their behavior may be a manifestation of their disease or a defense mechanism due to prior experience. That attitude you perceive, the failure to answer questions directly or wandering history, the avoidance of assistance, these are all bricks in the wall they have built up around themselves. They put up that wall as a self-preservation mechanism, however, for us as physicians and care providers, this should be a clue.

I can’t tell you how many times I’ve heard statements like “How could she be so stupid?” in relation to a patient who didn’t want to file a police report or talk to the social worker or be admitted to the hospital or go to the women’s shelter. Perhaps we didn’t take the time to find out that in fact she’s afraid to talk to the police because she is worried about how it will impact her partner’s career, or that perhaps they won’t believe her. Perhaps she doesn’t want to speak to the social worker because of the way they treated her the last time. Maybe she can’t afford to be admitted to the hospital because she’s already missed work on account of other injuries. Maybe she’s afraid her partner will hurt her children or family if they have not already.

Further, many things in our world are not binary, and being involved in an alcoholic and abusive relationship is not black or white, good or bad. There is no villain in my story. My abuser is an alcoholic and a survivor of abuse. He is human and made some poor choices. While I have painful memories that no child should have to experience, it is what it is. I also loved him as my stepfather and have incredibly fond memories.

We must remember that alcoholism itself is a disease. It is well documented to increase the risk of physical violence in both child abuse and intimate partner violence, particularly when there is a history of the same. Alcohol and substance abuse are also associated with an increase in the potential lethality of the violence in these altercations.

For victims of intimate partner violence, remember it is also not simple for them. There are layers of emotional complexity which are challenging to dive into in the Emergency Department. Try not to become angry or frustrated with your patient when they don’t accept your recommendation that they should simply leave their abuser. Not only are there potential safety ramifications, there may be financial and social implications as well. Folx are often separated from any substantive support system when in an abusive relationship, so the idea of going at things alone is incredibly intimidating and may not be feasible. 

With this in mind, what can you do in response to this talk? Take a deep breath. Slow down. Dig deep.  Then do these three things: 

1. Acknowledge any preconceived notions or biases you may have about alcoholism, intimate partner violence and child abuse. By identifying our own biases, we may be able to limit their negative impact on our therapeutic relationships, particularly around these challenging topics. 
2. Try to understand your patient’s story or perspective and how they got to the point in which they are sitting in front of you. For a moment, try to sit with them and connect. Help them to see their value as a human being. One moment of connection or slowly pulling those bricks away may just be what they need to identify their own intrinsic strength to move toward healing. 
3. Remember that intimate partner violence, child abuse and alcoholism are not limited to a certain sociodemographic group. Current research has focused primarily on heteronormative, cis-gender females. Keep your eyes open for this in all of your patients, regardless of gender identity, sexuality, or sociodemographics. If you are a researcher, please expand your inclusion criteria and consider other research questions.

Finally, choose your words wisely. Your learners and colleagues may have personal experiences with one or more of these and they are listening.

Watch the FIX19 talk below!