When Home is Not Shelter

Shelter at home. These words ushered in a new reality for us—one that brought with it experiences that most of us had not encountered in our lifetimes. The impacts of sheltering at home were many and wide-ranging. For survivors of domestic violence (DV), however, “shelter” at home was not shelter at all. In fact, it meant being trapped without reprieve in the worst version of the same painful and, at times, life-threatening, reality that they knew before.

Prior to the coronavirus outbreak, approximately 3 in 10 women and 1 in 10 men in the United States reported experiencing intimate partner violence (IPV), including rape, other forms of physical violence, and/or stalking by their intimate partner. Nearly half of all women in the United States reported psychological aggression by their intimate partner, and most female IPV survivors reported prior IPV from the same perpetrator. [1] For those trapped at home with their abusive partner, we can reasonably expect such behaviors to continue or even intensify.

Indeed, in the week following school closures in March 2020 to combat the coronavirus outbreak, police precincts across the United States recorded significant increases in DV reports. Jurisdictions as diverse as Portland, San Antonio, and Jefferson County (Alabama) reported increases in DV calls from 18 percent to 27 percent.[2] In New York State, a 30 percent year-over-year increase in DV reports spurred the creation of a new task force to address the DV crisis.[3] The National Domestic Violence Hotline reported a 9 percent increase in calls pertaining to domestic violence since COVID-related closures began.[4] It became abundantly clear that the coronavirus impact would be far-reaching, and not only affecting those who contracted the virus themselves.

This crisis of DV in the time of coronavirus has dramatic health care consequences. Chronic exposure to IPV is associated with mental health impacts such as depression, anxiety, post-traumatic stress disorder, and substance use. In addition to internalized blame and a shattered sense of self, difficulty regulating emotions, and relational difficulties, survivors may also evidence compulsive behaviors, a tendency toward self-harm, and suicidality.[5] Women who survive DV are almost four times as likely to experience suicidal thoughts as women who have not experienced DV.[6]

As health care systems have begun to address the impact of psychosocial stressors on health outcomes, it is crucial to remain vigilant to how IPV endangers our patients’ lives. Health care providers are uniquely positioned to be a lifeline for DV survivors because we may be one of the few sources of external support that a survivor can safely access without triggering suspicion and subsequent punitive violence from their abusive partner. Given the weight of this responsibility, it is essential for health care providers to devise a proactive and well-planned approach to ensure DV survivors in our care are safe from both external harm, as well as self-harm and consequent suicidality. Four key elements of a well-crafted DV safety strategy are:

Focused screening protocols folded into routine care, including care via telehealth

Screening and intentional inquiry can provide a safe space for the patient to discuss their partner’s abusive behaviors, expand on physical and psychological evidence of abuse, explore focused community resources, and plan for safety.[7] It is crucial to attend to these elements, and maintain a commitment to intentional discussions, particularly in the context of shelter-at-home risk factors.

Creative approaches to communication

This is key when the only contact with a health care provider may happen through phone, text, or video visits where the abusive partner may be within earshot. Strategies employed by various domestic violence organizations and hotlines for discreet communication without further endangering the survivor offer important lessons in this realm. For example, the Mask 19 campaign in Europe coached survivors to use the code word “mask 19” at local pharmacies to indicate the need for help[8]. Similar keywords can also be devised for the patient to convey risk to a health care provider during a telephone or video visit. Ideally, you’ll be able to communicate code words when the patient confirms no one is within earshot, but the onus is on you as the provider to be thoughtful and get creative on how to ensure privacy.

Attention to confidentiality

A survivor’s contacts with the outside world being “discovered” by the abusive partner can endanger the patient. Health care providers interacting with patients experiencing DV must take seriously the need to remind themselves and the patient about these risks. Survivors concerned about a number of stressors may not readily attend to such a “minor” detail, but these can prove lifesaving. Many DV organizations coach survivors to clear their browsing and chat history and health care providers may consider doing the same[9]. Similar attention should be paid to details shared on voicemail and in text messages.

Normalize in a non-judgmental way the desire to keep things quiet

—even when your symptoms betray you (visible signs of abuse, etc.). It is equally important to refrain from making the patient feel they must do anything. Helping them know that they can and you are there to support them is key. Providers are not saviors and survivors must be ready on their own terms.

With DV exacerbated by the coronavirus pandemic and its subsequent shelter-at-home orders, an effective and safe DV strategy is more crucial to your practice than ever before. In addition to the physical injuries survivors may endure, they are likely to struggle with chronic emotional injuries as well. Including focused screening protocols in existing routine care workflows and safety precautions in patient communications can be lifesaving interventions for your patients.

By embracing and actively leveraging your life-saving role for DV survivors, you can serve as a crucial bridge for your patients trapped in violent homes. It is important to note too, however, that this important role and the weight of its responsibility can be taxing, and bearing this heavy responsibility during an already enormously stressful time makes the challenge particularly difficult. It is vital for you, as a provider, to consider your own emotional needs, and seek adequate support and supervision from colleagues and supervisors to ensure you can continue to support patients, including DV survivors, for the long haul.

Anitha Iyer, PhD
Director, Behavioral Health Population Management
Mount Sinai Health Partners
Associate Professor of Psychiatry
Icahn School of Medicine at Mount Sinai