How do I ask my client if they are being abused?

Healthcare providers are likely to be the first point of contact for survivors of intimate partner violence or sexual assault. Women also identify health-care providers as the professionals they would most trust with disclosure of abuse. When they access health services for treatment of physical and/or psychological trauma, it is recommended that appropriate responses, including clinical interventions and emotional support, be integrated within clinical care.

The World Health Organization (WHO) does not recommend universal screening for violence of women by healthcare professionals, in developing countries, because of limited resources and referral procedures. However, the WHO does encourage health-care providers to raise the topic with women who have injuries or conditions that they suspect may be related to violence.

In some cases, the client might open up and start to talk about the violence they are facing. If a client is not opening up about domestic violence, mental health professionals can implement several important strategies to assess for it.

Look for defensiveness or denial

It is common for clients to not explicitly discuss domestic violence. It’s often the case that a client may not understand that their relationship is abusive. It’s why professionals should ask clients questions about their romantic/spousal relationships, and then use those responses to gauge whether or not the client is facing any abuse that may or may not constitute domestic violence.

Possible opening questions:

• To ease the client into talking about violence, ask non-judgmental and open-ended questions that can help them talk about their experience: “Domestic violence is fairly common. One in three women face domestic violence at some point in their lives. Has your partner or anyone else hurt or frightened you in any way?”

• Since domestic violence is so common, it is good to ask clients this routinely, “As an adult, have you ever been physically, emotionally, sexually or financially abused by anyone?”

• Is there anything at home that makes you unhappy?

• What happens when there are arguments in your household?

Look for signs of physical or sexual abuse

If clients present with signs that could indicate physical abuse—bruising, sprains and so on—it is important that professionals ask how the injuries were sustained, particularly if there is already a suspicion that abuse is occurring.

An important indication of abuse can be found in a client’s response to questions pertaining to the injuries—if the client is hesitant in their response or offers an explanation that seems unlikely or far-fetched, then there is a significant chance that domestic abuse is the cause. This reaction should be a major red flag that all professionals must recognize.

Some questions you can ask:

• I have noticed a number of bruises/cuts/wounds/burn marks on your body? Who hurt you? What happened?

• Many people I see with these kinds of wounds and injuries have been experiencing domestic violence. Is someone at home hurting you?

• You mentioned that your partner uses drugs/alcohol. How do they act when they are drinking or on drugs? Are they ever verbally or physically abusive?

• Are you worried that someone in your family could seriously injure or kill you or your children?

• Has anyone ever coerced you into sexual activity that you didn’t wish to engage in?

• Has your partner refused to have safe sex or use birth control?

Look for signs of emotional or financial abuse

Domestic abuse—whether physical, psychological,or both—can have repercussions for a client’s mental health. Consequently, it is crucial that counselors keep in mind that a client presenting with certain mental health problems could, in fact, be in an abusive relationship and that the relationship could be a significant factor contributing to their presenting problems, even if they don't explicitly say so.

If the client is hesitant to answer your questions, you can say—“I am asking you because I am concerned for your safety, and to find out if you need any information or support. I will not tell your family or partner about what you tell me.”

Some examples of questions to ask while looking for signs of emotional or financial abuse:

• Do you worry about your partner’s or other family members’ temper?

• We all fight at home. What happens when you and your partner fight or disagree?

• Has anyone ever prevented you from leaving the house, seeing friends, getting a job, or continuing your education?

• Has anyone acted jealous or tried to keep track of where you go and whom you meet?

• Have you ever feared for your safety around your partner, or other family members?

• Does anyone call you names, swear at you or threaten you?

• Are you (or have you ever been) in a relationship in which you felt you were treated badly? In what way?

• Does anyone control your finances or give you a limited allowance?

• Does someone threaten to cut you off financially if you disagree with them?

• Does anyone spend your money without your knowledge?

If the client refuses to answer the questions or denies facing abuse, respect their choice, but notice any signs and/or non-verbal signals that indicate distress and fear.

Structured tools like Composite Abuse Scale, Conflict Tactics Scale, , Indian Family Violence and Control Scale (IFVCS), Abuse Assessment Screen and Index of Spouse Abuse, are some of the commonly used assessment tools.

Although, their utility is greater in research settings as compared to a clinical setting, where routine history-taking and semi-structured interviews often provide sufficient information. Among these, the IFVCS is a 63-item scale that has been developed and validated specifically for India’s population, and includes four subscales: Control, psychological violence, physical violence, and sexual violence.

Handling abuse-related trauma in therapy is a series by White Swan Foundation in collaboration with Shakti. This series is a guide for mental health practitioners to help survivors of abuse heal with therapy. This series refers to survivors as women, however, we acknowledge that survivors can belong to any identity. The usage of the word "women" has been used to reflect laws that are focused on women as survivors of domestic violence, and other guidelines that are framed keeping women in mind.

Written by Bhumika Sahani, journalist and social worker by training; consultant at Shakti; and Dr Parul Mathur, resident doctor, Department of Psychiatry, NIMHANS