Telemedicine: A Lifeline for Patients Experiencing Intimate Partner Violence

About 33% of women and 25% of men experience intimate partner violence (IPV) at some point in their lifetime.¹ This widespread issue can leave individuals heavily guarded and controlled by their abusers, leading to “physical, sexual, or psychological harm.”¹

With the COVID-19 pandemic came an unprecedented boom in telemedicine across medical specialties, including mental health care. According to a survey of 3500 family practitioners and pediatricians, rates of telehealth offerings spiked from just 12% in 2016 to 90% by spring of 2020.¹

This rapid growth of telemedicine invited health care providers into the intimate setting of people’s homes, an increasing number of whom were cast under the dark shadow of IPV.² Research suggests that the isolating and stressful circumstances of the pandemic spurred higher rates of IPV worldwide.³ Electronic health care has been especially significant for patients in this population, introducing unique challenges, advantages, and considerations.

Domestic Violence Awareness Month is observed each year in October. To contribute to this vital conversation, we spoke with Allison Paugh, a Psychiatric Mental Health Nurse Practitioner (PMHNP) and learned more about this timely topic.

Allison has extensive experience working with patients in both in-person and telehealth settings. Overall, she feels that people facing IPV have benefited from the expansion of teletherapy.

“Many patients I have had who participated in telehealth have done well with the transition,” Allison shared. “In most cases, the patient feels this is more convenient for them whether that be due to transportation concerns, childcare, or other mental health symptoms that make telehealth a better option.”

Nonetheless, providers must thoughtfully consider the most appropriate ways to delivery teletherapy to patients dealing with IPV at home. Missteps can abruptly prompt the discontinuation of services or worse. Here are some crucial mistakes to avoid and best practices to incorporate in order to ensure the safe and successful delivery of care.

The Pros and Cons of Telemedicine in IPV Situations

Allison said many studies have found telehealth services to be well-accepted and helpful for individuals experiencing IPV. She explained, “There have been advantages (ie, easier accessibility, comfort in continuation of resources), but there have also been new challenges.”

“[Individuals experiencing IPV], who may have already lived in forced isolation, experienced increased feelings of isolation and loneliness [during the COVID-19 lockdowns]. [Those facing IPV] may also have heightened anxiety over loss of privacy and may present as more guarded during their telehealth visit due to fear of retaliation from their partner,” advised Allison.

Research suggests that survivors of IPV run the risk of escalating violence if an abusive partner becomes aware that IPV is being disclosed and discussed.⁴ Targeted strategies can help mitigate this risk and maintain communication and support from counselors.

Best Practices for Privacy and Effectiveness

According to Allison, “Implementing systematic privacy protection and trauma-informed approach has the potential to achieve comprehensive and psychosocial support.” 

She feels “a trusting and therapeutic relationship should not be compromised with telehealth services. Providers should be utilizing screenings that only require a yes or no response (due to partner listening), as well as providing supportive resources through email or sharing of online resources.”

Allison recommends following the CUES mnemonic:

• C for confidentiality
• U for universal education
• E for empowerment
• S for support

The National Health Resource Center on Domestic Violence offers a free resource that includes examples of telehealth scripts that encompass these principles.⁵ The American Psychiatric Association also has a free resource providers can download to learn how to ensure digital safety when providing teletherapy for patients experiencing IPV.⁶

Allison said, “Overall, in addition to implementing strategies and screenings, providers should be providing person-centered care that ensures privacy. The provider should be aware that violence may be happening and proceed with conversations with caution.”

A report published in the Indian Journal of Psychological Medicine outlines priorities for mental health providers when counseling patients in domestic violence situations. After establishing rapport, providers should teach concrete safety skills, like packing an emergency bag, locating helplines and shelters, and deleting call history with the therapist. They can talk through strategies for responding to different scenarios. Providers can also help patients learn to recognize behaviors associated with violence in the past, such as financial stress or substance abuse.⁴

Providers must use discretion when deciding if the benefits of teletherapy outweigh the risks. Some contraindications for teletherapy include patients with:

• Cognitive impairments
• Expressed thoughts of suicide or homicide
• An immediate risk of harm

Such cases should be referred to in-person care or emergency services. If a patient’s safety is at risk, the therapist should wait for the patient to initiate contact or contact an emergency helpline if unable to reconnect.⁴

How Does It Work in the Field?

Providers can ask specific questions to determine whether they have private access to patients experiencing IPV.¹

If they’re unsure whether the patient is alone, the provider can ask, “Is this a safe time for you to talk?” or “Are you alone?” If the provider knows that the perpetrator of abuse is present, they may say, “HIPPA laws require me to provide telehealth sessions without anyone else present.” Although the provider still can’t be completely sure that no one is listening in, these phrases can help.

Allison discussed how teletherapy worked for her patients. “I have found that the IPV patients with ‘low safety concerns’ have transitioned better than those who experience more complex IPV relationships,” she explained.

“Specifically, I was treating one patient whose partner did not ‘believe’ in medication and was unaware that the patient was receiving psychotropic medications.  When telehealth appointments were utilized, the patient was guarded and vague in answering had a quiet tone and felt distracted from the session. Eventually, for a period of time, the patient completely stopped all appointments.”

“Fortunately, she resumed telehealth appointments once the patient’s partner had a full-time job that allowed the patient to have privacy during sessions. The patient commented that the risk of their partner finding out that treatment included medication was greater than the benefit received from medication therapy.  During the time frame of stopping appointments (as well as medication), the patient’s progress deteriorated, and the treatment plan had to be adapted for the patient to again ‘start over’ at implementing strategies/coping techniques for further progress.”

Mental health providers must be vigilant and sensitive to patients’ situations at home. Some sessions may be more conducive to discussing IPV, while others may not. Nonetheless, it’s essential to maintain lines of communication and avoid risks that could compromise a patient’s ability to continue with teletherapy.

The Future of Teletherapy

Research on telemedicine during the pandemic shows that telehealth services were accessed more frequently by those experiencing IPV than people who were not. Experts have theorized that this may be because IPV takes a significant toll on physical and mental health, causing increased health care needs.² Now that steps have been taken to provide remote health services, many patients will likely continue to prefer this mode of care.

Allison feels the pandemic-related boost in telehealth is here to stay. “I feel that telehealth services will continue to be offered and utilized. Allowing telehealth services to have made a significant impact on the utilization of services,” she explained. “The pandemic has allowed us to expand specialized care in the home setting, hopefully improving patient outcomes and elevating patient experiences. As change occurs, providers are working to improve their change from ‘bedside manner’ to ‘webside manner.’”

This article originally appeared on Psychiatry Advisor