It is now commonly accepted that health care providers encounter many women who experience battering, since women who otherwise do not seek assistance for the battering itself do seek health and mental health care for the physical and psychological damage caused by the battering, or they seek it for their children. It is also commonly accepted that health care providers have often been unaware of or ignored the existence of the battering and its relation to illness or injury and possibly to the course of recovery and healing. Some health care providers, usually hospital emergency rooms and community health centers, are now beginning to consider their role in addressing domestic violence among battered women who come to them for treatment. Clearly, these providers have the potential to identify vastly more women experiencing domestic violence than currently come to the formal attention of the justice systems and traditional domestic violence services.
In Chapter 5 we presented many of the issues raised by extensions of domestic violence networks to include health care providers. Here we want to raise several additional issues, including: (1) whether, in addition to screening and identifying domestic violence, hospitals community health centers, and other providers should try to develop some internal capacity to counsel or otherwise help victims, or whether they should rely on referral networks; (2) what types of training might be appropriate for health care system personnel and who should provide it; and (3) the implications for types of services and approaches of the fact that many of the women identified through case screening in health care settings will not be ready to accept referrals to traditional domestic violence programs.
One of the key factors discouraging health care workers from implementing screening procedures for domestic violence is uncertainty about what they should do if they find it. If a community lacks resources to assist the newly discovered cases, or if the health care workers do not know of available resources and potential actions, they cannot refer new cases to appropriate sources of help outside their own settings. If the resources exist in the community, some of the difficulty can be overcome with training and education for health care workers. But, if the resources do not exist, or are in some ways inappropriate for the women whose situation is being discovered by screening in health care settings, health care workers may find themselves caught in a bind. One option is for health care workers to cooperate with current domestic violence service providers to help them expand their services in ways that would meet the needs of the women identified in health settings. As these services develop, referral could take place as usual.
An option other than referral is for health care settings to develop some level of internal capacity to address the needs of battered women. In hospitals this is likely to be limited to counseling in the immediate circumstance of having someone who screens in for battering. However, in community health center settings more extensive options are possible including running on-going counseling groups for women, as well as making individual counseling available and discussing options for legal and other types of action with the woman. Having health care agencies begin to set up their own services for battered women raises all kinds of questions and concerns, but also may offer women a greater range of options that may fit the circumstances and wants of some women better than the currently available array of services in agencies devoted exclusively to domestic violence issues. One important issue is the training and knowledge base of the health-based staff who would provide the additional services. It is important that they know a good deal about domestic violence patterns and issues, and also know a good deal about the life circumstances of the people they are likely to be working with. Who should provide the training, of what it should consist, how often it should be repeated, are all issues to be resolved.
A second important issue is what services should be offered. This issue includes the extremely touchy subject of what guiding philosophy or analysis of domestic violence should be used to structure the services and guide the information and advice given to women. In our site visits we found health care providers that were beginning to offer individual and group counseling for women who had been battered, some of whom, at least, were not interested in leaving their batterers. Nevertheless, they were interested in attending these sessions, and found it safer to do in the context of a health setting, where they could not be identified as seeking services for the battering (and they could tell their partner that they were going to the doctor, which was a destination acceptable to the batterer and therefore safe for the woman). To add further complications, community-based health care providers often serve ethnic minority populations who may feel more comfortable going to an ethnically compatible neighborhood service than going to an unknown battered women's service. The goals of these services include increasing the safety of the women participants, but not necessarily through the route of leaving the batterer, which is the implicit or explicit goal of most services specializing in helping battered women. It is easy to see that there are many issues to be resolved, but also many opportunities to expand services to reach potentially large proportions of the population of women who experience battering but are probably unlikely, at least in their present situation and consciousness, to seek help from the formal battered women's network or from the justice systems.