پزشکی اعتیاد و خشونت خانگی

Domestic violence is a major medical and legal problem, resulting in a great many deaths and injuries each year. Alcohol and other drug dependencies are frequently found in both the perpetrators and victims of violence. This fact gives addiction medicine practitioners a unique opportunity to intervene in both life-threatening disorders. This article gives diagnostic and intervention guidelines for dealing with the issue of domestic violence in the addiction medicine patient population.

Domestic violence is a major legal and medical problem where physicians who practice addiction medicine have a unique opportunity to intervene before permanent injury or death occurs, an opportunity not unlike that posed by an addicted person. There is often a great deal of confusion about what constitutes domestic violence, what the diagnostic signs and symptoms may be and what treatment options exist. A well-accepted definition of domestic violence is: “Assaultive behavior occurring in an intimate, sexual, theoretically peer, usually cohabiting relationship” (Ganley, 1989. Domestic violence is a pattern of controlling and assaultive behaviors carried out in the context of an adult intimate relationship. The pattern may include physical, sexual, and/or psychological attacks. The victim and the perpetrator are intimates, usually family (or ex-family) members. The victim in this situation is affected in many of the same ways as that of a victim of “stranger violence.” In addition, unique affects occur because the perpetrator (abuser) is an intimate. In this situation the physical injury and terror that occurs from either type of attack is also often accompanied by feelings of shame and guilt. Further anxiety is caused by the realization that the perpetrator is not a stranger, but, instead has ongoing access to the victim, knows the victim's daily routine and resources and is in a position to exert considerable power and control over the victim's daily life (physically, emotionally, and economically). Domestic violence is merely the latest term to be applied to a very old problem. Previous common terms were wife-beating, woman abuse, spouse abuse, marital assault, conjugal violence, or battering. These labels tend to reflect different efforts to focus on gender issues, the “marital” nature of the violence and of attribution of responsibility for the violence (Ganley, 1989). Historically, domestic violence has been noted to exist as far back as written records extend. How society viewed it varied greatly depending on how that particular society viewed the status of women. It was sometimes encouraged as an appropriate way to maintain an orderly household (Fortune, 1987). In the history of the Western world, religion and laws have taken a strong stand in designating women as inferior to men and in need of guidance, discipline, and control by men. This starts with the creation story, where Eve “led Adam astray” causing them to both get kicked out of the Garden of Eden. Among the other penalties, Eve was told “… he [your husband] shall be your master.” (Genesis 3:4) One of the more bizarre examples of this blaming of women was the 16th century European witch hunts, where many thousands of women were put to death for being witches. These largely religious attitudes toward women were later codified into law. English common law regarded the husband and wife as one unit, which was under the leadership of the man. He was responsible for the actions of his wife, children, and servants and therefore had the right to chastise them to “control their behaviors.” In the United States, as well as England, the law allowed the husband to control his wife with beatings, but imposed a limit. He could not use a stick larger in diameter than his thumb (hence the phrase “rule of thumb”). At other times domestic violence was viewed as a serious crime against the community. An example would be the Tlingit Tribe, native to southeast Alaska, where wife-beating caused the entire community to come together in a potlach where the abuser's clan made restitution to the victim's clan. This action made the consequences of such violence highly visible and expensive in material goods Fortune 1987 and Ganley 1989. Another example would be Australian aboriginal people. In general, societies where domestic violence is not tolerated tend to be those where women are on a more equal footing with men or even on a superior footing (matriarchal society). Domestic violence is by far the greatest single cause for serious injury to women. In this country a women is beaten every 15 seconds (Bureau of Justice, 1983). It accounts for more cases of major injury than rapes, muggings, or automobile accidents combined (Federal Bureau of Investigation, 1991). Twenty-two to 35% of hospital emergency room visits by women are the result of domestic violence injuries (U.S. Surgeon General, 1992). A woman is nine times more likely to be assaulted in her own home than on the street. Battered women are more likely to suffer miscarriages and to give birth to babies with low birth weights (Randall, 1990). According to Federal Bureau of Investigation (1988) crime reports, one third of all female homicide victims were murdered by a current (or former) husband or boyfriend. A more detailed study that looked specifically at one-on-one murder and non-negligent manslaughter cases from 1980–1984, showed that 52% of the women were killed by “male partners” (Brown & Williams, 1987). On the other side of the coin, 63% of the young men between the ages of 11 and 20 who are serving time for homicide have killed their mother's abuser (March of Dimes, 1992). “More than 50% of all women will experience some form of violence from their spouse during marriage. More than one third will be repeatedly assaulted every year” (National Coalition Against Domestic Violence, 1992). As demonstrated by cold statistics, it is obvious that domestic violence is highly painful and lethal to its victims. What the statistics do not convey is the immense level of fear, anxiety, and hopelessness engendered in the victim as a consequence of the violence and, in some respects, even more by not knowing when that violence will erupt.

Dealing with domestic violence in your practice will initially feel as awkward and uncomfortable as was dealing with addiction topics when you first undertook to do this. However, like addiction, there is a logical, effective method of handling the issue. Also, like addiction treatment, the failure to address the issue costs lives (Coleman Straus 1983)/p>