People surviving violence in their relationships and families may be experiencing increased isolation and danger caused by social distancing during the COVID-19 pandemic. Added stress and financial strain can negatively impact survivors and create circumstances where their safety is further compromised. Audrey Jiricko, MD, answers questions about intimate partner violence and how to get help.

Intimate partner violence is perpetrated by someone who is an intimate partner or was in the past or wishes to be in the future. It’s a pattern of controlling, coercive behaviors that are meant to establish power and control over another person. It could include physical violence or sexual violence, but if you look at the power and control wheel, a lot of people forget about the psychological aggression that’s so important in these relationships. 

Some of my patients who are in the most dangerous relationships have never had a black eye, they've never been sexually assaulted, but their every move is controlled. From the time they wake up to the time they go to bed, they're told whether or not they can leave the house, what they should wear, how they should do their hair, who they can associate with. If you look at the power and control wheel, these are just tools that are used to maintain that power and control. Controlling partners often use name calling and put downs which can be toxic. They isolate victims from supportive friends and family members. When called out on these behaviors, they often deny, minimize and actually blame the victim for their behavior. They may leave victims out of all important decision making, not letting them go to school, get a job, keep a job or access bank accounts. Intimidation by looks, actions or gestures or threats of violence or suicide also can affect the health of victims. A lot of people experience all those things on the inside part of the wheel but have never been hit or sexually assaulted, so they don't consider themselves as necessarily being in a really unhealthy relationship, but all of those things really affect people's health.

These actions can cross all boundaries from socioeconomic to racial and religious. Intimate partner violence can affect couples in heterosexual relationships as well as same-sex relationships. It’s unfortunately a common and really serious problem that affects millions of Americans. The good thing is it’s a preventable public health problem.

This is the really exciting thing to me and why I keep talking about this issue because I see so much potential for healthcare providers because the evidence and data really does show that if we screen, particularly for women of reproductive age, if we screen all these women and we identify people who are in intimate partner violence relationships and we connect them to resources, that evidence shows that we decrease violence and we can improve health and decrease healthcare costs. So, huge opportunity for us.

Yes. It's important to know that healthcare systems are a really good places because there's free confidential help for them, and we can help connect the dots. We aren't the experts in this area, we can't solve all problems, but we are one piece of the puzzle as far as screening, identifying the problem and then connecting that patient to resources. So, it's a really good place to discuss this problem.

As you can imagine, we all feel isolated. Patients in intimate partner violence relationships are even more so isolated. Tensions have increased, financial stresses have increased and you look at families who are experiencing violence – in the past maybe the kids went to school and maybe the victim went to work or school herself – and now everyone is at home and not able to reach out to other people for help. That’s made things worse. We know from our domestic violence advocates that calls in Utah have increased 50 to 75%. 

In healthcare, it's been tough because often screen people at annual exams or some of the pediatricians are screening at well child visits, but we're only seeing essential visits right now, so that really minimizes the touch points with victims. But we are doing video visits at Intermountain Healthcare, and so I encourage people to reach out that way and we're just going to have to be creative for the next couple of months.

There are really four important things to understand:

1. You're not alone. Unfortunately, this is a common problem and so many of my patients who are experiencing this feels so isolated. Even without COVID, they felt isolated. And they felt really guilty and ashamed. But just know you're not alone. 
2. You don't deserve this. Nobody deserves to be treated like this, no matter what point you are in your life. So, say everything else in your life is going fantastic or maybe you have a substance abuse problem or maybe you have a mental health problem you're struggling with. No matter what is going on in your life, you do not deserve to be called names, put down and controlled. 
3. Think about the connection to your health because so many of my patients who are survivors and have been victims, they are tough. They're really tough, resilient, smart people and some are also  great parents doing what they can to survive, and so they're not pausing and thinking about how this really is toxic to their health – both  their mental health and their physical health, and so I encourage people to pause and think about that and think about reaching out to healthcare providers on the issue. 
4. Most importantly understanding there are teams of people available and just waiting to help out. There are advocates that can help you through the Utah Domestic Violence Link Line, to connect with the advocates in your area and develop a safety plan. And there are lawyers who can help out with legal matters, financial support may be available, and so really just try to safely reach out in the ways that you can. if you're unable to make a phone call, thehotline.org is a great place because they have a chat line, and all of these options are free and confidential.

Understand what your resources are. You need to know the Utah Domestic Violence Link Line, and thehotline.org, those are both amazing resources. As you go out and talk about this issue with friends and family members, assume there are going to be survivors there because one in three women in Utah will experience this in their lifetime. Studies also show that one in seven men in the United States experienced severe intimate partner violence. 

Just listen and believe. It’s so powerful to listen to people. They may talk in a roundabout way about the struggles they're having in the relationship, and often it's 10 times or 100 times more difficult than they're really saying. Really listen, believe people who say they've been sexually assaulted or experienced intimate partner violence and avoid the rescuer mode. It's human nature, and this was a real struggle for me as a physician, I want to identify problems and I want to fix problems, and that's it. It's very hard for me to screen for this problem that I am not going to fix. These are complicated problems that involve many issues.  Of course, if there’s an emergency, you should call 9-1-1, but the vast majority of time, we need to listen, believe, and help people connect to resources and not feel like we have to fix the problem.

Teach healthy relationships. We have a good form from the red flag campaign that looks at healthy versus unhealthy relationships, understanding and educating yourself on what that looks like, and then teaching our children from a very young age, from pretty much when they can first start speaking about what a healthy relationship looks like. We’re not going to make any progress on this unless we have boys and young men and adult men engaging in this, modeling and teaching healthy, nonviolent, consensual relationships and what that looks like.

Support local advocates. The Utah Domestic Violence Coalition helps support member programs who are spread across our state, and these advocates are doing the really hard work. They’re essential workers during COVID-19. They’re showing up, they’re creating safety plans with folks, they’re running shelters, and I think they're forgotten about during these times. So, whether it's just sending them a thank you note or appreciating them, sending them donations when it's acceptable during COVID, and just financially supporting these places. Most of them are working on shoestring budgets, so that would be my final advice and something we can all do.

• Staying safe during COVID-19
• Futures without Violence: COVID-19
• Intimate partner violence: You are not alone