7 The Perpetrator

Perpetrators come into the health care system both for problems related to their abusive behaviors and for those that are not. They are patients in emergency departments, primary care practices, or specialty clinics. They may be inpatients or outpatients. There are few published studies of prevalence for domestic violence perpetrators in the various clinics serving men (except Gondolf & Foster, 1991). However, certain medical centers (e.g., Veterans Administration Medical Centers, military medical facilities, some HMO’s) with on-site perpetrator intervention programs do report receiving referrals of abusers from medical personnel who see these patients in a wide variety of medical clinics.

Perpetrators sometimes seek health care assistance for physical injuries they caused to themselves in the process of striking their partners or when terrorizing them with attacks against property (e.g., broken hands, feet, limbs, back injuries, head injuries, internal injuries, muscle strains, burns, cuts). Sometimes they are seeking medical attention for illnesses aggravated by their abusive behavior (e.g., diabetes, asthma, high blood pressure, heart problems, depression). Sometimes they have injuries from suicide attempts made to coerce their partners to remain in the relationship. One  abuser  shattered  the bone of his lower leg when the sledgehammer he was using to destroy his partner’s apartment kicked back.) Another terroriized his partner by telephoning her and threatening for 30 minutes to kill himself with dynamite. As she listened helplessly, he blew off one of his arms. Both men were identified as domestic violence perpetrators by medical personnel during treatment for their physical injuries and were referred to domestic violence intervention programs.

Sometimes perpetrators are seeking medical care for injuries caused by the victims’ desperate attempts to protect themselves or their children or by victims who strike back after years of abuse (e.g., injuries from objects being thrown, burns, knife or gunshot wounds). Sometimes the batterers are in the system for problems totally unrelated to their abusive behavior (e.g., bone marrow transplant, spinal cord injury, post traumatic stress disorder, schizophrenia, gall bladder surgery).

There is no simple, predictive profile that can be used to determine whether or not someone is a perpetrator of domestic violence. However, there are some common characteristics of abusers that are helpful to keep in mind when interacting either with a victim or with a perpetrator.

1.     Perpetrators of Domestic Violence Can Be Found in All Age, Racial, Socioeconomic, Educational, Sexual Orientation, Occupational, and Religious Groups

Perpetrators are a very heterogeneous population whose primary commonalty is their use of violence. They may be young, old, or in-between. They may be artists, athletes, teachers, health care providers, professionals, working class, unemployed, middle class, rich, or poor. They may be Protestant, Catholic, Muslim, Jewish, Buddhist, agnostic, or atheist.

Perpetrators do not fit into any specific personality or diagnostic category. While there is a great deal of discussion in the literature about the psychological profile of batterers, especially as it relates to predict- ing outcome in their rehabilitation (Saunders, 1993), it is premature to offer personality profile(s) for abusers. There appear to be clusters of personality charac- teristics for different abusers (Tolman & Bennett, 1990; Hamberger & Hastings, 1990; Saunders, 1992), just as there are clusters of personality characteristics for non-abusers. The literature suggests that there are different types of batterers who use different controlling tactics to different degrees (Gondolf, 1988; Issac, Cockran, Brown & Adams, 1994). Part of this variance may be explained by different types of batterers or by the fact that those studied are at different stages in their own histories as batterers.

The diversity of perpetrators is limited only by the diversity represented in a community. Sometimes a health care provider or community agency will deal with one group more than another (e.g., a particular socioeconomic class, ethnic group, or age group). This may lead to some inaccurate generalizations about perpetrators (or victims) as providers start to think of abusers solely in terms of the cases they see. In order not to make errors in identification of domestic violence, the health care provider should remain open to the possibility of domestic violence being an issue for diverse individuals. Clinical experience is a reminder that perpetrators come in many forms and ultimately can only be identified by knowing how they relate to their intimate partners.

2.     Domestic Violence Perpetrators Avoid Taking Responsibility for Their Conduct by Minimizing, Denying, Lying About or Justifying Their Abusive Tactics

Perpetrators minimize their abusive conduct and its impact on the victim and others by making the abuse appear less frequent and less severe than it really is (e.g., “I only hit once,” “I just pushed her to the floor,” “The children never saw the abuse,” “She bruises easily,” “I’m not one of those wife-beaters. I have never punched her”). In talking with others about the problem, perpetrators will sometimes use euphemisms for their violence, such as “We’re not getting along so well” or “We had a little fight last night,” when referring to incidents in which the victim required major medical attention for serious injuries.

Sometimes perpetrators acknowledge what they do, but justify it by externalizing responsibility for their behavior to others or to factors supposedly outside their control. The health care provider will hear many different ways abusers justify or blame others for their abusiveness. Perpetrators primarily blame the victims for the violence: “She wouldn’t listen to me,” “She’s an alcoholic,” “She’s crazy,” “I can’t handle her,” “My lover is the abuser,” “This pregnancy has made her wild,” “She’s suffering from post-partum depression,” “She’s clumsy,” or “She’s running around on me.” They also blame other factors: “I have PTSD (post-traumatic stress disorder)/hypoglycemia/ attention-deficit disorder/mood swings,” “I was drinking,” “The kids are just too much,” or “The EMT got his facts wrong. I didn’t do nothing that you wouldn’t do.” Sometimes they do not lie about their behavior because they believe they have the right to do what they do. When blaming, perpetrators fail to mention their violent behaviors and avoid taking responsibility for them.

Sometimes perpetrators lie about their abuse to avoid the external consequences of their behavior and to maintain control over their partner. They will lie to the victim, family, friends, police, judges, health care providers, and anyone else who has contact with them. They lie because they do not want to deal with possible consequences (e.g., arrests, prosecution, jail, loss of visitation, etc.).

Sometimes perpetrators use denial and minimization not only to avoid the external consequences but also to protect themselves from the personal discomfort of recognizing that they are abusing someone they love. This denial is a means of deceiving themselves. Just as there are alcoholics who are in denial about their drinking, there are perpetrators in denial about their battering. There are some perpetrators who are conflicted about what they are doing and they distort it through minimization, denial, or rationalization to make it more acceptable to themselves.

Regardless of why a perpetrator is distorting the truth, this distortion can be misleading to both victims and to health care providers and can present barriers to identifying domestic violence. Health care providers should be aware of perpetrators’ tendency to lie, deny, or minimize the violence and avoid colluding with abusers.

3.     Domestic Violence Perpetrators Control the Victim Through the Health Care System

Perpetrators use multiple tactics of control against the victim. Sometimes they enlist others in that control either through disinformation or intimidation. The tactics of control may be used to coerce the victim to stop talking about the abuse with the health care worker, to reunite with the perpetrator, to drop her objections to joint custody, etc. The following are examples of controlling behaviors that the health care practitioner may witness or hear about.

■     Stalking the victim to and from health care appointments;

■     Accompanying the victim to all appointments; sending the victim “looks” during appointments; refusing to let the victim be interviewed or examined alone;

■     Bringing family or friends to the medical facility to intimidate or cajole the victim or the health care provider;

■     Blaming the victim through long speeches about all the victim’s behaviors that supposedly “provoke” the abuse;

■     Crying and other displays of emotion or statements of profound devotion or remorse to the victim, alternated with threats or other psychological abuse;

■     Canceling the victim’s appointments with the health care provider; sabotaging her efforts to attend appointments by not providing child care, transportation, etc.;

■     “Physician-hopping” or “therapist- hopping;”

■     Denying the victim access to the perpetrator’s medical records that may support her issues or attempting to control or gain access to her medical records;

■     Withholding medication; under- or over-medicating the victim;

■     Using the legal system against the victim by requesting mutual orders of protection, making false charges of harassment/abuse against the victim, filing multiple divorce proceedings;

■     Continually testing the limits of visitation/support agreements by arriving late or not showing at appointed times or arriving drunk;

■     Threatening and/or implementing custody fights; and

■     Using any evidence of damage resulting from the abuse as evidence that the victim is an unfit parent (victim’s counseling records, victim’s treatment for depression or other medical  conditions, etc.).

Sometimes in his attempts to control the victim, a perpetrator will attempt to control the health care provider with the same tactics of power and control used against the victim.

■     Portraying self as the good patient who constantly praises the health care provider;

■     Intimidating the health care provider with a variety of threats or acts;

■     Harassment of health care provider by repeated phone calls, civil suits or threats of legal action, or false reports to superiors concerning supposed breaches of confidentiality, inappropriate treatment, or rude behavior;

■     Splitting health care teams by creating divisiveness among professionals (e.g.,”The doc is one of those women’s libbers,” “The nurse doesn’t like me,” “He takes my wife’s side”).

4.     Domestic Violence Perpetrators May Have Good Qualities in Spite of Their Abusiveness

Some domestic violence perpetrators may be good providers, hard workers, good conversationalists, witty, charming, attractive, and intelligent, yet they still batter their victims. Sometimes health care providers as well as victims are misled by these positive qualities and assume that the violence did not really happen or is an aberration of the perpetrator’s real personality since only individuals who are “monsters” could commit such acts. They may believe that the violence can be ignored because such a “good” person will most certainly stop the abuse. The reality is that even seemingly normal and nice people may batter and may be very dangerous. Battering stops only when perpetrators are held responsible for both their abuse and for making the changes necessary to stop the violence.

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