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Universal Screening for Intimate Partner Violence: A Systematic Review

Article in Journal of Marital and Family Therapy · July 2011

DOI: 10.1111/j.1752-0606.2009.00179.x · Source: PubMed

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Journal of Marital and Family Therapy
doi: 10.1111/j.1752-0606.2009.00179.x
July 2011, Vol. 37, No. 3, 355–369

UNIVERSAL SCREENING FOR INTIMATE PARTNER

VIOLENCE: A SYSTEMATIC REVIEW
Jeff Todahl
University of Oregon

Elaine Walters
Trauma Healing Project

Intimate partner violence (IPV) is known to be prevalent among therapy-seeking popula-

tions. Yet, despite a growing understanding of the dynamics of IPV and of the acceptabil-
ity of screening, universal screening practices have not been systematically adopted in
family therapy settings. A rapidly growing body of research data—almost entirely
conducted in medical settings—has investigated attitudes and practices regarding universal
screening for IPV. This article is a systematic review of the IPV universal screening
research literature. The review summarizes literature related to IPV screening rates and
practices, factors associated with provider screening practice, the role of training and
institutional support on screening practice, impact of screening on disclosure rates, client
beliefs and preferences for screening, and key safety considerations and screening
competencies. Implications for family therapy and recommendations for further inquiry
and screening model development are provided.

When women had discussed abuse with providers, it was generally because they had
been asked. (McNutt, Carlson, Gagen, & Winterbauer, 1999, p. 89)

Nearly a decade ago, Bograd and Mederos (1999) urged psychotherapists to screen all ther-
apy-seeking individuals for intimate partner violence (IPV).1 Proponents of universal screening
argue that routine screening is warranted as (a) IPV is prevalent in society and disproportion-
ately frequent among many client populations; (b) IPV is negatively correlated with well-being;
(c) IPV should be uncovered, if it is occurring, to provide useful and safe services; and
(d) spontaneous disclosure of IPV is unlikely (Phelan, 2007; Stith, Rosen, & McCollum, 2003;
Todahl, 2003). More cautionary positions, presumably held by many practitioners, seem to be
grounded in concerns that universal screening may (a) be overly intrusive; (b) alienate clients
and patients;2 (c) blur the boundary between clinical assessment and forensic investigation; and,
most importantly (d) inadvertently increase violence (Hamberger & Patel, 2004; Minsky-Kelly,
Hamberger, Pape, & Wolff, 2005; Tower, 2006). Should family therapists, regardless of the
presenting issue, raise sensitive questions about interpersonal violence with every adult client? Is
this necessary? Is it safe? Are therapy-seeking individuals in favor of such practices?
Among all health care professions, these questions may be particularly pertinent for family
therapists. Anecdotal evidence suggests that among those couples who seek help for IPV,
couples therapy is one of their most commonly sought and preferred forms of help (C. Rexius,
personal communication, June 20, 2008). These individuals and relationships often enter therapy
with particular interpersonal dynamics and social-contextual experiences. They have likely, for
instance, debated about who is to blame for the violence—or whether what has occurred is
violence at all. They may have struggled over the nature of their relationship (Watzlawick,

Jeff Todahl, PhD, Counseling Psychology and Human Services Department, University of Oregon; Elaine
Walters, Executive Director, Trauma Healing Project, Eugene, Oregon.
Address correspondence to Jeff Todahl, Counseling Psychology and Human Services Department, University of
Oregon, 1655 Alder St., Eugene, Oregon 97403-5251; E-mail: [email protected]

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 355

Beavin, & Jackson, 1967): whether ‘‘I can define myself on my own terms and be who I choose
to be in relation to you.’’ There may be concern surrounding whether ‘‘I can express my point
of view without harsh verbal or physical reprisal.’’ And, given additional interpersonal factors
and social norms, there is often silence about the violence. For example, in a study conducted in
one Commission on Accreditation for Marriage and Family Therapy Education–accredited pro-
gram, only 12% of 262 families initially reported IPV as the presenting problem even though
IPV was occurring in at least 40% of the families (Stith, Rosen, Barasch, & Wilson, 1991).
Although many authors, practitioners, researchers, and advocates have urged universal
screening (Aldarondo & Straus, 1994; Bograd & Mederos, 1999; Greene & Bogo, 2002), it is
not yet clear how—or whether—family therapists routinely conduct screenings. Evidence sug-
gests that family therapists do not routinely screen for IPV (Schacht, Dimidjian, George,
& Berns, 2009), that actual screening practices vary widely (Todahl, Linville, Chou, & Maher-
Cosenza, 2008), and that medical3 providers overall receive little to no training around the
complexities, nuances, and mechanics of IPV screening (Mitchell et al., 2008). Although
thoughtful and useful screening guidelines do exist (e.g., American Psychological Association,
2002; Family Violence Prevention Fund [FVPF], 2004), most do not adequately account for the
unique ethical and practice issues associated with relational therapies.

Professional Associations and Universal Screening

A rapidly increasing number of professional associations now recommend universal
screening. They include, in part: the American Medical Association (AMA); the American
Academy of Pediatrics Committee on Child Abuse and Neglect (1998); the American College of
Obstetricians and Gynecologists; the American Academy of Family Physicians; the American
College of Nurse Midwives; the American College of Emergency Physicians; and the American
Academy of Nurse Practitioners. Among U.S. mental health professional associations, only the
National Association of Social Workers (2002) and the American Psychological Association
(2002) recommend universal screening. The American Association for Marriage and Family
Therapy has not issued a recommendation or practice guidelines specific to IPV universal
screening.
The specific guidelines and recommendations urged by these organizations vary—though
taken together they generally recommend that providers routinely screen all female patients for
IPV (Jonassen & Mazor, 2003; McCloskey & Grigsby, 2005). The AMA (1992) encourages
physicians to screen universally; their policy equates universal screening with prevention, prefer-
ring proactive procedures over a wait-and-see strategy that inquires about IPV only when signs
or symptoms of violence emerge (Nelson, Nygren, McInerney, & Klein, 2004). The National
Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health
Care Settings (FVPF, 2004) recommends screening all adult and adolescent female patients;
male patients are screened ‘‘when indicated.’’
Although many professional associations and organizations now recommend universal
screening, others have argued either that universal screening is not appropriate or that existing
evidence for the merits of screening is inconclusive. Ramsay, Richardson, Carter, Davidson,
and Feder (2002) argued that as insufficient evidence exists to verify whether screening is associ-
ated with improved health outcomes for women, it is ‘‘premature to introduce a screening
program for domestic violence in health care settings’’ (p. 12). Others have argued that it is not
known whether screening leads to a decline in abuse and, therefore, screening at this time is
not warranted (Nelson et al., 2004). The U.S. Preventive Services Task Force (USPSTF) found
that the risks and benefits of screening are yet to be confirmed by rigorously designed clinical
studies and, therefore, the USPSTF could not recommend for or against routine screening
(Berg, 2004). Others argue that screening should only be conducted when physicians and mid-
wives have received education about abuse and have enough knowledge about local resources
to be able to respond appropriately (Webster & Holt, 2004).

356 JOURNAL OF MARITAL AND FAMILY THERAPY July 2011

 The idea of IPV universal screening in family therapy raises important questions. Is univer-
sal screening, particularly when violence is not the presenting issue, an inappropriate encroach-
ment of therapists’ agenda? Is IPV screening likely to interfere with therapist–client
relationships? Or, perhaps, can screening potentially foster and improve those relationships?
Other questions center around safety. For example, to what extent may IPV screening actually
increase danger? And, might the mere act of raising the issue of violence stir a precarious situa-
tion and lead to violent retribution? IPV screening also creates complex ethical questions,
particularly with regard to couples and relational therapy. Separating couples to conduct an
IPV screen can create an ethics and practice quagmire; it is complex and wrought with confi-
dentiality and boundary dilemmas. Finally, who should initiate a conversation about IPV, and
under what conditions, is not well established.
For the purposes of this article, screening is defined as a relatively brief information collec-
tion and preventive health care service in which ‘‘specific tests, standardized questions, or exam
procedures are routinely used to identify individuals who require specific interventions to
improve health’’ (Phelan, 2007, p. 204). IPV universal screening and assessment, in particular,
is a procedure that involves directly questioning—in writing and orally—every adult client,
regardless of the presenting issue(s), about current and previous IPV victimization (Bograd &
Mederos, 1999; Phelan, 2007; Todahl, Miller, & Platt, 2003; U.S. Preventive Services Task
Force, 2004). This article reviews the IPV universal screening research literature, with particular
emphasis on (a) medical providers’ attitudes and practices and (b) patients’ responses and per-
ceptions of IPV universal screening and assessment. Based on this review, training and screen-
ing practice recommendations are provided.

Article Selection Methods

Because research on IPV screening in nonmedical fields is extremely limited, this systematic
literature review draws on research almost completely conducted in the medical field.4 The
review, based on methodology described by Petticrew (2006) and Stevens and Milne (1998),
included several general criteria by which article eligibility was determined. These selection ele-
ments were grounded in the following questions: (a) did the study directly address at least one
of the literature review organizing questions (Table 1); (b) did the study include the targeted
population (i.e., health care recipient); (c) was the study conducted in a targeted setting (i.e., a
health care setting); (d) did the study use a well-established research design that seems appro-
priate given the research question(s); and (e) did the study meet minimum quality standards (as
outlined below). Based on these general criteria, for example, selected articles must have (a)
used qualitative, quantitative, or mixed methods design; (b) been published in a peer-reviewed
journal; (c) specifically investigated IPV universal screening in health care settings; and (d)
investigated at least one of the questions listed in Table 1.

Table 1
Literature Review Organizing Questions

1. What is the relationship between IPV universal screening and IPV detection rates?
2. What factors contribute to health care provider IPV universal screening practices?
For example, what distinguishes providers who screen on a routine basis from those
who do not screen?
3. How do clients ⁄ patients generally regard IPV universal screening? Do they approve
or disapprove?
4. What is the relationship between IPV universal screening and client ⁄ patient safety? What
is the relationship between IPV universal screening and client ⁄ patient health outcomes?

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 357

 Based on predetermined criteria, articles were included only if they met the following meth-
odological standards and included the following information: (a) IPV screening intervention
studies must have reported baseline data, pretest data, or between-group comparisons; (b) a
description of sample selection methods; (c) a statement outlining the research question(s); (d) a
description of data analysis; and (e) a listing of study limitations. These low-threshold criteria
were selected because of the overall scarcity of IPV universal screening research-based publica-
tions in the literature and given our desire to be more, rather than less, inclusive of diverse pop-
ulations in varied practice settings.
Studies published between January 19925 and January 2008 were searched via PsychINFO,
Psychology and Behavioral Sciences, Web of Science, Summit Union Catalog, and Medline.
Search terms included ‘‘intimate partner violence,’’ ‘‘universal screening,’’ ‘‘domestic violence,’’
‘‘risk,’’ and ‘‘assessment.’’ This search and a review of reference lists identified 1,021 articles.
Dissertations, studies that did not specifically address IPV screening (e.g., child maltreatment
screening), and peer-reviewed articles that did not include primary data collection or secondary
data analysis were excluded. Articles that reported on IPV screening instrument development
(e.g., Jory, 2004) and that investigated rates of IPV but did not specifically examine screening
protocols or screening attitudes and knowledge (e.g., Parkinson, Adams, & Emerling, 2001)
were also excluded.
Based on these criteria, the first author conducted the initial inclusion and exclusion selec-
tion decision. Following this preliminary sort, articles were included or excluded by consensus
between both authors. Based on this process and the selection criteria, 86 studies are included
in this review. All included articles were sorted by methodology (qualitative and quantitative),
participant type (provider, client ⁄ patient, or both), and purpose of the study (i.e., test an IPV
screen intervention; survey of IPV knowledge, attitudes, and beliefs). Table 2 summarizes these
findings.
The qualitative studies and quantitative descriptive survey-based studies included in this
review largely investigated patient and provider IPV screening attitudes, beliefs, concerns,
practices, and preferred practices. Provider survey participants included nurses (n = 1,642),
physicians (n = 7,288), mental health providers (n = 48), pediatric chief residents (n = 127),
medical residents (n = 538), psychiatrists (n = 817), social workers (n = 221), and dentists
(n = 358). Among provider survey participants’ gender differed widely by physician status.
Physician survey respondents were 64.3% male (n = 3,766); nonphysician survey participants
were 7.6% male (n = 84).
The intervention studies investigated the influence of an IPV screening activity (largely
IPV training) on (a) screening, detection, and documentation rates; (b) provider knowledge,
attitudes, comfort, and IPV screening self-efficacy; (c) skill acquisition; (d) IPV referral and
safety assessment behavior; (e) client ⁄ patient preferences; and (f) client ⁄ patient satisfaction.
The intervention studies occurred in varied health care settings (e.g., emergency department
6, family practice ⁄ primary care 7, community health 5, pediatrics 4, and university 3). Other
settings included managed care, obstetrics, urgent care, postpartum home visits, prenatal
clinics, and a women’s health clinic. Thirteen of the provider intervention studies included
physician participants, while other intervention studies included nurses (5), social workers
and psychologists (4), paramedics (1), administrators (1), and ‘‘other’’ providers (3). Finally,
the intervention studies were classified by methodology: (a) nonrandomized pre–post
(n = 23), (b) quasi-experimental design (n = 2), and (c) randomized between-group designs
(n = 6).

SYSTEMATIC REVIEW SUMMARY

The review was organized by the questions outlined in Table 1 and included the following
categories: IPV screening rates and practices, factors associated with provider screening prac-

358 JOURNAL OF MARITAL AND FAMILY THERAPY July 2011

 Table 2
Summary of Study Categories and Participant Characteristics

Quantitative Quantitative
Variable Qualitativea descriptive ⁄ surveyb interventionc

No. studies 14 41 31
Total n 372 21,433 10,849
Patient gender
Female 210 (100) 9,885 (95.1) 3,239 (100)
Male 0 509 (4.9) 0
Provider gender
Female 126 (77.8) 3,865 (42.3) 307 (72.8)
Male 36 (22.2) 5,262 (57.6) 115 (27.2)
Patient race
Asian 0 145 (3.2) 38 (2.9)
Black 59 (28.1) 753 (16.7) 741 (55.1)
Latino 53 (25.2) 277 (6.2) 64 (4.8)
White 98 (46.7) 3,109 (69.0) 440 (32.7)
Other ⁄ mixed 0 216 (4.8) 64 (4.8)
Provider race
Asian — 206 (6.6) —
Black — 114 (3.6) —
Latino — 157 (5.1) —
White — 2,489 (79.6) —
Other ⁄ mixed — 157 (5.1) —

Notes: Values in parentheses are expressed in terms of percentage.

a
Provider racial data included in 3 ⁄ 7 studies; reported as ‘‘white’’ and ‘‘non-white.’’
b
Provider racial data included for 3,123 ⁄ 11,039 participants.
c
Inadequate provider racial data included in studies.

tice, the role of training and institutional support on screening practice, impact of screening on
disclosure rates, and client response to screening.

IPV Screening Practices and Rates

To what extent are medical providers and therapists screening for IPV? And, when they do
screen, what do they tend to do? In the only qualitative exploratory study of family therapy
graduate students and IPV universal screening, researchers concluded that participants varied
widely in their most common practice patterns (Todahl et al., 2008): ‘‘Some waited for red
flags, while others screened routinely. Some routinely separated couples while others believed a
separation of this kind is rarely warranted’’ (p. 39). This finding is replicated in many studies in
a variety of medical settings (Phelan, 2007; Stayton & Duncan, 2005).
Evidence also suggests that universal screening occurs at low rates (Allen, Lehrner, Matti-
son, Miles, & Russell, 2007). For example, a survey of pediatricians and pediatric care-provid-
ing family practice physicians (n = 903) concluded that 12% of respondents routinely screened
for IPV at all well-child care visits, while 61% screened ‘‘selectively,’’ and 30% did not screen
at any time (Lapidus et al., 2002). In a sample of primary care physicians (n = 400), 11% of
physicians who provide prenatal care routinely screened during the first prenatal visit, while

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 359

10% of physicians routinely screened for IPV during new visits and 9% screened during peri-
odic checkups (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999). Similarly, Elliot, Nerney,
Jones, and Friedmann (2002) reported an overall screening rate of 10% among 1,103 surveyed
physicians. Overall, relative to family practice settings, screening more frequently occurs in pre-
natal and gynecological practices (Plichta, 2007) and screening rates overall reported in the
literature typically range from 1.5% to 39%, depending on setting (Renker & Tonkin, 2006).
Another study concluded that of 4,641 female emergency department patients, less than 25%
indicated they were asked about IPV by emergency room staff (Glass, Dearwater, & Campbell,
2001). Stayton and Duncan (2005), in a review of 32 descriptive studies, indicated that 3% to
41% of physicians routinely conduct IPV screens. Median screening percentages, when taking
into account provider surveys, chart reviews, and patient surveys, were estimated to be
15.5–22.7% (Stayton & Duncan, 2005). Empirically investigated IPV screening rates for family
therapists have not been reported in the literature.
In emergency departments and acute care settings where providers frequently encounter
IPV, rates are also reportedly quite low. In one study, 29% of emergency department charts
indicated a screen had occurred (Richter, Surprenant, Schmelzle, & Mayo, 2003). A study con-
ducted in a child welfare setting—also serving a population where risk is typically quite
high—indicated that only 43.1% of all families referred to the child welfare system were
assessed for IPV (Hazen et al., 2006).

Factors Associated With Provider Screening Practice

Several factors are associated with whether or not providers routinely screen for IPV, includ-
ing beliefs and attitudes about IPV, provider comfort level and sense of self-efficacy, and degree
of institutional support (Blasko, Winek, & Bieschke, 2007; Chamberlain & Perham-Hester, 2002;
Jaffe, Epling, Grant, Ghandour, & Callendar, 2005; Tower, 2006). With regard to attitudes and
beliefs, providers are less likely to routinely screen for IPV when they believe that (a) it will likely
do more harm than good (Dowd, Kennedy, Knapp, & Stallbaumer-Rouyer, 2002); (b) time does
not allow for screening (Erickson, Hill, & Siegel, 2001); (c) patients will be unresponsive or even
offended (Elliot et al., 2002; Gerbert, Gansky, & Tang, 2002); (d) screening is not within their
professional role (i.e., not a medical problem; Coker, Bethea, Smith, Fadden, & Brandt, 2002;
Jaffe et al., 2005); and that (e) IPV is not a problem among their patients or clients (Chamberlain
& Perham-Hester, 2002; Erickson et al., 2001).
Chamberlain and Perham-Hester (2002), in a survey of physicians (n = 305), concluded
that two factors were primarily correlated with physicians’ screening practices: (a) perceived
prevalence of abuse in their patient population and (b) physicians’ belief that they have a
responsibility to address partner abuse. Physicians ‘‘who estimated that 10% or more of their
female patients had experienced abuse were eight times more likely to have screened at initial
visits than physicians who estimated less than 5% of their patients had experienced abuse’’
(p. 63). Moreover, physicians who agreed that they have a responsibility to deal with abuse,
compared to physicians who were neutral or disagreed, were more than two times as likely to
screen at initial visits. When patients present with injuries, 86% of physicians asked direct,
specific questions about abuse; less than 10% did so in the absence of obvious physical
injury.
Provider comfort and confidence in intervening with IPV also seem to be highly associated
with screening behavior. Among family therapy interns, Todahl et al. (2008) found that
although participants varied in their attitudes and beliefs about universal screening, they unani-
mously expressed high anxiety and low confidence in their ability to effectively intervene with
IPV. Physicians report similar anxiety centered around (a) their ability—and anyone’s abil-
ity—to be helpful when a disclosure is made and associated feelings of futility (Cohen, DeVos,
& Newberger, 1997; Glowa, Frasier, & Newton, 2002; Waalen, Goodwin, Spitz, Petersen, &
Saltzman, 2000); (b) concern about insufficient resources (Garimella, Plichta, Houseman, &

360 JOURNAL OF MARITAL AND FAMILY THERAPY July 2011

Garzon, 2000); (c) discomfort in asking IPV screening questions (Jonassen & Mazor, 2003); (d)
anxiety about screening costs outweighing its benefits (i.e., ‘‘Pandora’s box),’’ including distrust
in the competence and capacity of the social service system (Dowd et al., 2002); and (e) general
anxiety about their own IPV knowledge level (Dowd et al., 2002). It is likely that family thera-
pists experience similar anxieties, concerns, and questions.

The Role of Training and Institutional Support on Screening Practice

Although research results are mixed, generally IPV screening training increases providers’
sense of intervention self-efficacy and increases frequency of screening and detection rates (Gar-
cia, 2002; Jonassen & Mazor, 2003; Waalen et al., 2000). Providers indicate that lack of train-
ing, knowledge, and education about IPV are barriers to identifying, treating, and referring
victims of IPV, and low knowledge is correlated with lower rates of screening (Cohen et al.,
1997; Ferris, 1994; Waalen et al., 2000). In one survey of obstetrician–gynecologists (n = 962),
49% felt inadequate to effectively deal with abuse in their practices (including screening)
because of lack of training (Parsons, Zaccaro, Wells, & Stovall, 1995).
Education about IPV rates, behaviors, dynamics, and screening generally increases provider
IPV screening, though education in itself does not sustain screening behavior over time (Waalen
et al., 2000; Wiist & McFarlane, 1999). Self-efficacy and screening behavior are mediated by
environmental factors, such as institutional support and supervision (Larkin, Rolniak, Hyman,
MacLeod, & Savage, 2000). Providers are much more likely to routinely screen for IPV when
their work environment provides opportunities, support, and accountability to do so (Allen
et al., 2007; Campbell et al., 2001; Tower, 2003). A one-time screening training in an emergency
room in Auckland, New Zealand, increased the identification of abused women and improved
providers’ acute management of those disclosures, though these changes were not maintained at
12 months (Fanslow, Norton, & Robinson, 1999; Fanslow, Norton, Robinson, & Spinola,
1998). Larkin et al. (2000) investigated the impact of a disciplinary action policy on providers
who screened patients at a rate lower than the target percentage. In this study in an urban
emergency department, medical providers were sanctioned if their records reflected screening
rates below 90%. In a pre–post analysis of the disciplinary action policy intervention, screening
rates rose from 29% of patients to 72.8% of patients overall.
Providers are more likely to screen when they ‘‘perceive their organization to be in support
of universal screening, when written screening policies exist, when standardized procedures for
screening, safety, and subsequent interventions are in place, when enforcement procedures exist
for staff (e.g., chart audits), and when brochures and posters are on display’’ (Allen et al.,
2007, p. 115). However, systemwide screening guidelines are not common in medical and social
service settings (Allen et al., 2007; Hazen et al., 2006; Jaffe et al., 2005). For example, in one
study only 28.5% of social workers, family practitioners, and gynecologists (n = 388) believed
that their institution had IPV screening guidelines (Tower, 2006). It is likely that screening
guidelines and institutional support are at least as equally underdeveloped in family therapy
practice settings.

Impact of Screening on Disclosure Rates

Emerging evidence suggests that screening generally increases patients’ disclosure of vio-
lence. Several studies, for example, concluded that at least 80% of IPV survivors disclosed their
abuse when screened (Hathaway, Willis, & Zimmer, 2002; Kramer, Lorenzon, & Mueller, 2004;
Krasnoff & Moscati, 2002). In a pre–post comparative study that tracked the number of IPV
referrals from a general pediatric clinic before implementation of the Partner Violence Screen
(PVS), researchers reported significant increases in identification of IPV (Holtrop et al., 2004):
In the 12 months before use of the PVS, our social work department received 9 refer-
rals because of DV from the general pediatric clinic, among a total of 5,446 guardians

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 361

 bringing 6,380 children for a total of 13,576 patient-care visits. In contrast, the social
work department received 164 referrals because of positive screening results among
5,445 caretakers ⁄ guardians bringing 7,429 children for 17,346 patient care visits in the
12-month study period after introduction of the PVS. (p. 1253)

In this setting, in the first year of screening, researchers reported that they identified nearly
‘‘17 times more domestic violence cases than in the previous year’’ (p. 1255). Increases of this
nature have been reported elsewhere in the literature (Moscati, Byrnes, & Krasnoff, 2000).
Several pre–post intervention studies concluded that adding a single, in-chart written IPV
screen question significantly increased rates of disclosure. For example, in a study that
included a review of 1,302 medical charts, Morrison, Allan, and Grunfeld (2000) found that
the addition of one screen question increased IPV detection rates from 0.4% to 7.5% during
the study period. Similarly, Freund, Bak, and Blackhall (1996) added a self-administered ques-
tion in a primary care setting that read, ‘‘At any time has a partner ever hit you, kicked you,
or otherwise physically hurt you?’’ The addition of this question increased IPV detection from
0% to 11.6%. Similar detection rates following a training intervention have been reported in
the literature (e.g., Shattuck, 2002). Finally, in a pre–post analysis of screening rates following
screening training and individual performance feedback for 12 medical residents, Duncan,
McIntosh, Stayton, and Hall (2006) reported an increase of screening from 60% of visits to
91% of visits.

Patient Response to Screening

Studies consistently find that female patients (survivors and nonsurvivors) believe that
it is appropriate for health care providers to ask about IPV. (Plichta, 2007, p. 227)

Under certain important conditions, women largely endorse IPV universal screening (e.g.,
Allen et al., 2007; Phelan, 2007; Plichta, 2007; Thackeray, Stelzner, Downs, & Miller, 2007).
Many patients endorse screening at very high rates (Tower, 2006). For example, in a survey of
1,313 women, 98% believed it is a ‘‘good idea’’ to screen for violence and 97% ‘‘felt OK’’ dur-
ing the screen process (Webster, Stratigos, & Grimes, 2001). Two percent of participants in this
study believed that providers should not routinely inquire about IPV. Caralis and Musialowski
(1997) found that a majority (74%) of women want their physicians to ask about IPV and most
(68%) would report if asked, yet only 12% were so asked. Burge, Scheider, Ivy, and Catala
(2005), the only researchers in this review to include male patients, reported that 96% of male
(n = 84) and female (n = 169) patients believed physicians should ask about ‘‘family conflict.’’
In addition, a survey of 645 young women (ages 15–24) found that 90% of participants
believed that IPV screening by a medical provider is a ‘‘very good’’ or ‘‘somewhat good’’ idea
(Zeitler et al., 2006).
Intimate partner violence screening also is largely endorsed by IPV victims and survi-
vors (Tower, 2006). For example, in a study of 4,641 women in 11 hospital emergency
departments, a vast majority of abused and non-abused participants supported routine
screening, though less than 25% were asked about violence by emergency room staff (Glass
et al., 2001). Also in this study, ‘‘women in all IPV categories overwhelmingly supported
routine screening (80–87%), with non-abused women being most supportive (89%)’’
(p. 147). Moreover, although many women who are physically abused by their partners do
not discuss these incidents with their physicians, they nevertheless largely prefer that their
providers inquire about violence (Fogarty, Burge, & McCord, 2002; Rodriguez, Sheldon,
Bauer, & Perez-Stable, 2001). In one survey, women who had experienced physical violence
in the last year were significantly less likely (p < .05) to report that they believed IPV
screening is a good idea, though even 80% of this group was in favor (Zeitler et al., 2006).

362 JOURNAL OF MARITAL AND FAMILY THERAPY July 2011

Finally, Krasnoff and Moscati (2002) found that of 528 women identified as IPV victims in
an urban emergency department, 475 (89%) agreed to speak to an advocate—and of those,
258 (54% of those seen by the advocate) accepted case management. The authors remarked:
‘‘It is remarkable that 85% of IPV victims accepted the opportunity to speak with an advo-
cate’’ (p. 490). In this study participants seemed to be quite willing to extend a conversation
about their victimization beyond the narrow scope of an IPV screen. These findings were
corroborated by all of the seven qualitative studies in this review that inquired about
patient beliefs about IPV universal screening (e.g., Belknap & Sayeed, 2003; Chang, Decker,
et al., 2005; Dowd et al., 2002).
Naturally, screening is not preferred by everyone and important disclosure barriers exist
for patients. For example, Thackeray et al. (2007) found that 7.9% of women surveyed indi-
cated they would feel angry or offended if questioned about IPV victimization. In a study of
1,010 women in a primary care setting, 20% (n = 202) objected to IPV universal screening if
violence were not the purpose of their visit (Richardson et al., 2002). Authors of a systematic
literature review of 20 peer-reviewed quantitative studies concluded that 43–85% of female
respondents were in favor of IPV universal screening (Ramsay et al., 2002). This variability is
likely because of real preferred differences, setting, and the scope of the actual screening ques-
tion. Quantitative or qualitative research that investigates family therapy client attitudes about
an actual screening experience has not been reported in the literature.
Research suggests that patients are more likely to support universal screening under condi-
tions well that include (a) privacy; (b) a nonjudgmental, nonpressured, and supportive environ-
ment; and (c) informed consent—especially with regard to why a screen is being conducted,
who will have access to the information, and how the information may be used (McNutt, Wal-
termaurer, McCauley, Campbell, & Ford, 2005; Thackeray et al., 2007). Researchers consis-
tently conclude that many survivors strongly prefer that their medical provider ask privately
about IPV (Chang, Cluss, et al., 2005). In one study a participant stated: ‘‘The partner should
be directed, not asked, to leave the examination room’’ (Hamberger, Ambuel, Marbella, &
Donze, 1998, p. 580). In another study, 86% of female respondents indicated that they would
be more likely to disclose IPV if ‘‘I was sure the health care provider wouldn’t take any action
without my permission’’ and 84% if ‘‘I was sure that what I said would be kept totally confi-
dential’’ (Zeitler et al., 2006). Renker and Tonkin (2006) found that among the 66 women who
were both abused and screened during pregnancy, only 11 disclosed abuse (16.7% disclosure
rate). However, 29 abused women who denied abuse when screened by their medical provider
indicated they would have accurately disclosed their victimization if they had known that vio-
lence disclosure was legally reportable in their state only when a victim is seriously injured or
wounded with a lethal weapon (p. 348).

DISCUSSION

Several limitations of this systematic review should be considered. Articles were not
excluded based on their methodological merits. Therefore, although the review is likely quite
inclusive, the data by which conclusions are drawn are based largely on nonprobabilistic sam-
pling strategies, noncontrolled designs, and instruments that do not have well-established prop-
erties and constructs. In addition, no effort was made to identify relevant unpublished articles,
dissertations, and studies that may have been excluded from the publication record because of
nonsignificant findings. As such, we cannot determine the extent to which publication bias is a
factor in our findings. Finally, this review is conceptual only. Findings are based on our impres-
sions of the preponderance of the data rather than on a systematic, numerical synthesis of the
IPV screening literature.
Additionally, the data include very few male respondents, do not represent diverse popula-
tions well (e.g., many studies do not report racial status of providers, client ⁄ patient income

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 363

data, and urban ⁄ rural residency status of clients ⁄ patients), and very poorly represent family
therapists and other mental health providers. Patient socioeconomic information and perpetra-
tors’ attitudes and beliefs about screening are also largely missing in the data. Despite these
limitations, several tentative conclusions can be inferred from the literature, and this review cre-
ates a focal point for further inquiry. These conclusions and recommendations are described in
this section.
We believe that any effort to identify effective IPV universal screening practices should
weigh several factors that are often given light attention in the literature—including among the
articles in this review. For instance, researchers and clinicians have emphasized the risks associ-
ated with IPV screening. This conversation is vital, though should be extended to include the
risks associated with ignoring and failing to identify IPV. IPV screening presents certain risks,
as does providing counseling services in the context of unrecognized physical, sexual, or emo-
tional violence. Research that investigates strategies to mitigate both kinds of risks is needed.
In addition, we urge a careful review of IPV universal screening outcome expectations. What is
a successful screen? What are its hoped-for outcomes? In our view, although a disclosure of
violence can be one outcome of a successful IPV screen, markers of a successful screen should
be extended to include (a) harm reduction and an increase in well-being; (b) setting the stage
for future disclosures or help seeking—and identifying this particular setting as one of those
potential sites for disclosure (e.g., ‘‘it’s safe to talk about IPV here’’); (c) normalizing and giving
legitimacy to a discussion about IPV; (d) creating a connection (i.e., reducing isolation); (e)
interruption of internalized emotionally abusive messages (e.g., ‘‘you’re crazy’’); and (f) an
opportunity to provide practical information, including handouts, local resources, and refer-
rals—even when abuse is not disclosed. Further, the benefits of universal screening, relative to
selective screening (i.e., when indicated because of red flags), have also been given little atten-
tion in the research literature. The merits of universal screening, for instance, may include (a)
increased expertise and comfort for practitioners (and, subsequently, their clients) because of
routine experience; (b) avoidance of clients’ sense of being singled out because of a personal
characteristic, circumstance, or symptom; and (c) creation of an opportunity for IPV-related
education ⁄ questions and answers whether or not the client has direct experience of IPV.
Based on this systematic literature review, it appears that IPV universal screening instruc-
tion generally increases providers’ confidence in their ability to screen in a safe manner and
subsequent screening and detection rates, although these increases are usually not maintained
unless one’s practice environment includes an expectation for screening—including screening
policies, procedures, and practitioner accountability. Providers are perhaps also more likely to
screen when they believe that IPV is a factor in their patients’ lives and believe that screening is
their responsibility and within their role. Further, under certain conditions (e.g., nonjudgmental
attitude, privacy, and rationale provided for purpose of the screen), patients—including victims
of violence—are generally supportive of IPV universal screening (Krasnoff & Moscati, 2002).
Emerging evidence also suggests that IPV universal screening can be conducted safely, increases
rates of disclosure, and can lead to more appropriate handling of presenting and underlying
concerns (Phelan, 2007). However, although qualitative research suggests that generally patients
may appreciate a competently conducted screen and response to IPV disclosure, no controlled
experimental outcome studies have investigated the correlation between IPV screening,
increased well-being, safety, and health outcomes. Ramsay et al. (2002), in their review of the
screening outcome literature, ‘‘found little evidence for the effectiveness of interventions in med-
ical settings with women who are identified by screening programs’’ (p. 10). Others have drawn
similar conclusions (e.g., Nelson et al., 2004; Wathen & MacMillan, 2003).
The articles included in this review are almost exclusively drawn from medical journals and
are based, likewise, on data collected in medical contexts. Development of a line of research
that generates data and practice methods that are systemically minded and particularly relevant
for family therapy students, practitioners, supervisors, policy makers, and clients is needed

364 JOURNAL OF MARITAL AND FAMILY THERAPY July 2011

(e.g., Froerer, Brown, & Lucas, 2007). For instance, it is likely that many systemically oriented
clinicians are ambivalent and ⁄ or perplexed about the relationship between IPV universal screen-
ing and the ‘‘no secrets policy,’’ protective confidentiality, and the right to information dis-
closed by one party in the context of conjoint couples therapy. In addition, family therapy
supervision models have not incorporated IPV universal screening knowledge, and it is likely
that a majority of family therapy training clinics do not have established IPV screening policies
and procedures. Finally, although very useful curriculum materials exist in the family therapy
literature with regard to IPV overall (e.g., Haddock, 2002), empirically evaluated IPV universal
screening protocols6 do not yet exist and are needed. IPV universal screening models that build
on Bograd and Mederos’s (1999) pioneering recommendations, and that incorporate current
evidence, are also needed (Todahl & Walters, 2009). These protocols, in particular, should
address each of the following elements: (a) training on the prevalence and dynamics of IPV; (b)
information that distinguishes a continuum of violence, from mild, isolated violence to a con-
text of coercive control; (c) informed consent policies and language; (d) individual interview
procedures; (e) ethical considerations related to information disclosed in an individual session
in the context of conjoint therapy; (f) danger, lethality, and imminence literature; (g) procedures
associated with violence disclosure; (h) IPV-tailored safety planning; (i) personal attitudes and
self-efficacy; (j) adaptation of models for diverse populations (e.g., Shoultz, Phillion, Noone, &
Tanner, 2002); and (k) considerations with regard to screening adolescent clients.
Family therapists’ familiarity with the procedural details of universal screening, the nuances
to consider when working with IPV and diverse populations, and the potential benefits and
unintended negative consequences associated with screening are not well understood. In our
view, family therapists have a unique social and professional responsibility to more carefully
examine the role of IPV in our work, to carefully study emerging evidence related to IPV
screening, and to better educate ourselves about IPV and its relationship to clinical practice.
The act of routinely inquiring about IPV contrasts interpersonal and social silence surrounding
IPV. As such, a discussion about IPV universal screening raises important questions about
family therapists’ role in society, their role in clients’ lives, and the nature of therapist–client
relationships.

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NOTES
1
For the purpose of this article, IPV is defined as a pattern of assaultive and coercive
behaviors, including physical, sexual, and psychological attacks, as well as economic coercion,
that adults or adolescents use against their intimate partners (Koverola & Panchanadeswaran,
2004).
2
In this review, we will use the term patient rather than client as IPV screening research is
based almost entirely on patients in medical settings.
3
In this review, we will use the term medical to refer to providers who work primarily in a
traditional medical context (e.g., pediatricians in pediatric offices and nurses in emergency
rooms), as IPV screening research is based almost entirely on providers in these settings. We
use the term provider later in the article to suggest that findings in medical settings may general-
ize to providers in other settings, such as family therapists in outpatient mental health settings.
4
The vast majority of screening and assessment research has been conducted by the medical
community in medical contexts. A research study exclusively devoted to IPV universal screening
among family therapists has not been reported in the literature.
5
Based on the AMA’s IPV Screening Practice Guidelines publication date.
6
An IPV ‘‘protocol’’ can be defined as a comprehensive set of policies, procedures, and
instruments implemented at the agency ⁄ organizational level and carried out by individual
providers.

July 2011 JOURNAL OF MARITAL AND FAMILY THERAPY 369

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