When Home Isn’t Safe: Addressing Domestic Violence, Suicide, and the Mental Health Crisis

Hello, and I am your host, Dr. Val de Crowder, also known as Dr. V, a board certified emergency medicine physician that is committed to empowering you with life-saving health information. Please make sure to subscribe, like, or comment, and follow me on all social media outlets, um, YouTube, as well as my podcast, What the Health Is Happening. Today's topic is When Home Isn't Safe, domestic violence, suicide, and the mental health crisis, and how is it impacting all of us? Today's topic may be distressing for some listeners, and we are going to share crisis resources throughout this program. Today we're talking about two interconnected crises that are happening in homes in our neighborhoods and in our communities, and that show up in the emergency department every single day. Um domestic violence and suicide. As an emergency medicine physician, I have seen both walk through the doors of the emergency department. These are not mere abstract statistics. These are real people. These are mothers, fathers, sons, daughters, and um we need to know as a community that knows these folks how we can best support them. Last week I was I was really called to really change the topic for this week to this particular topic with the um murder suicide that involved the former uh Lieutenant Governor of Virginia, Justin Fairfax, and his wife um Dr. Serena uh Fairfax, who uh was a dentist. And you know, we decided to actually change the topic that that we had originally planned and actually instead actually talk about uh domestic violence and uh and suicide. And after we decided to change gears and work on this topic, and while we were working on this topic, um then the event occurred in Shreveport, Louisiana, uh, where uh Shamar Elkins killed his seven children, a cousin and also himself. And so I really want to actually kind of really break this down because there really is an intersection between domestic violence and suicide, and I want to kind of go over each of them separately and then how they kind of operate together and what you can do and what are the signs to actually make, you know, that you can uh recognize in your own community. So let's start with first the domestic violence piece of it, which is also sometimes called intimate partner violence. And basically, it is a pattern of behavior that is used by one person to gain or maintain power or control over another in an intimate relationship. So it can look like physical abuse, it can look like emotional abuse, it can look like psychological abuse, verbal abuse, name-calling, putting down people, cursing. It can also include sexual coercion, it can include uh financial abuse, being very controlling around financing, and it can also include digital or any sort of stalking abuse. Um, this actually impacts people of every race, every income level, all sorts of gender, age, and sexual orientation. It is not a private family matter. It is a public health emergency, and I want people to really see it from that perspective because that really allows you then to actually support and help family members that may be impacted by this. One in four women and one in nine men experience severe intimate partner violence in their lifetime. On average, three women are are murdered by intimate partners every day in the United States, and intimate partner violence accounts for about 15% of all violent crime in the United States. So only about half of domestic violence incidents are ever reported to the police. So there's another 50% that actually just never never get reported, no one ever really knows about them, and people are in those situations really suffering in silence. Um, children who witness domestic violence are more likely to experience developmental problems, mental health illnesses, and they may become victims or abusers themselves. Um African American women face disproportionately high rates of intimate partner violence homicide, nearly two and a half times more often than white women. And domestic violence costs us in the U.S. economy about$3.6 billion in lost productivity, medical cost, et cetera. So now the intersection of domestic violence with suicide. So let's talk real briefly about suicide, and then I'm going to really go into how this all actually works together and what we can actually do to actually interrupt some of these patterns. So suicide is any sort of self-directed, injurious behavior with the intent to die. Sometimes it is people talking about suicide, thinking about suicide, planning suicides. There may be also people who joke about it. Um and don't take that lightly if someone is actually joking about it. All of the thinking, talking, joking, planning, all of that is an emergency. Um it is really, really important that if you interface with anyone that is having these types of behaviors, that you either call 911 or 988 and or go directly to the emergency department. So the connection between domestic violence, domestic violence and suicide is often really overlooked. So survivors of domestic violence, whether or not it was someone who was actually injured or witnessed an injury, they are three to five times more likely to die of suicide. Abusers may also use the threat of suicide as a tool of coercion and control. So this is actually one of the things that was going on, I know, down in Louisiana with uh with that father. If you divorce me, um I'm going to, you know, hurt you and the children. Um so sometimes it is used to actually get control or to actually force people not to do things that they may want to actually do. Some abusers actually uh kill their partners and then die by suicide, which is actually what we experienced in these instances that occurred this week. One of the things that people should realize is that when someone dies of suicide, there were about 27 to 30 people who attempted it for every suicide death there is. Women actually attempt suicide more frequently than men, but men are more successful at it. So men will often use more lethal means to actually uh commit suicide, and for that reason um they are often, they often die by suicide more frequently. Firearms are used in about half of all suicide deaths. Um you have increased risk associated with veterans and also LGBTQ plus uh youth. The other thing is, you know, in our in the black community, there's kind of uh kind of a myth that, you know, we don't commit suicide uh as often as is done in the white community, and that is actually proving to be wrong. Um suicide rates, particularly amongst black youth, have significantly increased. Um so we are really seeing this more often in our community over the like the past uh two decades. So when you when you talk about um, you know, when we look at the intersection of these uh things, um recent data from the CDC underscores that there's a pattern that ER physicians, police, and advocates have long recognized, which is that domestic violence and suicide frequently occur together. Um it may be where um there are there's intimate partner violence that escalates. Um it may be that there were warning signs that were missed by family or by medical proprietors or even by law enforcement. Um so I think I wanted to go over really kind of what are the things that you should actually uh be concerned about if you actually are experiencing them. So one of the first things that I think is really important uh when we are actually uh dealing with uh domestic violence or depression or suicidality, you want to really pay attention if someone is not enjoying the things that normally made them happy, if they are disengaging, uh maybe they are not showing up to family events, uh, maybe they have um excuses for not being around or not being present. Any talk of of suicidality is uh you should immediately call 911-988 or go to the emergency department. Um we have there's a lot of times when you have uh resistance. You have uh family members or friends that may resist going to the emergency department. So I I want to talk a little bit about that as well. Um I have had people who put family members in a car, acted like they're going to a restaurant, and brought them to the emergency department. Um I have had family members that actually just call 911 and allow um uh the police or paramedics to actually handle the situation. We have had situations where the police or paramedics have been called to help someone who's in a mental health crisis, and that person literally runs away. Um and um you can still do the 302 paperwork that will help to protect them, and when they are found, they are then brought to the emergency department. So I want people to really understand what this actually really looks like. You really have to be a stand for your for your family members and for and for the for the for the people and for your loved one, loved ones. Um it is it is really important when you see these sorts of things or hear these sorts of things occurring that you don't take them lightly and you actually make sure to get them help. The other thing that you will see sometimes is you will see people get upset or mad. That person filed a 302 on me, or that person um made me go to the emergency department. I would rather have a family member be mad with me and be alive than not actually be alive. So let me actually talk about some of the systems that are in place and what does this actually look like? Um so when you actually um, you know, we as first responders and first responders are emergency medicine physicians, paramedics, police, firefighters, um, there's a lot of things that actually are um that are in place. So in some states, um there are mandatory arrest laws. So when a when a police officer is called about a domestic violence situation, they will make an arrest. There will be one person that will be arrested even without uh the victim's cooperation. And that is actually done for a couple of reasons. There was a lot of a lot of instances in the past where the police were called for domestic violence, and then what would happen would be the police would leave and of course the fighting would just restart. So part of the reason why they arrest one party is to actually sort of give uh a physical separation and a physical cooling off. Um officers also kind of conduct a lethality assessment protocol, which is a series of questions to actually gauge whether or not there's any eminent danger such as firearms or or a history of strangulation or any um any threats uh to um any threats to kill. Um one of the things that is really important is strangulation is one of the most critical warning signs for homicide. So victims who are strangled are seven times more likely to be killed by their abuser. So if you are listening to my voice and you have been uh subjected to domestic violence and you have been strangled, you must get into a safe place because the the likelihood of that actually changing to homicide is very, very high. You'll also, when the police come in a situation of domestic of domestic violence, the officers will not interview the victims in front of the alleged abuser. They will usually take people into separate rooms and try to get a more honest and open answers from both parties. Some victims may refuse to press charges or recant and say, oh no, this didn't really happen. But the officers are really trained to kind of um see through that. Um in certain states, there are mental health co-response teams. So that is the pairing of a police officer with a mental health provider. It could be a clinical licensed social worker, it could be a psychologist, and that is also done in many cities so that when the police show up, they are also paired with someone that is a mental health professional. Now, in the emergency department, when you begin to interface with the hospital, there are several things and that are in place to actually even detect domestic violence or even the risk of suicidality. So the Joint Commission is an independent nonprofit organization that accredits and certifies all hospitals. So you may hear a hospital say, We're accredited, we're an accredited hospital. They have been accredited by the organization called the Joint Commission. So the Joint Commission requires all hospitals to have written policies on identifying and responding to domestic violence victims. Also, we as physicians, ER physicians, and nurses are trained to use certain screening tools. So there are certain screening tools called, um, one is called HIIT, which is hurt, insult, threatened, screamed. And this goes into how often did your partner insult or threaten or scream or or put you down. Um there's also safe questions, which ask things around how how safe do you feel in your home? Um, you may actually go to the emergency department for something completely unrelated. You could be having chest pain and shortness of breath. And at triage, they will ask you, do you feel safe in your home? And you may wonder, why are they asking me this? Well, the main reason why they're asking you this is because people do not show up to the emergency department and say, I'm in a domestic violence situation. That is never the chief complaint. Patients who actually are experiencing domestic violence come into the emergency department for other things. They'll say they have a headache. They say they'll have they'll say they have a stomach pain. Um, they may say I fell or I twisted my ankle. So, because of that, we ask everyone who shows up to the emergency department, do you feel safe in your home? So that is something that is asked almost all the time. The other thing that is asked a lot is we also screen people for suicidal risk, for depression and suicidal risk. One of the main scoring tools that we use for this is called the Columbia Suicide Severity Rating Scale. And basically, it is a scale that actually asks people, you know, have you thought about hurting yourself? Have you been, have you had a change in your mood recently? So it is a scoring scale, and there are certain numbers, and if you actually are very high, then your chart is m is marked as high risk for suicidality. Now, this is really important because there are people that attempt to commit suicide in the emergency department. Okay? So once a chart is actually ranked or or flagged, then I actually know as a physician that's actually practicing that I need to put this patient in a room where the room is safe, maybe there's no cords or strings or curtains. I also, if we're going to feed the patient, we are not going to give them a tray that has even a butter knife on it. So there's all of these things that are actually put in place. In some situations, I will also mark the patient as restrict to hospital. And what restrict to hospital means is that they can't leave. And basically, um during the time that they're in the emergency department, we will do an exam and usually some lab test and see if they can be medically cleared. And medically cleared means that, you know, there's not a medical problem that is going on. So, you know, their diet if they have diabetes, their diabetes is under control. If they have high blood pressure, their high blood pressure is under control. Um, in some cases, uh patients have already attempted at home to actually take medication or overdose on medication, so we may need to wait for several hours until those medications are no longer active in their system. Um in some cases, patients are intoxicated. There's a lot of suicidality associated with drug and alcohol use, and so we may have to wait several hours for those things to actually come out of their system. So all of these things are actually done to then medically clear the patient. And then once the patient is medically cleared, then we can actually determine what would be the best level of services for them. If it is someone who has a high risk of suicidality, um we may do an involuntary commitment if they are not uh agreeable to actually go in and get treatment, and that is paperwork that I basically sign and other physicians sign, which then actually provides a 72-hour hold. And during that 72-hour hold period, we actually prov we find an inpatient medical bed. Sometimes we have to renew the hold because we may not find a bed within 72 hours. Um, but that hold is renewed until we actually find an inpatient uh psychiatric bed, and then we transfer the patient from the emergency department to that psychiatric bed through the use of a transport system that is familiar with handling patients that are in a mental health crisis. So I describe that so that you guys kind of understand, you know, what happens if I call 911 or I bring my patient to the emergency or bring my family member to the emergency department, what what actually uh happens? In some cases, um, once the patient is removed from the environment, maybe um they have if they've got alcohol or drugs on board, those uh things are um metabolized out. Um there are some patients who then voluntarily agree to get mental health uh inpatient mental health services, and they will um sign, sign themselves in themselves. And then lastly, we have patients that maybe you know they they just need their medications refilled, or they need to get their appointment moved up. Or there's a lot of times where it's very difficult to start mental health care from home because often if you call, you'll be you'll be given appointments that might be months later. So some people kind of come to the emergency department, see a behavioral health specialist in the emergency department, and then can get set up with uh outpatient services. In some situations, we also have what we call partial placement programs, and these are programs where you're not gonna go stay overnight. You might you might stay for a couple of hours. These are particularly good for when we have children and teenagers that have mental health crises because this allows them not to miss school and they can still continue to go to school and get their education and also get the mental health services that they actually need. So when you actually look at mental health clinicians and crisis counselors, you will uh find a lot of various things that may actually occur. There are now several uh what we call almost like behavioral health emergency departments, where they are standalone facilities that are specifically for those folks that are going through a mental health crisis. Um, in some cases, um, when uh the when people go there, um they will actually create a safety plan. And a safety plan is really a personalized document. That is created with the patient, which identifies warning signs, coping strategies, who are you going to call, support contacts, and steps to take that the patient agrees to take before the crisis escalates. It's really, really um important to actually engage the patient in this because this is actually a document that they're basically agreeing to. You will also see sometimes where there is what we call lethal means counseling. And this is counseling to reduce access to firearms, uh, reduce access to medications, reduce access to knives and sharp objects. Um and this has really been really, it's a really important proven suicide prevention strategy. And so it is something that really, really uh makes makes a difference. So all right, I've got a little bit of time for a couple of questions. I want to actually take a couple of questions that that I actually had emailed in. Lena says, if a family member tells me they are thinking about suicide, what do I say and what do I not say? So I think one thing is important is, you know, a lot of times if someone actually is gonna speak to you and tell you that they're that's what they're thinking about, they actually really trust you to open up and be that vulnerable. So one of the things to not do is to don't don't judge them and don't say, oh no, you would never do that, or come on, you know, uh not you. You know, don't listen to what they have to say without interrupting them and actually without refuting what they're saying. Because whatever they're telling you, that is their truth. The other thing that is important is do not promise secrecy because you know, people die in the darkness of secrecy. So please do not promise secrecy. You know, you want to actually stay with them and say, you know, is can I actually help you get some help around this? Would you like to see someone to get some help around this? You know, query them about what actually is going to actually make a difference for them. You will see some resistance often to people getting help. Apparently, with the person in Shreveport, uh, Louisiana, uh, family members did try to intervene and he would always say he was okay. So don't take I'm okay or I was just joking. Um tell other family members that actually may also help you actually get this person into the emergency department or into even a clinic appointment. So that is really um, really, really important. I want to just speak quickly about uh the resources. The suicide lifeline is 988. You can use 988 as well as 911. There's also a national domestic violence hotline, which is 1-800-799-7233. You can also text to actually access that National Domestic Violence Hotline, and you text to 8878. Lastly, there are a lot of dual diagnosis programs and trauma-informed programs so that that way people can actually get integrated care if they're actually dealing with domestic violence and also uh things such as uh any sort of addiction, et cetera. So I wanted to just, you know, I wanted to kind of provide this information today so that you can kind of look and see what what's going on with the people in your community. And um it, you know, how can you actually make a difference if you see someone in your family that is actually struggling? I hope this has really been helpful. Um, I think it's really, really important that we realize that this is all around us, uh, whether or not we know it or not. Please make sure to to check my podcast, What the Health is Happening. If you're missing any of these episodes, you'll see all of them replayed here. I want to really thank you guys for hanging in there with me with this conversation. This was a difficult conversation, but I think a very important conversation for our community. I want you to stay informed and empowered about your health.