Integrating Trauma-Informed Clinical Interviewing Skills in Medical Education for Screening Domestic Violence and Abuse

By Nargis Asad¹, Shahina Pirani¹, Sonia Sameen², Jawed Akbar Dars³, Tania Nadeem¹

Affiliations

1. Department of Psychiatry, The Aga Khan University, Karachi, Pakistan
2. Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan
3. Department of Psychiatry and Behavioural Sciences, Jinnah Postgraduate Medical Centre, Karachi, Pakistan

doi: 10.29271/jcpsp.2024.08.996

ABSTRACT
A pre-post-training workshop was conducted among 22 postgraduate trainees of the Psychiatry and Emergency Department of a public sector hospital in Karachi. The workshop aimed to build the capacity of postgraduate trainees in trauma management by providing training on screening, clinical interviewing skills, and Psychological first aid to those exposed to domestic violence (DV). The effectiveness of each training module was evaluated by conducting a brief assessment before and after each module and scores were compared using the Wilcoxon signed-rank test. The post-test showed significant improvement in participants’ knowledge on screening of domestic violence and trauma symptoms (p = 0.026) and psychological first aid (p <0.001). Postgraduate training programmes need to integrate trauma screening and management education, to prepare healthcare professionals to deal with sensitive clinical presentations at their work settings.

Key Words: Postgraduate trainees, Trauma, Domestic violence, Medical education, Workshop.

Trauma is a global health problem. Substance Abuse and Mental Health Services Administration defined trauma as “an exposure to event or circumstances resulting in physical, emotional and / or life-threatening harm with lasting adverse effects”.¹ Domestic violence (DV) is one of the traumatic experiences that affects women and girls’ mental health, leading to serious mental and physical health sequel.² Globally, almost one-third (27%) of women aged 15-49 years reported that they have been subjected to some form of physical and / or sexual violence by their intimate partner.²

Healthcare professionals (HCPs) play a fundamental role in providing coordinated multi-sectoral care to DV victims. Women experiencing violence contact HCPs frequently without disclosing violence to them. HCPs are well-positioned to take care of violence victims; as they can identify DV while providing care to them, offer continuity of care, and refer for further management. However, this crucial role of HCPs to identify and provide appropriate care is not usually implemented due to several significant barriers.
 

A recent meta-analysis indicated several barriers experienced by HCPs while dealing with DV victims that include lack of policies, resources, privacy, increased workload, insufficient knowledge, skills, and prejudicial attitudes towards violence victims.³ In-service training of HCPs is one of the widely suggested ways to address these barriers and improve access to quality healthcare for trauma and DV victims.⁴

A pre-post training workshop was conducted for postgraduate trainees of the Emergency and Psychiatry Department of a public sector hospital in Karachi, Pakistan. The workshop aimed to build the capacity of postgraduate trainees in trauma management by providing training on screening, clinical interviewing skills, and psychological first aid to those exposed to domestic violence.

The specific objectives of the workshop included; understanding the importance of screening domestic violence in clinical settings in the patients presenting with general mental health-related complaints; demonstrating effective clinical interviewing skills in the victims of domestic violence; and familiarising oneself with principles of psychological first aid in their clinical encounters with survivors of domestic violence to manage trauma related to DV.

Before the workshop proceedings, ethical approval was ob-tained from the Aga Khan University’s Ethical Review Com-mittee (Reference Number: 2022-7657-23180) and permission was obtained from the head of the study setting. A written informed consent was also taken from all the attendees.

This was a three-day, 12-hour workshop conducted onsite from January to March 2023. The workshop followed a standard format starting with a round of introductions, listing goals and expectations of the participants, and setting ground rules for the sessions. Three modules were offered namely screening of domestic violence and trauma symptoms; clinical interviewing skills; and psychological first aid and pathway to referral for survivors of violence (Figure 1). WHO resources on psychological first aid, clinical policy and guidelines on response to intimate partner violence, and training curriculum on domestic violence screening for health professionals were referred.^5,6 Sessions were conducted by a team of mental health professionals consisting of clinical psychologists, child and adolescent psychiatrists, and an adult psychiatrist.
 

Figure  1:  Overview  of  training  sessions.

A total of 22 postgraduate trainees attended the training workshop, including 15 (68.2%) females and 7 (31.2%) males. Among them, 14 (63.6%) were undergoing training in Psychiatry and 8 (30%) in Emergency Medicine. With reference to their designation, 13 (59%) were residents, 6 (27.27%) were resident medical officers, and 3 (14%) were clinical psychologists. Their work experience ranged from at least a month to at most 5 years.

To assess the effectiveness of each training module on the participants’ knowledge, a brief assessment was conducted before and after each module. The first module focusing on domestic violence and trauma symptom screening recorded the complete data of 16 participants. Six participansts’ data readings were excluded from the sample owing to incomplete information and missing values. The second and third modules focusing on the conduction of clinical interviews and the provision of psychological first aid, respectively, recorded the complete information of 17 participants.

Data analysis was performed using the Stata version 17. Descriptive statistics were computed for categorical variables by computing their frequencies and percentages and for continuous variables by computing their median. The Wilcoxon signed-rank test was conducted to compare the knowledge score before and after each training module. A p-value of <0.05 was considered significant.

Among three modules, two reported a significant difference in participant knowledge, namely screening for domestic violence and trauma symptom (p = 0.026) and the psychological first aid (p <0.001).

The results of the participants’ pre- and post-test knowledge scores across all three modules are summarised in Table I.

Table I: Pre- and post-test scores of participants’ knowledge across three  training  modules.

Assessment	Module 1		Module 2		Module 3
Knowledge score range	4-10	7-11	5-8	4-8	2-5	2-5
Median knowledge scores	Pre	Post	Pre	Post	Pre	Post
	9	10	7	7	3	5
p-value	0.02*		0.58		<0.001*
*Wilcoxon matched-pairs signed-rank test significance p-value.

The pedagogy of conducting the workshop was based on collaborative teaching approaches employing active participation of everyone. Socratic methods were used to generate discussion that required participants to exercise critical thinking. Hypothetical clinical case vignettes were used to teach skills of clinical interviewing. Throughout the sessions, participants demonstrated active engagement, most of them shared that this was the first-ever workshop they attended on the sensitive topic of trauma and violence management. Participants were awarded the Certificate of Attendance after completing the workshop. 

Qualitative feedback through open ended questions from participants clearly identified training gaps and new learning obtained, approaching a trauma victim, asking appropriate questions, and the principle of psychological first aid were areas of new learning for them. Most helpful strategies listed by participants were interactive discussions and clinical case vignettes. Participants’ areas of improvement suggested for future sessions included the use of role plays and longer duration workshops.

Based on the post-workshop feedback, it can be ascertained that significant clinical information is lost simply because there is inadequate capacity to communicate and frame appropriate questions to screen for trauma-related sensitive information. To have a comprehensive clinical approach to patients visiting Psychiatry or Emergency Departments, training curricula need to be enhanced to integrate trauma informed screening and care for domestic violence and abuse particularly in public sector institutions.

Consistent with the findings by Arora et al., there were nume-rous challenges in conducting in-service training sessions in public sector health facilities.⁴ These include HCP’s lack of time due to heavy patient flow, inadequate numbers of staff, high turnover rates, limited infrastructure, lack of support services for referrals, and resources.

This workshop suggested that training was useful for trainees’ clinical skill-building and improving knowledge when dealing with DV and trauma cases. Ongoing in-service training is needed for sustainable change in healthcare professionals’ knowledge, attitudes, and clinical practice towards trauma victims. Moreover, local postgraduate training programmes need to integrate trauma and violence screening and management education to prepare HCPs to deal with sensitive clinical presentations at their work settings.

ETHICAL  APPROVAL:
Ethical approval for the workshop was obtained from the Aga Khan University’s Ethical Review Committee (Reference no: 2022-7657-23180).

PARTICIPANTS’  CONSENT:
Written informed consent was obtained from all the trainees.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
NA: Conceptual mapping of the workshop.
SP: Literature research and protocol development.
JAD: Coordination with the workshop participants.
NA, TN: Workshop training sessions.
SS: Data analysis and results.
SP: Drafting of the manuscript.
NA: Critically revision of the manuscript.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Substance abuse and mental health services adminis-tration. Trauma and violence, 2022. https://www.samhsa.gov/ trauma-violence.
2. World Health Organization. Violence against women. 2021. https://www.who.int/news-room/fact-sheets/detail/violence-against-women.
3. Hudspeth N, Cameron J, Baloch S, Tarzia L, Hegarty K. Health practitioners' perceptions of structural barriers to the identification of intimate partner abuse: A qualitative meta-synthesis. BMC Health Serv Res 2022; 22(1):96. doi: 10.1186/s12913-022-07491-8.
4. Arora S, Rege S, Bhate-Deosthali P, Thwin SS, Amin A, Garcia-Moreno C, et al. Knowledge, attitudes and practices of health care providers trained in responding to violence against women: A pre- and post-intervention study. BMC Public Health 2021; 21(1):1973. doi: 10.1186/s12889- 021-12042-7.
5. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO Clinical and Policy Guidelines. Geneva: WHO; 2013. Available from: https://www.who.int/publications/i/item/9789241548 595.
6. World Health Organization. Caring for women subjected to violence: A WHO curriculum for training health care providers. WHO; 2019. Available from: https://iris.who.int/ bitstream/handle/10665/330084/9789241517102-eng.pdf?sequence=8.