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December 15, 2011

Helping Battered Women

Violence is an increasing problem in our society. Police and social scientists have long been concerned with the level of violence in our streets. Juvenile specialists have noted the link between violence at home and the increased likelihood of adolescent crime. Of the adults that the courts have remanded to me for treatment, the majority have come from emotionally or physically abusive homes. Even witnessing violence can leave emotional scars as deep as being the recipient of violence.
In this social context, battered women deserve a special focus. The battered women
Michael K. Gilbertson, Ph.D., B.C.E.T.S.
Violence is an increasing problem in our society. Police and social scientists have long been concerned with the level of violence in our streets. Juvenile specialists have noted the link between violence at home and the increased likelihood of adolescent crime. Of the adults that the courts have remanded to me for treatment, the majority have come from emotionally or physically abusive homes. Even witnessing violence can leave emotional scars as deep as being the recipient of violence.
In this social context, battered women deserve a special focus. The battered women themselves are of course the primary victims. But the secondary victims are their children. Boys who witness their mothers being battered are more likely to commit acts of violence themselves. Girls who observe domestic violence are more likely to tolerate abusive partners as adults, thus subjecting another generation to the same sad dynamics.
So, how do we intervene? The answer is related to questions that colleagues and I have often asked ourselves and each other: Why do battered women tolerate the abuse for so long before seeking help? And why, even after receiving help, do they so often return to their abusive partners?
In her ethnographic study, Patricia Gagne (1992) writes of Leah and her abusive husband Andy. After years of violence at Andy's hands, Leah left. A shelter worker helped her relocate. But after several months she returned to Andy. "You know, with everything in my heart and soul I did not want to come back, and why I did I really don't know" (p. 409). This paper proposes some answers to Leah's question.
As the problem is multifaceted, likewise, the answers are complex. These women are not helped sufficiently, in part because focus at the ecological levels of the state and the community reduces focus on the individual. The reasons for this inadequate response involve the theoretical constructs of status, sexism, and (failure to consider) how systems interact. Systems' interaction explains how victim behavior and social perceptions interact to keep even helpful emphasis off the victims. Systems' interaction also specifically acknowledges mutually interactive aspects of attachment theory and the biochemistry of trauma--received or witnessed.
Understanding the Problem
Bell and Jenkins (1993) reveal the staggering amount of violence in contemporary American inner cities. Equally disturbing to these authors was the amount of life-threatening violence that Black youths witnessed. They were growing up amid victimization of alarming proportions. Not surprisingly, they found that the effects of witnessing violence were cumulative and that perpetration of violence by the youth was related to the violence witnessed.
Increasingly, researchers are recognizing that an environment of chronic violence and its perceived dangers causes many children to adapt in dysfunctional ways. The maladaptive patterns are usefully understood within the framework of Posttraumatic Stress Disorder (PTSD), (Garbarino, 1992), a point to which I will return later. As I noted earlier, girls who witness battering grow up, in disproportionate numbers, tend to be abused themselves (Waites, 1993). Another way of viewing this is that people who have been directly or indirectly victimized are likely to be victimized again (McFarlane & van der Kolk, 1996).
So, clearly, one point of intervention to break this cycle of violence would involve interrupting domestic violence against women. In the field of cultural anthropology, researchers like Jacquelyn Campbell (1992) have found that, across cultures, wife battering is linked to male dominance and cultural norms that tolerate domestic violence. Because of findings like Campbell's, a solid argument exists that, at the institutional/state level, part of the problem is that legislatures are composed primarily of men--men who are presumably influenced by a culture that encourages them to view women as objects of possession (Gagne, 1992).
Status theory and Marx's theories of power may dovetail here. Longres (1995) cites an experiment by Wendy Harrod where subjects deferred to others who they thought were being paid more. The experiment is used in support of social exchange theory. It could just as well support status theory: more social power flows to those with the most status, a component of which is material possessions. In any case, more power and status accrue to those who possess than to those who are objects of possession, and Marx was undoubtedly correct to presume that those in powerful, high-status positions are unlikely to readily alter their positions (Longres, 1995). But despite a possible reluctance to alter a status quo from which they benefitted, lawmakers have begun to respond to issues of domestic violence. Still, even as laws increasingly begin to reflect our national concern about domestic violence, the rates of battering still climb (Waites, 1993), and women continue to return to abusers--further swelling the domestic abuse numbers.
Could more be done at the ecological level of the community? Campbell (1992) for one feels that the neighborhood level should be the focus of our efforts. In small communities progress was initially slowed by the patriarchal thinking that Van Soest & Bryant (1995) found typical in the United States.
Workers at women's crisis shelters have told me that patriarchal factors resulted in de facto sexism when it came time to seek funding for buildings or staff. Despite these formidable difficulties, crisis centers with predominantly female staff and board members exist in most communities with which I am familiar. Still, the rates of spousal abuse show no signs of leveling, and having a safe refuge hasn't prevented many women from returning to be revictimized.
I do not mean to suggest that because neither laws at the state level nor interventions at the community level have halted the rise in wife battering that we should withdraw our attention from either level. Public awareness campaigns addressing domestic violence could benefit from better funding at both levels. And certainly society-wide attention to poverty could only be beneficial since low socioeconomic status correlates with domestic abuse (Whipple & Webster-Stratton, 1989 cited in Webster-Stratton, 1990).
Nevertheless, if we are going to shed light on the vexing problem of why so many battered women put up with abuse and then return to their victimizers when they do have a way out, we must examine the individual. For many Social Workers the discouraging fact remains that despite better laws and shelter programs, most of the women they help will return to the same abuse. We do these women a disservice if we ignore the problem at the intrapsychic level.
So why isn't intrapsychic information about victims of violence more widely assimilated and dispersed? It is not because we lack a systematic body of research that would help us understand victims of trauma. Information about the biochemistry of PTSD, and attachment theory give us a useful series of lenses with which to view revictimization. That the information is not better known to clinicians may be because of the same theoretical constructs I already examined: status theory and theories of sexism.
Social Work, a predominantly female field, has in its recent history taken a dim view of intrapsychic emphasis, linking it with patriarchal Freudian thought and blaming it (among other things) for the perceived failure of the profession to heed the larger social issue of impoverishment during the Great Depression (Simon, 1994). One could argue that assuming an intrapsychic emphasis would not enhance one's professional status as a Social Worker.
Perhaps more central to issues of status and sexism is a legitimate concern among women that any focus that smacks of blaming the victim is inherently unjust. John Longres (1995) elaborates the position of William Ryan (who coined the term "blaming the victim") this way: "Social service workers also blame the victim when they acknowledge the societal causes of problems but intervene only at the level of the individual" (p. 8). If the victims are overwhelmingly female, as in spousal battering, blaming them for their troubles also becomes the crassest sexism.
Is there a way out of this dilemma? Perhaps, but first we must recognize it as a false dilemma. Looking for points of intervention is not the same as blaming the victim. If we feel victims are at fault, we have no need to intervene; we can justify ignoring their plight. But if we wish to help battered women, one possibility is to find ways to enable them to change patterns of behavior. That would be genuine self-empowerment. And it does not mean we have to cease addressing issues at the state or community level. However, we can only help individuals empower themselves if we understand the biochemistry and attachment dynamics of trauma.
Understanding the Problem at the Level of the Individual
Trauma researchers have frequently noted the link between trauma and retraumatization (Browne & Finkelhor, 1986). For our purposes this phenomenon is the statistical tendency to be a victim of repetitive trauma after suffering childhood abuse. Briere & Runtz (1988) found women who had been abused as minors were more likely to have been in abusive adult relationships. Diane Russell (1986) noted in her study that women who had a history of incest were twice as likely to report physical violence in their marital relationships as women who had no such childhood history.
So what may be happening here? Well, colloquially we speak of people who seem to crave danger as "adrenaline junkies." We would be closer to the mark if we dropped the implied moral judgment and looked elsewhere than adrenaline. It is true that a frightening situation produces epinephrine (adrenaline), but it also triggers the release of endogenous opioids (endorphins and enkephalins) whose purpose is to produce analgesia. The ability to inhibit pain in a traumatic situation is an obvious advantage.
There is, however, a downside. Our own opioids are as addictive as exogenous opioids. In an article exploring self-injury in adults, Thompson and his colleagues (1994) noted that release of endogenous opioids had the same reinforcing potential as heroin or morphine. They speculated that individuals may continue harmful behaviors to avoid the discomfort of withdrawal. This fact has led van der Kolk (1989) to describe the resulting "addiction to trauma" as a mechanism for understanding the apparently compulsive behavior of self-abuse that characterizes many trauma victims. The more flagrant forms of self-abuse like cutting on oneself or headbanging may first suggest themselves as addictive behavior, but allowing someone else to do the damage may share the same link to opioids release.
Nor does the effect need to be maintained from childhood until marriage by continual abuse to retain its potency. When people with PTSD were exposed to a stimulus that resembled a trauma occurring two decades earlier, they developed an opioids-mediated analgesia that was equivalent to 8 mg of morphine (Pitman, van der Kolk, Orr, & Greenberg, 1990).
Several women from physically abusive relationships whom I have treated have told me of sensing the familiar buildup of domestic tension, then provoking a fight "just to get it over with." This response is an occasional part of the well known cycle of domestic violence. What is not expected is the answer I often get when I ask about their emotional state as the fighting begins. Several women have thought about it, then spoken of a sense of calm that obviously puzzled them. Given the numbing effects of endogenous opioids, their emotional response to violence may be understandable. Since they do not understand it, their appraisal of their behavior usually invokes shame.
And shame is the bridge to understanding how negative self-appraisal and attachment theory interact with the biochemistry of trauma to further perpetuate the cycle of revictimization. When battered wives were children, those who suffered abuse at the hands of caregivers were at risk to endure understandable threats to their attachment bonds. Disruption to attachment bonds with caregivers due to neglect or abuse produces distorted identity schema resulting in "bad me" appraisals. Not understanding the biochemistry of why they tolerate abuse or feel paradoxically calm when being battered leads abused women to feel shame, which reinforces the negative self-appraisal first put in place by disrupted attachment bonds. So an examination of attachment is in order.
We are biologically programmed to establish a secure bond with our caregivers. This drive is most pronounced under the threat of danger--even if the danger is from our caregivers. Beverly James (1994) uses the phase "trauma bonding" to describe how children are forced by trauma to cling in a nondiscriminating fashion to abusive caregivers no matter what the cost.
The cost is usually to self-esteem. Since children must preserve the attachment bond or the illusion of a pseudoattachment, they do so by what in object relations theory is called "splitting," to convince themselves that their parents are good and the bond is secure. Since "bad parent-good parent" splitting creates too much cognitive dissonance without the aid of traumatic dissociation and amnestic barriers, a more common split is "good parent-bad me." This tendency makes more sense when considering the egocentrism of young children whereby they attribute things happening to them as due to their own actions (Piaget, 1962). Years later many people first traumatized as children feel responsibility for their own abuse and perceive themselves to be unlovable or despicable (van der Kolk, 1996). These dynamics are often encouraged by abusers who generally refuse responsibility for their actions and are only too willing to blame their victims for imagined transgressions.
Once locked into a "bad me" split, children must selectively pursue evidence of their unworthiness. The resulting guilt can only be expiated by punishment. Many of my abused clients have said that they feel a vague sense that they will be punished and that they feel as if they "deserve" such punishment. If this tack seems a little too psychodynamic (dare I say Freudian?), then at least it should be clear how a low sense of self-worth, coupled with overresponsibility, could lead a woman to make excuses for her battering husband.
At this point a reader familiar with the Stockholm Syndrome might wonder if that phenomenon is relevant to the discussion. It might be. Several years ago in Stockholm a bank robber held a woman as hostage for several days in the bank's vault. When rescued, the woman denied that her captor was responsible for her pain. She was in fact quite indignant at the force the police had used to capture her assailant. She seemed to be infatuated with the gunman.
The key here might be the infantilization of the hostage who was dependent upon her captor for food, water, and toilet privileges. Frank Ochberg (1995) thinks this traumatic age regression (my term, not Dr. Ochberg's) accounts for the almost primal gratitude for life's necessities that many hostages feel if they're shown even a little kindness. He specifically links the Stockholm Syndrome with the bond many battered women feel for their abusers.
Lest the above seem too simplistic a portrait of some battered women, a portrait that paints them as largely incompetent, I would add that I have witnessed the above dynamics in very professionally accomplished women. Bessel van der Kolk (1996) finds the same occurrence: "High levels of competence and interpersonal sensitivity often exist side by side with self-hatred . . ." (p. 196).
How widely spread could the above dynamics be? Though overgeneralization should be avoided, aspects of attachment dynamics may account for more revictimization than a skeptic might think. Reviewing previous research, van der Kolk & Fisler (1994) found that a majority of children who experienced abuse or neglect developed disorganized attachment patterns.
Implications for Practice and Policy
Now that a base for understanding revictimization has been suggested, let me begin this section by observing how victim behavior patterns, mediated by trauma addiction and trauma bonding, could interact with systems at the state and community levels to reinforce victim stereotypes. Looking at the repetitive nature of victim behavior without understanding it can lead to reductive labeling. Specifically I have in mind the terms female masochism and Borderline Personality Disorder (assigned overwhelmingly to women). The former term presumes that pain gives psychological gratification without understanding the biochemical basis for the behavior. The latter term presumes an innate character flaw without considering the traumatic etiology. It is significant that Herman and van der Kolk (1987) found that Borderline Personality Disorder was associated with a history of abuse.
Pejorative labeling in our culture can only make it harder for professionals who wish to help battered women to obtain the legal protection and the immediate aid they need. But as I have argued, avoiding labeling by refusing to examine individual behavior keeps Social Workers from intervening effectively at the level we often encounter domestic violence: face to face.
What the above suggests is that in our professional practice we must educate ourselves about the dynamics and biochemistry of PTSD. I have found few things as immediately gratifying to women as when they truly grasp that their behavior is understandable and, by implication, treatable; they are not unworthy, shameful humans. Of course this places the burden on clinicians to master the therapeutic treatments used for trauma-based disorders and a burden on non-clinical Social Workers to know when and to whom to refer.
At the policy level we must be prepared to argue for the treatment intervention time needed to help clients rework complex attachment patterns and deal with actual withdrawal from their own opioids. In an era of managed care it will be a formidable undertaking to argue for more, not less, financial aid at the state and local levels.
Recommendations for Further Research
At this time medications commonly used to help with withdrawal symptoms from exogenous opioids are pretty much limited to Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine to help with the attendant depression and benzodiazepines to calm the patient. In any case, using carefully monitored SSRIs and benzodiazepines for battered women in shelters would be a useful pilot study if carefully designed.
Another promising area could be (are you ready for this?) - acupuncture. Avants and his colleagues (1995) have shown some forms of acupuncture to be beneficial for treating opioids addiction. A pilot study with battered women could be economically designed.
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