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May 23, 2012

Domestic Violence

A National Center for PTSD Fact Sheet
By Michelle Rice, Ph.D.

Domestic violence is a prominent public health issue in the United States. It is the most frequent cause of serious injury to women, more than car accidents, muggings, and stranger rapes combined.1 This fact sheet provides information regarding the definition of domestic violence, the prevalence of domestic violence, the dynamics of abusive relationships, the effects of domestic violence, treatment for victims and perpetrators, and resources offering assistance.

What is domestic violence?

Domestic violence is defined as the use or threat of use of physical, emotional, verbal, or sexual abuse with the intent of instilling fear, intimidating, and controlling behavior.1 Domestic violence occurs within the context of an intimate relationship and may continue after the relationship has ended. The types of domestic violence are as follows1,2:

*        Physical abuse: Verbal threats of violence, pushing, shoving, hitting, slapping, punching, biting, kicking, holding down, pinning against the wall, choking, throwing objects, breaking objects, punching walls, driving recklessly to scare, blocking exits, using weapons

*        Emotional/Verbal abuse: Name calling, coercion and threats, criticizing, yelling, humiliating, isolating, economic abuse (controlling finances, preventing victim from working), threatening to hurt children or pets, stalking

*        Sexual abuse: Unwanted touching, sexual name calling, false accusations of sexual infidelity, forced sex, unwanted pregnancy, sexually transmitted diseases, HIV transmission

Researchers in the field of domestic violence have compiled characteristics of batterers, which can be utilized to predict the likelihood of battering.  The more characteristics present in a person, the greater the likelihood of battering.1

The most predictive indicators are:

*        History of past battering
*        Threats of violence
*        Breaking objects
*        Use of force during arguments

The following are also warning signs:

*        Unreasonable jealousy
*       Controlling behavior
*       Quick involvement in the relationship
*        Verbal abuse, blaming others for problems
*       Cruelty to children and animals
*        Abrupt mood changes

What is the prevalence of domestic violence?

It is very difficult to estimate the rate of domestic violence because the majority of victims never disclose that they are involved in partner violence. It is estimated that, regarding violent behavior toward females within the context of an intimate relationship, only 20% of all rapes, 25% of all physical assaults, and 50% of all stalking are ever reported to the police.3 Victims may be reluctant to come forward for a variety of reasons.

First, they may fear retaliation from their partner. They may have been directly threatened that if they tell anyone they will be killed, or they may just fear the worst.

Second, there is shame associated with choosing a partner who could be violent, and there is shame associated with staying with a violent partner.

Finally, some victims may have tried to seek help from the police, the courts, or others and been dissatisfied with the help they received. The following statistics as reported in Fischbach and Herbert4 and Tjaden and Thoennes,3 shed light on the prevalence of domestic violence (statistics are for the U.S. only):

*        20-30% of American women will be physically abused by a partner at least once in their lifetimes
*       1.3 million women and 834,732 men are physically assaulted by an intimate partner annually
*       201,394 women are forcibly raped by an intimate partner annually
*       11% of women in homosexual relationships and 23% of men in homosexual relationships report being raped, physically assaulted, and/or stalked by an intimate partner
*       503,485 women and 185,496 men are stalked by an intimate partner annually
*       1-25% of all pregnant women are battered during pregnancy
*        30-40% of women’s emergency room visits are for injuries due to domestic violence
*       30% of women killed in the U.S. are killed by their husbands or boyfriends
*        50% of men who assaulted their female partners also assaulted their children
*        3.3 million children witness domestic violence each year

What are the dynamics of an abusive relationship?

Research focusing on the dynamics of abusive relationships has resulted in several ways of understanding the interactions between the batterer and the victim. The first conceptualization is that of the Cycle of Violence,5 consisting of three stages: the tension building stage (tension in the relationship gradually increases over time); the acute battering stage (tension erupts, resulting in threats or use of violence and abuse); and the honeymoon stage (the batterer may be apologetic and remorseful and promise not to be abusive again). The cycle continues throughout the relationship, with the honeymoon stage becoming shorter and the episodes of battering becoming more frequent or more severe. The honeymoon stage reinforces the victim's hope that the batterer will change and contributes to the victim staying in the relationship.

The concept of Traumatic Bonding6 has also been developed to explain the dynamics of domestic violence relationships. Essentially, strong emotional connections develop between the victim and the perpetrator during the abusive relationship. These emotional ties develop due to the imbalance of power between the batterer and the victim and because the treatment is intermittently good and bad.  In terms of the power imbalance, as the abuser gains more power, the abused individual feels worse about him- or herself, is less able to protect him- or herself, and is less competent.  The abused person therefore becomes increasingly dependent on the abuser.  The second key factor in traumatic bonding is the intermittent and unpredictable abuse.  While this may sound counterintuitive, the abuse is offset by an increase in positive behaviors such as attention, gifts, and promises. The abused individual also feels relief that the abuse has ended.  Thus, there is intermittent reinforcement for the behavior, which is difficult to extinguish and serves instead to strengthen the bond between the abuser and the individual being abused.

Finally, abusive relationship dynamics can also be understood through the concepts of Approach and Avoidance.7 The mix of pros (love and economic support) and cons (fear and humiliation) present in the battering relationship leads to ambivalence on the part of the victim. The victim is likely to want to approach the positives in the relationship but avoid the abuse. This struggle between wanting to keep the relationship and wanting to remain safe makes it difficult to decide whether to leave or stay in the relationship. On average, women leave and return to an abusive relationship five times before permanently leaving the relationship.

What are the effects of domestic violence?

Domestic violence has wide ranging and sometimes long-term effects on victims. The effects can be both physical and psychological and can impact the direct victim as well as any children who witness parental violence.

The physical health effects of domestic violence are varied. Victims may experience physical injury (lacerations, bruises, broken bones, head injuries, internal bleeding), chronic pelvic pain, abdominal and gastrointestinal complaints, frequent vaginal and urinary tract infections, sexually transmitted diseases, and HIV.2,8 Victims may also experience pregnancy-related problems. Women who are battered during pregnancy are at higher risk for poor weight gain, pre-term labor, miscarriage, low infant birth weight, and injury to or death of the fetus.

There are also many psychological effects of domestic violence. Depression remains the foremost response, with 60% of battered women reporting depression.9 In addition, battered women are at greater risk for suicide attempts, with 25% of suicide attempts by Caucasian women and 50% of suicide attempts by African American women preceded by abuse.4

Along with depression, domestic violence victims may also experience Posttraumatic Stress Disorder (PTSD), which is characterized by symptoms such as flashbacks, intrusive imagery, nightmares, anxiety, emotional numbing, insomnia, hyper-vigilance, and avoidance of traumatic triggers. Several empirical studies have explored the relationship between experiencing domestic violence and developing PTSD. Vitanza, Vogel, and Marshall10 interviewed 93 women reporting to be in long-term, stressful relationships. The researchers looked at the relationships among psychological abuse, severity of violence in the relationship, and PTSD. The results of the study showed a significant correlation between domestic violence and PTSD.

In each group in the study (psychological abuse only, moderate violence, and severe violence), women scored in the significant range for PTSD. Overall, 55.9% of the sample met diagnostic criteria for PTSD. In further support of the strong relationship between domestic violence and PTSD, Mertin and Mohr,11interviewed 100 women in Australian shelters, each of whom had experienced domestic violence. They found that 45 of the 100 women met diagnostic criteria for PTSD.

Children may develop behavioral or emotional difficulties after experiencing physical abuse in the context of domestic violence or after witnessing parental abuse. Children's responses to the violence may vary from aggression to withdrawal to somatic complaints. In addition, children may develop symptoms of depression, anxiety, or PTSD.1

How are the effects of domestic violence treated?

Psychological treatment for victims and perpetrators can be helpful in the aftermath of domestic violence. For battered women, Hattendorf and Tollerud5 recommend a feminist therapy approach in which traditional gender roles are challenged and empowerment of the victim is a primary focus. Individual therapy for victims of domestic violence should begin with a primary focus on safety, particularly if the woman is currently in an abusive relationship. The therapist should assess the current level of dangerousness and lethality in the relationship based on the following factors concerning the batterer: threats of homicide or suicide, possession of weapons, acute depression, alcohol/drug use, history of pet abuse, and level of rage.1 The presence of these factors increases the level of potential lethality in the batterer.

In addition to assessing lethality, the individual therapist should develop a safety plan with the victim. A safety plan may contain a strategy for how to leave a dangerous situation; the preparation of a safety kit (clothing, medications, keys, money, copies of important documents) to be kept either near an exit route or at a trusted friend's house; and arrangements for shelter (made without the batterer's knowledge of the location).1

Once lethality and safety have been addressed, the longer-term goals of treatment for the battered woman can be addressed. These goals include helping the woman identify the impact of abuse on her life and helping her work toward empowerment.5 Victims can be empowered by regaining their independence and reconnecting with supports and resources that may have been cut off due to the isolation of domestic violence. In addition, the victim?s children may need their own treatment to address their responses to witnessing or experiencing abuse.

For some victims, additional treatment may be needed to target symptoms of depression, PTSD, substance abuse, or other disorders found to occur in the presence of domestic violence.

Batterers can also benefit from treatment, although it remains unclear exactly how effective treatment is in breaking the cycle of batterers' violence. Batterers benefit most from batterer treatment programs, which in part focus on identifying what domestic violence is. These programs also focus on helping batterers develop a sense of personal responsibility for one's actions and for stopping the violence.1Batterers can also be treated in individual therapy, but the focus of treatment must be on the violence. While some batterers and victims may seek to engage in couple's therapy to address the abuse in their relationship, couple's therapy is not recommended while violence is occurring in the relationship. In addition, it is recommended that each member of the couple complete their individual treatment first, before beginning any couple's therapy.1

What resources are available?

National toll-free Domestic Violence hotline: 1-800-799-SAFE (7233)

List of National and State Domestic Violence Hotlines:

National Coalition Against Domestic

Family Violence Prevention Fund:

1. Harway, M. & Hansen, M. (1994). Spouse abuse: Assessing and treating battered women, batterers, and their children. Sarasota, Florida: Professional Resource Press.

2. Jones, R.F. & Horan, D.L. (1997). The American college of obstetricians and gynecologists: A decade of responding to violence against women. International Journal of Gynecology and Obstetrics, 58, 43-50.

3. Tjaden, P. & Thoennes, N. (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey. National Institute of Justice/Centers for Disease Control and Prevention.

4. Fischbach, R.L. & Herbert, B. (1997). Domestic violence and mental health: Correlates and conundrums within and across cultures. Social Science Medicine, 45, 1161-1176.

5. Hattendorf, J. & Tollerud, T.R. (1997). Domestic violence: Counseling strategies that minimize the impact of secondary victimization. Perspectives in Psychiatric Care, 33, 14-23.

6. Dutton, D.G., & Painter, S.L. (1981).º Traumatic bonding: The development of emotional attachments in battered women and other relationships of intermittent abuse. Victimology: An International Journal, 1, 139-155.

7. Barnett, O.W. (2001). Why battered women do not leave, part 2: External inhibiting factors?social support and internal inhibiting factors. Trauma, Violence, and Abuse, 2, 3-35.

8. Bohn, D.K. & Holz, K.A. (1996). Sequelae of abuse: Health effects of childhood sexual abuse, domestic battering, and rape. Journal of Nurse-Midwifery, 41, 442-456.

9. Barnett, O.W. (2000). Why battered women do not leave, part 1: External inhibiting factors within society. Trauma, Violence, and Abuse, 1, 343-372.

10. Vitanza, S., Vogel, L.C., & Marshall, L.L. (1995). Distress and symptoms of posttraumatic stress disorder in abused women. Violence and Victims, 10, 23-34.

11. Mertin, P. & Mohr, P.B. (2000). Incidence and correlates of posttraumatic stress disorder in Australian victims of domestic violence. Journal of Family Violence, 15, 411-422.

Original Article

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