As more and more clients are entering therapy with concerns related to abuse, such as domestic violence incidents, it seems prudent to review how these issues might play a role in mental health and treatment. The facts on domestic violence are startling. Estimates by the National Coalition Against Domestic Violence, Bureau of Justice, and Centers for Disease Control and Prevention suggest that a woman in the United States is beaten or assaulted every 9 to 13 seconds, with one-third of all reported female homicides killed by an intimate partner. Additionally, up to 10 million Americans reportedly experience some type of domestic violence annually. Sadly, data from ten countries suggests that between 55 to 95 percent of women who have been abused by partners have never contacted shelters, non-governmental organizations, or the police for help. For those that do reach out, it is suggested that one-half of restraining orders obtained against perpetrators are violated. Furthermore, this is already an expensive crime for something chronically underreported: the cost of partner violence in the United States is estimated to exceed $5.8 billion per year, which is divided into direct medical and health care services ($4.1 billion) and productivity losses ($1.8 billion) (http://www.unifem.org/campaigns/trust_fund_10th_anniversary/facts_figures.html).
Research into this domain has taken many different approaches. A review of family literature from the 1990s found several themes, such as the distinctions between types or contexts of violence, issues of control, the effects of violence on families and broader society, and mechanisms of coping (Johnson and Ferraro, 2000). Authors have suggested that there are four patterns of partner violence known as common couples violence (CCV), intimate terrorism (IT), violent resistance (VR), and mutual violent control (MVC) (Johnson, 2006). Unlike IT, CCV is noted to be less likely to escalate over time, less likely to involve severe violence, and more likely to be mutual. IT, however, is said to be motivated by one member wishing to exert control over their partner often with emotional abuse. While more often observed in men, IT has been found to exist in lesbian relationships as well. There is a lack of data on VR compared to the other areas, which suggests that some findings (e.g., almost all individuals self-defending themselves are women; VR is an indicator that a woman will soon leave her abusive partner) may not hold up. Finally, MVR is a rare pattern that involves a mutually violent and controlling couple.
Researchers have also examined different relationship types. Findings in same-sex relationships suggest that psychological abuse involves threats of “outing” their partner, and that battered lesbians are less likely to be supported by friends or social service workers due to gender stereotypes. Cohabitating couples report more violence than dating or married couples, but only among CCV couples. Of note, while CCV involves mutual acts of violence, one study suggested males were more often the aggressor in 31% of those couples compared to 8% in which the women were more frequently violent. There may also be different reasons as to why men and women become violent that should be considered within treatment (e.g., social constructs of gender models).
Additional research has investigated the types of perpetrators, such as individuals who present differently psychologically (e.g., sociopathic and violent versus deeply emotionally dependent on the relationship), or racial/ethnic and gender differences. Specifically, a 1995-1996 National Violence Against Women survey suggested that 13% of Asian/Pacific Islander, 21% of Caucasian, 26% of African American, 27% of Mixed Race, and 31% of Native American/Alaskan Native women reported physical assault by an intimate partner. However, these numbers may reflect cultural openness to reporting incidences more than actual prevalence of violence among these groups. Socio-economic status may also play a role in prevalence, as studies on low-income women suggest an extremely high level of interpersonal violence as compared to those from higher social and economic backgrounds. Yet recent work suggests that violence may be the precipitating factor for poverty and as a barrier to raising income and employment status, rather than the other way around. However, women ages 18-24 appear to be at greater risk for victimization, along with women receiving public assistance and lesbian and bisexual women (Moracco, Ruyan, Bowling, and Earp, 2007). Other risk factors have been identified among a cohort from the particularly violent South African society such as female childhood violence, female lack of education, financial concerns, status of women in society, and normative use of violence as part of exercise of power (Jewkes, Levin, and Penn-Kekana, 2002).
A related line of inquiry has examined the relationship between mental disorders and domestic violence. The National Comorbidity Survey conducted between 1990 and 1992 among 8098 people ages 15-54 consisted of in-person interviews assessing for pre-marital psychological conditions (Kessler, Molnar, Feurer, and Appelbaum, 2001). They found that premarital disorders in men but not women were predictive of subsequent domestic violence. Specifically, major depression, generalized anxiety disorder, alcohol dependence, and nonaffective psychosis positively predicted minor domestic violence while dysthymia, antisocial behavior, and again nonaffective psychosis positively predicted severe domestic violence. While completely speculative, the authors propose that these results may be explained by feelings of low self-worth from mood disorders plus perceived lack of control from anxiety disorders that then predispose those men to violence. A review article assessing the alterative side to this research highlighted that there is a high prevalence of being a victim of violence among psychiatric patients (Oram, Trevillion, Feder, and Howard, 2013). Specifically, one-third of female in-patients and out-patients reported lifetime partner violence, which is higher than prevalence among general population samples, although no study included non-psychiatric control participants.
Other approaches to psychological disorders have focused on the aftermath of violence, such as the correlation between domestic violence and post-traumatic stress disorder in women. One review study found that 31% to 84% of battered women exhibit PTSD symptoms, and were more likely to have a history of serious childhood assault, major depression, and substance abuse (Jones, Hughes, and Unterstaller, 2001). Women in domestic violence shelters were also at a higher risk for PTSD (40-84%) than victimized women who were not in shelters, but they were also at higher risk for other psychological disorders. Furthermore, the likelihood of PTSD was found to be increased among those who had multiple abuse experiences, and its intensity was correlated with the extent, severity, and type of the abuse. Given these factors, treatment of domestic violence victims must involve careful evaluation of pertinent presenting issues. Treatment for perpetrators must also be considered, although a review study suggested that treatment effects of CBT and related therapy modalities for domestically violent males were small, with minimal impact on reducing recidivism beyond police intervention (Babcock, Green, and Robie, 2004).
While domestic violence inherently involves ethical issues in treatment, such as assessing a clinician’s boundaries for directly intervening in their client’s safety, there have also been ethical guidelines proposed for research done in this area. The World Health Organization published ethical and safety recommendations (as reviewed in Ellsberg and Heise, 2002) that included ensuring research team members receive specialized training and ongoing support for themselves, since the research may be emotionally taxing for all involved, not just participants. Team members are also advised to be able to refer participants to other resources should they request or require additional support, and to possible build in those services into the study should alternatives not be available. The guidelines further stipulate that study designs must include actions aimed at reducing any distress caused by the research, that prevalence studies must add to existing literature about how to minimize under-reporting of abuse, and that all researchers and donors must ensure that findings are used to advance policy and intervention development.
The clause addressing participants’ distress and their safety is especially significant; these participants are particularly at risk for becoming distressed by things like insensitive interviewing, having to recall painful details/experiences, or concerns that the abuser might retaliate if privacy and confidentiality are not strictly upheld. Although it might be taken for granted in a country that has a governing body like the Institutional Review Board, researchers worldwide must ensure that informed consent is thoroughly and appropriately conducted. Above all, the WHO challenged researchers to carefully consider the risks and benefits of such studies and to more strongly consider the immediate social impact of their work than some other areas of research might do.