Domestic violence can have a range of mental health consequences. According to the Domestic Violence & Mental Health Policy Initiative’s training manual Access to Advocacy, women experience poorer physical and mental health as a result of abuse. Advocates confirm this, with many noting that the number of clients—women and children—with trauma-related, mental health needs has been increasing. Likewise, over half of women seen in a range of mental health settings either currently are experiencing or have experienced abuse by an intimate partner. Nonclinical studies examining the prevalence of intimate partner violence in the general population also reveal multiple associated mental and physical health effects.
Although for many women symptoms abate with increased safety and social support, for others this is not the case. And, while many abuse survivors do not develop psychiatric conditions, a number of studies have shown that women who have been victimized by an intimate partner are at significantly higher risk for depression, anxiety, posttraumatic stress disorder (PTSD), somatization, medical problems, substance abuse, and suicide attempts, whether or not they have suffered physical injury. Researchers have found that nearly 50% of survivors of domestic violence experience depression, over 60% experience PTSD, and nearly 20% experience feelings associated with suicidality. Domestic violence also increases women’s risk for substance abuse. Abusive partners frequently coerce women into using drugs or alcohol, and substance abuse is a common method of relieving pain and coping with anxiety and depression. Substance abuse, itself, puts women at greater risk for victimization.
For many women, abuse by an adult partner is their first experience of victimization; for others, domestic violence occurs in the context of other lifetime trauma. A number of studies have begun to explore the link between histories of physical and sexual abuse in childhood and experiencing partner abuse as an adult. Women who are sexually abused as children or who witness their mothers being abused appear to be at greater risk for victimization in adolescence and adulthood. Additionally, studies of battered women in both clinical and shelter settings are finding increased rates of childhood abuse and childhood exposure to domestic violence. For women who have experienced multiple forms of victimization (e.g., childhood abuse; sexual assault; historical, cultural, or refugee trauma), adult partner abuse puts them at even greater risk for developing posttraumatic mental health conditions.
The development of mental health symptoms in the context of domestic violence is influenced by a number of factors in addition to the severity and duration of the abuse. For example, low-income women have the highest risk of being physically and/or sexually victimized throughout their lives. These experiences, however, do not occur in isolation; a body of clinical literature describes the retraumatizing effects of more subtle forms of social and cultural victimization (e.g., microtraumatization due to gender, race, ethnicity, sexual orientation, disability, and/or socioeconomic status). Thus, although intimate partner violence is itself associated with a wide range of psychological consequences, women living in disenfranchised communities face multiple sources of stress in addition to violence, including social discrimination, poorer health status, and reduced access to critical resources.
Domestic Violence, Lifetime Victimization, And Mental Illness
While most survivors of domestic abuse do not develop long-lasting psychiatric disabilities, women living with mental illness often have histories of abuse. Studies across a variety of mental health settings have found significant rates of lifetime abuse among people living with mental illness, with those in inpatient facilities reporting the highest rates (53% to 83%). Researchers have found similar rates of adult victimization by acquaintances, strangers, family members, and intimate partners among people with psychiatric disabilities.
Domestic violence presents particular risks for individuals with mental illness. Exposure to ongoing abuse can exacerbate symptoms and impede recovery, making it more difficult to access resources and increasing abusers’ control over their lives. Stigma associated with mental illness and lack of clinical training about domestic violence reinforce abusers’ abilities to manipulate mental health issues to control their partners; undermine them in custody battles; and discredit them with friends, family, and the courts. For example, abusers may commit or threaten to commit their partners to psychiatric institutions. They may force women to take overdoses, which are then presented as suicide attempts, or they may withhold medications. They may also assert that accusations of abuse are simply delusions, lying outright about their partners’ behaviors or rationalizing their own (e.g., by claiming their partner “needed to be restrained”). Poverty, homelessness, institutionalization, unsafe living conditions, and dependence on caregivers exacerbate these risks, leaving individuals with psychiatric disabilities vulnerable to victimization by a range of perpetrators—within families, on the streets, in institutional and residential settings, and by intimate or dating partners. Domestic violence, itself, is often a precipitant to homelessness.
Despite these concerns, the mental health system has not systematically responded to these issues, and there have been systematic efforts to build community partnerships with domestic violence and mental health consumer advocacy programs to address the mental health effects of domestic violence and other lifetime trauma. Because of this lack of collaboration between sectors, many women and children are left without a safe way to address these concerns. In addition, many providers are left without resources to support them in doing this work.
Implications Of Trauma Theory For Working With Survivors Of Domestic Violence
More recently, trauma theory has begun to be viewed as a potential framework for bridging clinical and advocacy perspectives. The emergence of trauma theory over the past three decades has created a significant shift in the ways mental health symptoms are conceptualized and in our understanding of the role abuse and violence play in the development of psychological distress and mental health conditions. Trauma theory, which arose out of observations of the experiences of survivors of civilian and combat trauma, views symptoms as survival strategies— adaptations to potentially life-shattering situations that are made when real protection is unavailable and normal coping mechanisms are overwhelmed. Trauma theory helps destigmatize the mental health consequences of domestic violence by recognizing the role of external events in generating symptoms, normalizing human responses to traumas such as interpersonal violence, and creating a framework for understanding the ways in which the biological, emotional, cognitive, and interpersonal effects of chronic abuse can lead to future difficulties in a person’s life.
It also affords a more balanced approach to treatment— one that focuses on resilience and strengths as well as psychological harm. Lastly, a trauma framework fosters an awareness of the impact of this work on providers, and emphasizes the importance of provider self-care, along with administrative, consultative, and peer support.
Although trauma models are not a substitute for advocacy-based approaches that help survivors achieve freedom and safety and work to end domestic violence, trauma theory can greatly inform and enhance advocacy work by increasing understanding of the psychological consequences of abuse and how trauma affects both domestic violence survivors and the providers and programs that serve them. Trauma models offer guidance on creating services that are sensitive to the experiences of survivors of chronic abuse and that incorporate an understanding of how those experiences can affect individuals’ ability to regulate emotions, process information, and attend to their surroundings. The models also provide tools for responding skillfully and empathically to individuals for whom trust is a critical issue, without having one’s own reactions interfere. Trauma-informed service environments provide emotional as well as physical safety and are consistent with advocacy models in their focus on empowerment, collaboration, and choice. They are also designed to ensure that services themselves are not retraumatizing to survivors and provide strategies for attending to the effects that bearing witness to another’s painful experiences has on advocates as well.
Adapting trauma theory to create more comprehensive and attuned advocacy models holds promise for creating services that are more responsive to survivors’ experiences and needs. While existing trauma models need to be adapted and reframed to address the particular issues faced by survivors of domestic violence, ongoing dialogue will be necessary to address the applicability of these models for a diverse range of communities and to develop alternate models for healing that may be more community based. Whether it is finding ways for domestic violence programs to enhance their ability to respond to trauma-related mental health issues, or ensuring that those women and children with greater needs are able to access culturally relevant, trauma-specific mental health care, issues of philosophy, resources, training, and collaboration are highly important. Developing the capacity to respond more effectively to trauma and mental health issues will require thoughtful consideration of these issues.
- Golding, J. M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14(2), 99–132.
- Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. San Francisco: Jossey-Bass.
- Warshaw, C. (2001). Women and violence. In N. Stotland & D. Stewart (Eds.), Psychological aspects of women’s health care: The interface between psychiatry and obstetrics and gynecology (pp. 477–548). Washington, DC: American Psychiatric Press.
- Warshaw, C., Pease, T., Markham, D. W., Sajdak, L., & Gibson, J. (2007). Access to advocacy: Serving women with psychiatric disabilities in domestic violence settings. Chicago: Domestic Violence & Mental Health Policy Initiative.
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