Domestic violence and mental health: correlates and conundrums within and across cultures

Gender-based violence, only recently emerging as a pervasive global issue, contributes significantly to preventable morbidity and mortality for women across diverse cultures. Existing documentation suggests that profound physical and psychological sequelae are endemic following intimate partner violence. The presentation of domestic violence is often culture specific. A new lexicon, prompted by the expansion of human rights analysis, describes particular threats to local women including dowry deaths, honor murder, saiti, and disproportional exposure to HIV/AIDS as well as globally generic perils including abuse, battering, marital rape, and murder. While still fragmentary, accruing data reveal strengthening associations between domestic violence and mental health. Depression, stress-related syndromes, chemical dependency and substance (ab)use, and suicide are consequences observed in the context of violence in women's lives. Emerging social, legal, medical, and educational strategies, often culture specific, offer novel local models to promote social change beginning with raising the status of women. The ubiquity, gravity, and variability of domestic violence across cultures compel additional research to promote the recognition, intervention, and prevention of domestic violence that are both locally specific and internationally instructive.     

IS231A transposition: conservative versus replicative pathway

OBJECTIVE:To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting. DESIGN: Focus group data conducted and analyzed with qualitative methodology. SETTING: Three community-based mental health centers and one women's shelter. PARTICIPANTS: Twenty-one women in group therapy for domestic violence. MAIN RESULTS: Eighteen (86%) of the 21 women had seen their "regular doctor" in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse. CONCLUSIONS: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences.     

Trauma, Depression, Coping, and Mental Health Service Seeking Among Impoverished Women.

The authors examined the relationship among trauma, coping, depression, and mental health service seeking in a probability sample of sheltered homeless and low-income housed women. Results highlight the diversity of trauma. In a longitudinal analysis, women who lived in shelters or experienced major violence had a twofold increase in their risk of depression over the 6-month follow-up. In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health service seeking among traumatized women. Modifying coping strategies may ameliorate some of the negative impact of trauma and potentially enhance mental health service use among at-risk women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of low-severity violence to women's health

OBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been "pushed or grabbed" or had someone "threaten to hurt them or someone they love" in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. MAIN RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p < .0001). Psychological distress also increased with increasing severity of violence (mean total SCL22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p < .0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.     

Domestic violence: a hidden problem for general practice

Domestic violence is a common problem that may affect more than a quarter of women. It is a complex area in which to undertake research. Studies often focus on selected populations and exhibit a diversity of design, making comparison difficult. This review focuses on physical violence by men against women partners or ex-partners, and exemplifies important issues for general practitioners. Domestic violence frequently goes undetected. This may be the result of doctor's fears of exploring an area perceived as time-consuming, where knowledge is lacking and where they feel powerless to 'fix' the situation. Women may not reveal that they are experiencing violence, sometimes because doctors are unsympathetic or hostile. Nevertheless, women wish to be asked routinely about physical abuse and want to receive immediate advice and information about their options if necessary. Women experience a range of health and social problems in association with domestic violence, including depression, anxiety, substance abuse and pregnancy complications. However, none of these features is specific enough to be useful as an indicator of violence. Therefore, doctors should routinely ask all women direct questions about abuse. This recommendation can be incorporated into guidelines, which should be implemented widely in the UK, to improve the care of women experiencing domestic violence. In parallel with this, the educational needs of general practitioners should be addressed. Further research is needed to establish the prevalence of domestic violence in women presenting to general practice and to investigate how the problem is currently being addressed. If progress is to be made in tackling domestic violence, action within primary care is just one part of this: a fundamental change in the attitudes of men towards women is required.     

Myocardial infarction and percent arteriographic stenosis of culprit lesion: report from the Program on the Surgical Control of the Hyperlipidemias (POSCH)

Domestic violence is a significant public health issue affecting women. Numerous medical organizations have recommended that routine screening of women be conducted to assist in the prevention, identification, and care for victims of violence. This article examines the scope of domestic violence in women, reviews ways to recognize abuse, examines the potential impact of abuse upon health and discusses the management of victims.     

The Ablate and Pace Trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. APT Investigators

Despite gaps in research, this review argues for distinguishing family maltreatment from family violence, a differentiation between minimal or moderate abuse and serious endangerment, physical injury, or sexual violation. Most acts now defined as violent or abusive are moderate, and stressful life circumstances contribute to their development. Research suggests that abuse may develop through multiple pathways. The consequences of abuse appear to be general, but more commonalities may be found by examining more subtle and complex effects. Many interventions have attempted to prevent or treat family violence and its consequences, and several show promise. More systematic research is needed, but several changes in intervention seem warranted now. For instance, (a) mental health professionals should not be required to report maltreatment while a family is engaged in therapy; (b) the social service system needs to rediscover its roots in supporting families under stress, including in cases of moderate maltreatment; and (c) swift and decisive legal intervention is needed in cases of serious family violence.     

"Persist. persist.": A qualitative study of women's decisions to disclose and their perceptions of the impact of routine screening for intimate partner violence.

Objective: To understand the conditions under which a group of women recruited from antenatal, mental health, and substance abuse services disclose abuse in response to routine screening for intimate partner violence and their constructions of the impact of routine screening. Method: In-depth interviews with 20 women followed up 6 months after disclosing abuse in response to screening. Results: Women were in diverse situations relating to trajectories of abuse that included continued abuse despite interventions and abuse cessation within relationship. Women disclosed their abuse after making active judgments about safety on three dimensions: from the abuser, from shame and from relinquishing control. Most women described valued impacts from screening, though this was less common for those who had previous contact with statutory agencies. The process of asking shaped constructions of abuse, giving name to it. Health workers' responses to disclosures often helped to create a sense of connection. Conclusions: These effects align with Herman's work identifying naming and reconnection as important steps in recovery from trauma. The diversity of women's situations may explain difficulties in achieving significant findings by RCTs on screening impacts. Screening can bring about important changes for some women and is not simply a strategy for identification and referral. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

An overview of the nature, causes, and consequences of abusive family relationships: Toward differentiating maltreatment and violence.

Despite gaps in research, this review argues for distinguishing family maltreatment from family violence, a differentiation between minimal or moderate abuse and serious endangerment, physical injury, or sexual violation. Most acts now defined as violent or abusive are moderate, and stressful life circumstances contribute to their development. Research suggests that abuse may develop through multiple pathways. The consequences of abuse appear to be general, but more commonalities may be found by examining more subtle and complex effects. Many interventions have attempted to prevent or treat family violence and its consequences, and several show promise. More systematic research is needed, but several changes in intervention seem warranted now. For instance, (a) mental health professionals should not be required to report maltreatment while a family is engaged in therapy; (b) the social service system needs to rediscover its roots in supporting families under stress, including in cases of moderate maltreatment; and (c) swift and decisive legal intervention is needed in cases of serious family violence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The National Child Traumatic Stress Network: Collaborating to improve the standard of care.

Mental health practitioners are often called upon to provide services to children, adolescents, and families in the aftermath of traumatic experiences such as child neglect, sexual or physical abuse, family/domestic violence, sexual assault, interpersonal violence, school and community violence, serious accidental injury, catastrophic medical illness, traumatic bereavement, or mass casualty events, including natural and man-made disasters. The National Child Traumatic Stress Network (NCTSN) was established in 2001 to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. This article describes the development of the NCTSN, its structure, programs, and many of the products and resources--including online lectures, training programs and videos, and searchable databases of child trauma resources--available through the NCTSN Web site (www.nctsn.org) to assist professionals in providing state-of-the-art assessment, treatment, and services to these children and their families. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol dependence and domestic violence as sequelae of abuse and conduct disorder in childhood

OBJECTIVES: To examine in the Navajo population: (1) the importance of childhood abuse as a risk factor for conduct disorder; (2) the importance of each form of abuse and conduct disorder as risk factors for alcohol dependence; and (3) the relative importance of each form of abuse, conduct disorder, and alcohol dependence as risk factors for being a perpetrator and/or victim of domestic violence. METHOD: The study is based on a case-control design. Cases (204 men and 148 women) between the ages of 21 and 65 were interviewed in alcohol treatment program and matched to community controls. There were two groups of controls: alcohol dependent (374 men, 60 women) and nonalcohol dependent (157 men, 143 women). When adjusted for stratification by age, community of residence, and sex, the combined control groups comprise a representative sample of the Navajo male and female population 21-65 years of age. RESULTS: The prevalence of physical and sexual abuse before age 15 is within limits observed in other populations. Each form of abuse is a risk factor for conduct disorder. Along with conduct disorder, physical abuse is a risk factor for alcohol dependence. Physical abuse and alcohol dependence are independent risk factors for being involved in domestic violence as both perpetrator and victim. There appears to have been no secular trend in the incidence of childhood abuse over the past several generations, but there is suggestive evidence that domestic violence has become more common. CONCLUSIONS: Physical abuse is a significant risk factor for alcohol dependence as well as for domestic violence independent of the effects of alcohol abuse. The effects of sexual abuse with regard to both domestic violence and alcohol dependence do not appear to be significant.     

Surgical treatment of ventricular septal defect complicated by pulmonary hypertension at high altitude

Home care providers have a professional and legal obligation to help prevent their elderly patients from being abused and neglected by family members and other home care providers. The elderly are often in a vulnerable situation because they depend on family members or others to help with personal care, housekeeping chores, and money management. A recent article in a major newspaper illustrates the problem. It reported that Mr. X, who was 84 years old, had been without food or water while he lay curled in the trunk of his car for 2 days before he was found by the police. When found, he reported that he saw daylight only when his housekeeper lifted the car trunk lid to ask him if her forgery of his check looked authentic. After he was rescued, he acknowledged that he was confused about why his housekeeper, who had befriended him, had turned on him. He expressed concern for her and hoped she would get a break in her sentencing. "She didn't kill me," he said. This situation is not that unusual. Elder abuse and neglect is a major public health problem in the United States, with most cases hidden from public scrutiny. The National center on Elder Abuse reports that cases of domestic abuse against the elderly increased from 117,000 in 1986 to 241,000 in 1994, and that represented only a fraction of older Americans who were abused and neglected in their homes. The Center estimates that 818,000 elderly Americans were victims of various types of domestic abuse in 1994. They believe the rise in reported cases illustrates a growing pattern of violence and neglect among the nation's expanding elderly population.     

The complexities of domestic violence.

Comments on the article by Robert Bornstein, "The complex relationship between dependency and domestic violence: Converging psychological factors and social forces," (see record 2006-11202-003). Although a more focused examination of the psychological factors involved in domestic violence is welcome, there are some factual errors in Bornstein's article that need attention and represent a general problem in reports of domestic violence. Bornstein wrote, "Studies indicate that more than 95% of abuse perpetrators are men" (p. 595) and then proceeded to assess dependency in male perpetrators and female victims of intimate partner violence (IPV). The study indicating that more than 95% of IPV perpetrators are men was not cited and is, in fact, fictitious. The best empirical evidence indicates an entirely different finding. Clinical predictions of dangerousness made in psychiatric emergency rooms often underestimate female dangerousness. Risk of harm to children has often been based on wife abuse-child abuse incidence co-occurrence estimates from shelter house samples of women and erroneously generalized to community samples. For these reasons, regeneration of the gender paradigm by Bornstein, or others, serves to misinform the profession. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress in children and adolescents exposed to family violence: I. Overview and issues.

Exposure to child physical abuse and parents' domestic violence can subject youth to pervasive traumatic stress and can lead to posttraumatic stress disorder (PTSD). This article presents evolving conceptualizations in the burgeoning field of trauma related to family violence exposure and describes how the often repeating and ongoing nature of family violence exposure can complicate a PTSD diagnosis. In addition, recent literature indicates that children exposed to family violence may experience problems in multiple domains of functioning and may meet criteria for multiple disorders in addition to PTSD. Considerations salient to the recognition of traumatic stress in this population and that inform assessment and treatment planning are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Overview: Forging research priorities for women's mental health.

After a decade of reports underscoring the inadequacy of existing scientific knowledge for understanding gender differences in mental disorder and its treatment, the National Institute of Mental Health has developed a women's mental health research agenda with five priority areas for research: diagnosis and treatment of mental disorder, mental health issues for older women, violence against women, multiple roles, and poverty. This overview highlights some of the major findings in each of these five areas and introduces the more in-depth treatment given in this Psychology in the Public Forum section to the areas of violence, poverty, and multiple roles. It also underscores the importance of identifying sources of gender bias in all mental health research. Women's mental health issues have become officially recognized as part of the NIMH research agenda. Only time and continued monitoring will determine how these official policy priorities will become translated into actual funding and research initiatives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pilot studies for proficiency testing using fluorescence in situ hybridization with chromosome-specific DNA probes: a College of American Pathologists/American College of Medical Genetics Program

This paper proposes that a comprehensive, long-term program with a case-management focus will produce better outcomes and be more cost-effective than the current approach to managing the illnesses of women on Temporary Assistance for Needy Families (or TANF, formerly known as AFDC) who are afflicted with both drug dependency and mental illness, i.e. a dual diagnosis. It is proposed that this comprehensive approach would diminish the generational cycle of substance abuse, dysfunction (including violence), and dependence on public support, which is too often the pattern in single-parent homes where the mother has been dually diagnosed. For our purposes, dual diagnosis is defined as any mental health diagnosis using the DSM-IV criteria coexisting with a diagnosis of substance abuse, whether licit or illicit. Current drug policy, particularly as it applies to those with a dual diagnosis, has an emphasis on criminal justice system solutions. It is extremely expensive (incarceration alone is variously estimated as costing $25,000 to $45,000 per year per person), and does little to treat, prevent, or consequently, reduce the problem. The model design discussed in this article provides for comprehensive treatment and support services to women with a dual diagnosis receiving TANF. Its goal is to help break the family cycle of system dependency. The article hypothesizes that if a well-designed program evaluation is implemented, it will demonstrate savings in reduced health care, criminal justice, and social service costs.     

Clinical Implications in Healing from Domestic Violence: A Case Study.

Violence against women by their intimate partners continues to be widespread today. Practicing psychologists who treat female clients will see the consequences of immediate and long-term emotional effects of abuse. The author uses a psychologist's personal story of domestic violence and healing from abuse to illustrate the psychological issues and concerns battered women face in their healing. The author then gives eight recommendations for treating battered women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological Effects of Domestic Violence on Children and Their Mothers.

While domestic violence and child abuse are known to be highly correlated, several related areas of functioning of victim mothers and children are not well researched and have implications for the provision of services. Fifty mothers and children were referred by service agencies for independent structured interviews and psychological assessment. Assessment focused on evidence of posttraumatic reexperiencing, avoidance, physiological arousal, associated symptoms, and parenting skills. A complex pattern of results documented high levels of abuse and associated trauma disorders in both the children and their mothers. However, the presence of disorders was generally not correlated between children and mothers, and affected mothers were less likely to seek mental health services for their children (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A public health perspective on "The ethics of asking and not asking about abuse."

Comments on the article by K. Becker-Blease and J. Freyd (see record 2006-03947-003), which provides a thought-provoking and important perspective regarding the ethics of researchers asking or not asking adults about abuse they experienced as children. Many of these authors' concerns with research on abuse during childhood apply equally to abuse and violence experienced at all life stages. Focusing on intimate partner violence (IPV), we wish to amplify upon and respond to their observations from the perspective of public health scientists involved in large-scale telephone survey research on violence (including family violence, IPV, sexual violence, and suicide). We strongly agree with Becker-Blease and Freyd that decisions not to ask about abuse play directly into the social forces that perpetuate IPV and other forms of violence as pervasive and pernicious social and public health problems. From a public health perspective, the question is not whether to ask but how to ask about participants' experiences with violence and abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)