Counselling and Psychotherapy after Domestic Violence

A Client View of What Helps Recovery

Jeannette Roddy

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137434593
• Topic: Psychology
• Subtopic: Personality in Psychology
• Index: Psychology

This is a refreshing and thought provoking book, presenting the views of female and male counselling clients about their experience of therapy after domestic violence. It brings together the existing literature and client views to present a new perspective on how to approach counselling with individuals who have experienced domestic violence.

1

Differing Views in Research and Practice

What is domestic violence?

There have been references to physical harm in heterosexual relationships in religious texts for many years (Colossians 3:19; Sura 4:34) and hence the concept of violence occurring within the family between intimate partners is not new. However, the experience of domestic violence has often been hidden behind closed doors as individuals have struggled to share the difficulties they were having with their relationship. More recently, this form of abuse has become more visible in our society as a result of many years of campaigning by groups such as Women’s Aid and Refuge, and more recently, ManKind and Respect. Story lines have been written over the years for television programmes such as Casualty, EastEnders and Coronation Street to raise awareness of the issue and to signpost organisations which may be able to help. Press articles highlight times when there is expected to be an increase in violence, such as Christmas when families can be in close contact for a period of days (Pidd, 2013) or during sporting events such as the World Cup (Duell, 2014). These are times when emotions can run high increasing the risk of family disputes and, possibly fuelled by alcohol, potentially leading to serious physical assault.

It is believed that 90% of domestic violence incidents are perpetrated by men on their female partners (Department of Health, 2005) and health guidance focuses on the physical safety of women and children with appropriate referral to advocacy support and third sector refuge organisations for those most at risk. The cost to the UK government of domestic violence was estimated as £3.1bn in 2004, primarily made up of legal costs associated with protecting victims from further harm and medical costs from treating the injuries sustained (Walby, 2004). Statistics showing that two women per week are killed by their male partner highlight the need for women to take action to leave highly abusive relationships quickly (Women’s Aid, 2007). This had been addressed through increased funding from the UK government to provide more advocates (Home Office, 2011) to support women with children in protecting themselves from their abusive partners, which in turn may reduce the cost burden on the public sector.

This view of domestic violence has been described as the public story (Donovan, 2014), that is, abuse perpetrated by men on women. Although it is generally accepted as primarily an issue for heterosexual women, domestic violence is also experienced within Lesbian, Gay, Bisexual, Transgender/Transsexual and Intersexed (LGBTI) communities and by heterosexual males. The latest definition of domestic violence in the UK (Home Office, 2012), implemented in 2013, clearly states that such abuse is not only male to female, but can include same sex relationships and female to male abuse, as well as being intergenerational. The definition includes not only physical violence but also sexual, financial, emotional and psychological abuse, introducing the concepts of controlling, threatening or coercive behaviour. Subsequently the government has indicated its intention to create a new offence for such behaviour, to allow prosecution and punishment (Home Office, 2014).

Although these actions by the government indicate an acknowledgement of the potential seriousness of psychological abuse, historical spending on mental health services for victims of DV has been relatively small. When considering Walby’s (2004) study, the amount estimated as spent on mental health was just over 5% (£176m) of the total spent on DV (at £3.1bn). The updated study (Walby, 2009) omitted spending on mental health, suggesting that the expenditure was not sufficiently large to highlight. It would appear that the cost of mental health provision as a result of domestic violence is relatively small compared to other costs, supporting the continued priority for physical safety. Nevertheless, health guidance for responding to domestic violence, which was rewritten in 2014, now specifies the need to provide evidence-based treatment for any mental health conditions, either pre-existing or developed as a result of their experience, for victims (National Institute for Health and Clinical Excellence, 2014).

Although the recognition of the need for mental health services for those who have experienced domestic violence is welcomed, the requirement for evidence-based treatment may prove problematic. A government funded report (Ramsay, Rivas and Feder, 2005) concluded that the quantitative evidence base for mental health interventions with DV was poor and, in alignment with previous reports (Chalk, King, National Research Council/Institute of Medicine et al., 1998; Wathan and MacMillan, 2003), there was little research of an appropriate quality available to make firm recommendations. Ramsay et al. (2005) suggested that, from the available data, advocacy should be preferred over counselling for women still in abusive relationships. Although the government has suggested that there would be additional support for victims available through their new mental health strategy (Department of Health, 2011) this specifically mentions family therapy as an intervention for DV, rather than individual therapy for victims. This could also preclude treatment for those not in a traditional family unit or those who have left their abusive partner. A recent briefing report for GPs does highlight the mental health impact of DV, but focuses on disclosure from women still in relationships and recommends referral to an advocacy service (Sohal, Feder and Johnson, 2012). The new health guidance for DV (National Institute for Health and Clinical Excellence, 2014) specifically asks practitioners to ensure safety assessments are included in any treatment plans and to make referrals to advocacy services and domestic violence agencies as appropriate. All of this guidance seems to indicate that most patients will be in abusive relationships at the time of seeking help and require other support.

Mental health problems after domestic violence

With the current emphasis on responding to the risk to physical safety, through assistance to leave the relationship and the provision of legal sanctions against violent spouses, life for individuals after leaving a domestically violent relationship has received much less attention. Even so, the mental health implications of living with a physically abusive partner have been recognised for many years (Walker, 1979; Dutton, 1992; Herman, 1992; Sanderson, 2008; Nicolson, 2010) and can lead to an increased risk of depression, suicidal ideation, posttraumatic stress disorder and lack of trust (termed general suspiciousness when first identified by Walker (1979)). Whilst Ramsay et al. (2005) recommended psychological intervention for those who had left their relationship and subsequently suffered depression or lack of self-esteem, they felt they could not recommend a specific form of treatment as there was insufficient evidence. Instead they suggested that further research was required to find out more about what women needed and it is hoped that this book will help with that request. The question is perhaps not only whether mental health issues develop before or from domestic violence, but also whether they continue once the relationship is over.

Depression

One of the most cited research papers involving a meta-analysis of earlier DV research (Golding, 1999), suggested that mental health problems were likely to be present after experiencing DV. For example, Golding (1999) found that the average prevalence of depression within those studies was 47.6%, compared with general population studies showing rates of depression between 10.2% and 21.3%. She also noted that on average 60.6% of women in refuges reported depression. Whilst she concluded this may be due to the recent violence they had experienced, it is also possible that fleeing to a refuge and leaving behind one’s previous life had an effect. What is perhaps more striking about the data is that experiencing severe violence requiring a move to a refuge only increased the proportion of women feeling depressed by 13% on average. However, it is possible that for some women, making the decision to leave could have had a positive effect. Other factors can play a part in developing depression, including living alone, having a low income or being unemployed (Hegarty, Gunn, Chondros et al., 2004), each of which could be factors for individuals potentially relocating. Perhaps all that can be stated with certainty from the data is that a woman who has experienced domestic violence has a greater risk of developing depression.

This shows the difficulty for researchers in establishing whether the reported depression is a result only of the abuse or whether changed life circumstances play a part. It may be inappropriate to make assessments or judgements based only on the degree of violence in the relationship as past history, psychological abuse, other relational issues and current life situation may also have an impact. For example, in a study involving 403 women from Northwest USA who had had physically abusive relationships, two-thirds of the research participants had experienced domestic abuse as children and around half had suffered some form of childhood sexual assault (Walker, 2000). This description of having a history of previous abuse has been found in other research (Howard, Riger, Campbell et al., 2003; Hegarty et al., 2004; Rushlow, 2009), although the proportion measured has been as low as 25% of the participants. This still indicates a reasonable probability that some women experiencing depression after DV will have a childhood history that may, in part, be contributing to their current mental health issues.

There has been continued debate about the extent to which DV experienced as an adult, rather than previous life events, plays a part in the individual’s mental health (Ehrensaft, Moffitt and Caspi, 2006). One finding from a survey of 444 Italian women found that DV does impair mental health, but that the impairment is greater for those who suffered childhood abuse (Romito, Turan and De Marchi, 2005). On the other hand, a UK meta-analysis of 41 studies from across the world could only conclude that individuals with existing mental health issues were at higher risk of experiencing interpersonal violence (IPV) (Trevillion, Oram, Feder et al., 2012). This is a complex issue which is difficult to analyse quantitatively due to an individual’s continued experiences, both positive and negative, throughout life. Experiencing childhood abuse will not necessarily result in the abuse continuing through DV into adulthood. In addition, it is important to note that not all people experiencing DV will suffer from mental health problems. It is possible that other factors are present.

Learned helplessness

Another study, conducted with 101 women from eight refuges in Israel, found learned helplessness to be a statistically significant factor in developing depression whilst the total amount of violence perpetrated was not (Bargai, Ben-Shakhar and Shalev, 2007). ‘Learned helplessness’ is a term used to explain what happens to people when they are placed in a situation where, no matter what response they make, they are powerless to affect the outcome (Seligman, 1975). Over time, the number of attempts the individual makes to change things diminishes. The person learns that it makes no difference what they try and they begin to believe that they are powerless now and in the future. This concept was later developed in the USA to describe ‘Battered Woman Syndrome’ (Walker, 1977). This linked the helplessness potentially learned in childhood as a result of experienced abuse with the helplessness experienced in adulthood through DV, offering an explanation for why people who suffer childhood abuse may be more susceptible to its continuation in later life. However, learned helplessness does not specifically require the presence of physical violence but does require a means of control over the individual. This could include, for example, the threat of violence to the individual or others, or the threat to disclose shaming information to others.

The association of feelings of powerlessness with depression after DV was also noted from a longitudinal study which followed women leaving a refuge (Campbell, Sullivan and Davidson, 1995). The study assessed 83% of the women as depressed to some extent on leaving and after ten weeks this had reduced to 59% of the women. However, an assessment six months later found no further reduction, even for those who had remained free of violence during that time. Campbell et al. (1995) commented that the women who still felt powerless after leaving and had poor social support networks were more likely to remain depressed. The introduction of poor social networks as a concept is important here. Aspects of power and control which have been identified within DV models of abusive behaviour include isolation of the individual, as well as economic, emotional, sexual and psychological factors (Domestic Abuse Intervention Programs, 2012), as in the current UK definition of DV discussed earlier. Isolation from family and friends could be described as both emotional and psychological abuse.

More recent research findings suggest that experiencing psychological abuse may be a more significant factor in poor mental health after DV than previously found. In a three year longitudinal study of 2,639 women within families in the USA (Adkins and Kamp Dush, 2010) the greatest increases in depression were seen in those living in a physically and psychologically abusive environment. Perhaps surprisingly, at the end of the study, those women who had left their abusive relationship appeared on average to have the same levels of depression as those who had remained. Leaving the relationship could create physical safety but psychological aspects of the abuse, such as feelings of powerlessness, could remain unaddressed. The National Violence Against Women Survey (NVAWS) in the USA involving 6,790 women and 7,122 men, found that all forms of IPV resulted in depressive symptoms for both men and women, although those symptoms increase where psychological IPV through power and control (assessed using items from the Power and Control Scale (Johnson, 1996)) was specifically used (Coker, Davis, Arias et al., 2002).

Physical or psychological abuse

A comprehensive study investigating lifetime and recent instances of physical and emotional abuse was conducted in Valencia, Spain (Pico-Alfonso, Garcia-Linares, Celda-Navarro et al., 2006). The study recruited 182 women, 52 of whom had not been abused and 130 of whom were victims of IPV, from the local community. All of the women in the study who had been physically abused (75) had also been psychologically abused, and 25 of these women had also been sexually abused. Of the 55 women who had been psychologically but not physically abused, nine had also been sexually abused. Suicidal thoughts were experienced by 7.7% of women who had not been abused, rising to 43.6% for those who had been psychologically abused. This suggests that psychological abuse alone can have a negative impact on mental health. Where physical and psychological abuse were combined, 58.7% of the women reported suicidal thoughts. Roughly 1 in 4 of the abused women in the study reported making a suicide attempt and this rose to 1 in 2 where physical abuse was also present. This increase in suicide attempts in response to physical violence has been reported elsewhere (McLaughlin, O’Carroll and O’Connor, 2012) but it is also important to note the relatively high rates of suicide attempts without physical violence. Data from the UK suggests that there may be three completed suicides and 30 suicide attempts for women each week as a result of domestic violence in the UK (Webster, 2015), although this could be an underestimate. From a mental health perspective, this study suggests that such suicide attempts may have been prompted by psychological and/or physical abuse.

Currently, we have no robust data on the extent of psychological abuse in relationships in part because there is still no agreement on how this could be most appropriately measured (Follingstad, 2007). However, data has been collected globally to differentiate between physical and non-physical abuse (Straus, 2009). Such data is available in the UK from the National Crime Survey 2010/2011 (Smith, Osborne, Lau et al., 2012). This suggested that around 7% of women (1.2 million) and 5% of men (800,000) over the age of 16 were victims of domestic violence in the previous 12 months. Of those, 57% of female and 46% of male victims suffered non-physical abuse whilst about a quarter of men and women suffered a physical injury as a result. This suggests that there are twice as many men and women potentially suffering from forms of abuse other than physical violence. It also suggests that the number of physical attacks (excluding sexual assault) experienced by men and women are comparable, although this does not allow for the severity of the attack. Nevertheless, this presents a different situation to that given at the beginning of this chapter, where it was suggested that 90% of DV attacks were male to female (Department of Health, 2005).

The difference in these positions can be explained through different academic perspectives. Broadly, there appear to be three different views: family systems theorists (for example M. A. Straus), feminist researchers (for example M. P. Johnson) and psychologists interested in perpetrator violence (for example D.G. Dutton).

Initially, feminist researchers in the UK identified the cause of DV as male dominance within a relationship, which they believed was supported through a patriarchal society (Dobash and Dobash, 1980). Around the same time, in the USA, family violence surveys involving a cross-section of the American public, like the UK one above (Smith et al., 2012) showed that men and women perpetrated violence in roughly equal measure at home (Straus, Gelles and Steinmetz, 1980; Straus, 2009). Feminist researchers then identified specific patterns of systematic abuse as relating specifically to DV which described the tactics and strategies that men might use to dominate their partners (Pence and Paymar, 1993; Domestic Abuse Intervention Programs, 2012). The family systems group in turn produced a measurement of conflict within the relationship to identify negotiation, psychological aggression, physical assault, sexual coercion and injury within a relationship: the Conflict Tactics Scale (CTS2) (Straus, Hamby, Boney-McCoy et al., 1996).

This approach was criticised by feminist researchers, suggesting that the conclusions drawn relied too heavily on data analysis and the reported actions lacked any understanding of the motivation behind, meaning of, and context for, DV (Ross and Babcock, 2009). Measuring defined actions without linking those to a pattern of victimisation or control could simply reflect a desire to get one’s own way rather than systematic abuse. Therefore behaviours which had been described as abusive in men and now measured in women could not necessarily be construed as indicative of DV. To support this view three different categories of abusive behaviour from a feminist perspective were defined: violent resistance (acknowledging that women will at times want to fight back to regain some control prior to leaving their partner), intimate (rather than patriarchal) terrorists (acknowledging that the domination of a family may not be completely about patriarchy or gender) and mutual violent control (where two intimate terrorists are fighting for control of the relationship) (Johnson and Ferraro, 2000). Although this model appeared to accept that women were capable of exerting power and control, Johnson and Ferraro (2000) indicated that the psychological effects of abuse would be felt mainly by those suffering from intimate terrorism (male or female), which equated to a very small proportion of those involved in conflict situations and, in their opinion, almost all of them women. Thus they argued that psychological harm resulting from DV occurred in a very small number of female cases.

However, linking psychological harm specifically to a combination of severe physical and psychological abuse was at odds with some of the earliest research in DV (Walker, 1979). This had clearly identified psychological and physical abuse as separate and important factors in causing emotional harm. Included within Walker’s (1979) research was identification of the Cycle Theory of Violence, a cyclical pattern of abusive and reconciliatory behaviour by the man which holds or binds the female partner psychologically to the relationship. This pattern was later also confirmed by psychologists studying male perpetrator behaviour (Dutton, 1995) and the Cycle Theory of Violence is still recognised as a significant part of DV and used as part of training in DV across the world today (Agnew Davies, 2013). Walker’s later research only included women who had experienced physical abuse due to the complexity of measuring the impact of psychological abuse alone (Walker, 2000). However she noted that ‘the women’s ratings showed that the psychological abuse created longer-lasting pain than did many of the physically induced injuries’ (Walker, 2000, p. 260).

In 2006, Dutton published a book, Rethinking Domestic Violence, stating that perpetrators of both genders could be found (Dutton, 2006). ...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables
• Acknowledgements
• List of Abbreviations
• Introduction
• 1. Differing Views in Research and Practice
• 2. Accessing Appropriate Counselling
• 3. The Female Experience of Counselling
• 4. The Male Experience of Counselling
• 5. Endings and Life after Counselling
• 6. Working with Domestic Violence Clients
• 7. Conclusions
• Appendix 1: Contact Details for Domestic Violence Support
• Appendix 2: Research Methodology Summary
• References
• Index