Treating Adult Trauma Survivors

Understanding Severe and Prolonged Trauma

It is essential for clinicians to understand the phenomenological experiences of the

lives of clients who have survived trauma and how their real-life situations have

shaped their belief systems and worldviews.

Knowing the client

The therapist needs to gain an understanding of how survivors perceive their own

lived worlds, their relationships, and their sense of self.

Additionally, the therapist needs to be aware of the client’s ability to self-regulate,

which would include assessing for high-risk behaviors such as substance abuse,

promiscuity, self-injury, and suicidality.

Additionally, the therapist needs to be flexible in the way in which they work with

survivors, being alert for transference issues in the client and countertransference

reactions on the part of the therapist.

Assessing the early attachment histories of trauma survivors helps in case

formulation. Clinicians need to ask about early family disruption, absent caregivers,

abandonment, death of a caregiver, neglect, violence, history of failure to thrive, and

serious medical conditions requiring invasive medical procedures and longer hospital

stays.

Any of the aforementioned early history, alone or in combination, can contribute to

emotional distancing and anxiety; in turn, this can create inability to bond or attach,

relationship difficulty, and affect dysregulation.

Establishing a trusting therapeutic relationship can be a challenge while working with

trauma survivors because of the clients’ lack of trust, affect dysregulation, and

unstable relationships.

The empathy, support, consistency, and attentiveness offered by the therapist are

unfamiliar to many survivors and can be threatening to survivors precisely because

these are often outside the realm of their experiences.

The client’s lack of trust further complicates treatment, as trauma therapy involves

the survivor thinking about his or her history, which typically is avoided so as not to

experience the overwhelming feelings, sensations, and thoughts related to the

traumatic past.

Many survivors feel too much or feel too little. This can appear like a volcano about

to erupt in the therapy (hyperarousal) or, by contrast, like disappearing into the wall

(hypoarousal), thus requiring the therapist to help the client to decrease the

hyperarousal or increase the hypoarousal so that the therapeutic work can occur

within the client’s “window of tolerance”.

This is the space in which a client can work, without becoming hyperaroused or

hypoaroused, but this window initially is limited in therapy. Over time, and as a

function of therapy, this window expands.

Working with adult trauma survivors necessitates attentiveness on the part of the

therapist, especially in assessing and understanding the symptoms that the client is

presenting.

The therapeutic relationship is an attachment relationship and can contribute to

improved emotional regulation in the client.

Additionally, the therapist needs to have a working understanding of how trauma

can affect the mind as well as the body, and how trauma can have an impact on

survivors’ overall functioning in multiple domains, including home, relationships,

work, school, and community and even on survivors’ worldviews and core

values/beliefs.

Therapy with trauma focus particularly requires that the therapist have an

awareness and understanding of dissociative symptoms and how these might

manifest in the client.

It is imperative that the clinician have some comprehension of complex trauma

disorders.

Additional symptom clusters for complex traumatic stress disorders have been

identified and include the following:

 affect and impulse dysregulation;

 biological self-regulation/somatization such as a physical symptom, like pain,

that is not entirely medically explained;

 alterations in consciousness, that is, pathological dissociation;

 perception of the perpetrator, for example, a focus on revenge;

 self-perception that includes shame or guilt;

 relationships that lack trust or include revictimization;

 systems of meaning marked by hopelessness.

The current literature on trauma in the areas of development, attachment, and

neuroscience address the importance of incorporating the cognitive, emotional, and

somatic aspects of trauma in treating traumatized individuals.

A sensorimotor approach centers on the physical as well as the psychological aspects

of trauma. Survivors of trauma can be overwhelmed with sensorimotor symptoms in

such forms as intrusive images, sounds, smells, body sensations, physical pain,

constriction, numbing, and inability to modulate arousal.

Sensorimotor therapy emphasizes the importance of using body-centered

approaches to decrease these reactions and allows for change in the client.

Traumatic memories are not held in narrative form but in sensory fragments and are

held in the neuropathways throughout the brain in the form of smells, sounds,

touch, sensations, and images.

They can invade into the client’s awareness whenever the client encounters a

trigger, that is, a reminder of the trauma, or when the client experiences a similar

emotional reaction that was present at the time of the trauma.

Triggers can be subtle or more obvious; they can be situational, like when the

survivor’s child reaches the survivor’s age of abuse, or they can consist of sounds,

smells, or gestures, for example, which were a part of the trauma experience.

Adult survivors may experience memories of the trauma as if they were happening in

that given moment.

They may be overwhelmed by the barrage of physical sensations, and may even lose

a sense of the present, as they relive an experience from their specific past. These

intrusions occur during consciousness and are known as flashbacks.

Dissociation is also a hallmark symptom of traumatized individuals. Chronic

traumatization contributes to dissociation that can alter one’s perceptions, thoughts,

and emotions and interferes with information processing.

Levels of impairment and delayed development

Trauma exposure occurring in infancy and early childhood, especially on the part of

the primary caregivers, interferes with normal psychobiological development in

children.

Specifically, in infancy, right brain development is affected by and interferes with the

maltreated child’s ability to regulate intense affect; this can further contribute to

long-term effects of pathological dissociation.

The human stress response to trauma has been characterized as one of either fight,

flight, or freeze. This response, based on biological changes in the child’s body and

mind, is one over which the child has no control.

Trauma can rob a child of the ability to self-protect: the younger the child, the less

likely it is that the child can fight or flight, thus resulting in the child’s body going into

a freeze mode. When in this state, the infant or young child is not able to respond in

a self-protective manner, especially physically.

Traumatic events diminish the child’s ability to trust, and they deflate the child’s

sense of empowerment.

Researchers in one study (De Bellis et al., 1999) found that abused and neglected

children have brains that are as much as 7% smaller than the brains of the control

groups of nonabused children. They also found abnormalities in the corpus callosum.

This results in the right and left hemispheres not working together and thus

interfering with emotional and cognitive processing and lateralization occurs.

These researchers also noted that in children who have endured longer periods of

abuse, the cerebral volume in the brain was smaller, and the children displayed more
 trauma symptoms such as hyperarousal, avoidance, dissociation, and intrusive

images or thoughts.

In abused children the cortex in the left hemisphere is not fully developed; this, in

turn, affects language and reasoning skills. Additionally, the reduced capacity of the

left hemisphere causes the child to be at risk for developing depression.

Other researchers have determined that chronic trauma results in affect

dysregulation, sleep disorders, startle reactions, sensory-motor dysfunction,

dissociation, learning problems, relationship issues, anxiety and panic attacks, and

avoidance of specific situations or events.

Treatment

The treatment of trauma requires an in-depth knowledge on the part of the

therapist in understanding and being able to identify dissociation.

It is imperative that clinicians have a strong understanding of the effects of traumatic

events on clients and use best practices when treating trauma in order to avoid

“therapeutic misadventures.”

Phases of treatment

Trauma therapy typically covers three phases. The issues addressed in the first stage

may resurface during each phase of treatment, making therapy a highly recursive

process.

Safety is the focus of the first stage, and accurate assessment is critical. The client

may outline various traumatic stressors, much like a grocery list, and may show

minimal, if any, affect when recounting terrifying events.

 The therapist must establish the framework from which the therapy will proceed,

including a discussion of boundaries and limits. These typically need to be repeated

at every phase of treatment and often are tested by the client.

The use of expressive arts therapy including drawing, sculpting, painting, dance

movement, music, writing, meditation, and exercise can tap into the creativeness

and mindfulness of the individual.

These activities work with other areas of the brain, sometimes enabling clients to

express aspects of the trauma that have not been communicated verbally or on a

cognitive level. They can be adapted to all three stages of therapy.

Providing opportunities for clients to make choices is also important throughout the

therapeutic process, as survivors often were not given much opportunity to make

decisions.

Safety and stabilisation

Establishing a therapeutic alliance becomes challenging due to the lack of trust,

which has been well ingrained in trauma survivors. This is further complicated by the

fact that survivors feel unsafe in their bodies and in personal relationships.

Of primary concern is the client’s safety. Safety refers to the physical safety of the

environment where the therapy occurs as well as to emotional safety of the client.

Safety also includes issues outside of the therapy session and between sessions.

In this phase, the therapist can expect that crises will arise. Therefore, the therapist

needs to anticipate this and to give the client clear direction on how a particular

crisis needs to be handled between sessions and outside of therapy.

Typically, clients test the genuineness of the therapist to ascertain that, no matter

what, the therapist will not reject them. The therapist can expect transference issues
within this phase. These can be emotionally charged and overwhelming for the

client.

Client transference is related to the level of mistrust that the client has learned, as

well as to the betrayal the client experienced at the hands of those who were

supposed to be protective and caring, but who were not.

One example of acting out is client self-harm. Therapy in this phase includes efforts

to stabilize a client’s urges to self-injure and to manage suicidal thoughts, eating

disorders, and substance abuse.

Engaging the client in writing a safety plan, signed by both the client and the

therapist, is a helpful way to engage both in promoting safety. The signed contract

needs to include high-energy activities. Less intense actions also are helpful.

The contract spells out a variety of alternatives for the client to decrease the

intensity of the stressor, including both passive and more aggressive activities. It also

needs to list at least three support people whom the client can call before calling the

therapist.

Learning ways to calm the body down and decrease hyperarousal states are essential

for survivors during the safety phase.

Safety also refers to the pace of the therapy, and the therapist needs to educate and

encourage the client on how and when to “put on the brake”.

The brakes are needed when trauma symptoms escalate; the goal then becomes

allowing the client to regroup by calming the body, temporarily ignoring self-

depreciating words or feelings, and letting the sensation decrease.

 The therapeutic relationship is pivotal in working with adult survivors; this requires

learning and then using the client’s strengths and internal and external resources, as

well as areas where they struggle or are lost.

The therapist teaches and demonstrates coping daily skills that address overreactive

functioning, also encouraging the client to learn more adaptive responses that can

lead to self-confidence and more productive emotional functioning in the client.

This may include improved sleep patterns, better personal hygiene, increased

exercising, nutritional eating patterns, and mindfulness/meditation

Psychoeducation is also another aspect of the first phase. Explaining the effects of

traumatic stress, including its biological and psychosocial ramifications, is one option

that can contribute to reducing fear and normalizing the client’s symptoms and

reactions.

Processing the trauma

The stabilization that was established and the coping, grounding, and containment

skills that were developed in the safety phase are essential for the client to be able

to process the traumatic memory.

Productive trauma processing only can occur when the following conditions are

present: the therapeutic alliance must be solid; the client needs to have developed a

firm sense of safety and competent skill management; and the client and therapist

must be willing to engage in the difficult trauma work of managing the flood of

traumatic material on somatic, emotional, cognitive, and spiritual levels.

The client must have active input as to whether he or she wants to do this work;

while remembering the trauma may be essential to continued therapy, a client

should never be pushed when not ready or led by the therapist in revealing

memories.

The focus in the second phase is to incorporate the traumatic memory into a

narrative about the survivor’s life. The traumas are then framed as experiences in

the life of the client and are no longer the basis for personal identity.

Along with an expression of related cognitive schemata, the narrative needs to

include the imagery and sensory aspects of the event(s), including body sensation

and emotion; otherwise, the narrative is not complete.

It is essential that the therapist is attentive to the individual survivor’s ability to self-

regulate, which will vary. Attunement with the client allows for adjustments to the

way the therapist intervenes, offers support, and guides the therapeutic process

with the client; this enables the client in “operating the brakes”.

If the survivor becomes hyperaroused or experiences intense trauma symptoms, the

session needs to slow down, thereby reinforcing the importance of the collaboration

between client and therapist.

Stabilization with the use of previously learned coping skills needs to be

implemented when the survivor experiences an increase in hyperarousal during this

phase of processing.

The therapist needs to be aware of the client’s ability to self-regulate in each session,

as well as noticing the increasing ability of the client to regulate over time.

Clients may choose to write or draw at different points in the trauma processing, and

it is the role of the therapist to remind the client that reading a journal entry or

describing a drawing can have a powerful healing impact when shared together in

session.
 This has a pendulum effect, going from the past to the present, and can be helpful in

titrating the intensity of the trauma processing.

At times, the client and/or the therapist may notice hyperarousal or intensification of

other symptoms. When this occurs, from a sensorimotor perspective, the therapist

may encourage the client to stop the words and focus only on the body sensations

until the arousal calms down.

In this way, as the therapy continues, the cognitive and emotional aspects of the

memory can then be titrated at a level that meets the capacity of the client in

dealing with the traumatic memories. The goal is to avoid retraumatizing the client

and to integrate the memory as part of the trauma narrative.

It is important to reinforce the client’s efforts, to reaffirm his or her capability in

working through the overwhelming emotions and memories, and to encourage the

client in rebuilding a sense of self.

Reconnection and integration

During the third phase of therapy, the focus is to move the client on the path of

creating a normal lifestyle, with a view toward the future that may include school,

work, a career, formulating new relationships, intimacy, and a renewed sense of self;

the aim is to enable the survivor to reengage in life in an emotionally regulated

manner.

For many survivors, the concept of pleasure is foreign, as their lives have been

centered on negativity and overwhelming situations. The ability to have positive

experiences is limited because typically elevated emotions, positive or negative, are

reminders of past trauma.

 During this phase, clients are encouraged to participate in positive activities;

however, this can create a dilemma, as many clients have little idea as to what would

be fun, and therapists may need to provide positive challenges in order to increase

client tolerance for positive emotions.

The crises experienced by clients in this phase of therapy tend to be minimal. Clients

have developed or redeveloped their capacities to trust others, and they also are

more keenly aware that, in certain situations, it is appropriate not to trust people or

situations that may cause harm.

In this final phase of treatment, the client often shows insight as they begin to

comprehend the level of chaos and dysfunction that they have experienced.

Empowerment has extended meaning for the client in this stage.

No matter what, how, or whether the family of origin responds, it is a victory for the

survivor; they finally can name what they experienced, initially in therapy, but with

the therapist as a witness.

Thus, in this stage, the survivor is able to determine whether to discuss the trauma

openly with their family; this is a profound and individual decision.

Principles of treatment

Trauma treatment requires a multidimensional approach that includes body

awareness and processing, creative expression, grounding and containment,

assessment, psychoeducation, cognitive adjustment, and medication.

Therapists need to assist clients in developing coping skills in order to manage

hyperarousal; increasing self-awareness to assess the intensity of arousal;

encouraging the maintenance of a level of functioning high enough to manage

 individual daily life responsibilities; managing triggers and trigger situations, rather

than avoiding them; and increasing the client’s personal control and efficacy.

Treatment limitations

Clients with histories of complex trauma can be volatile, and the therapist needs to

be attentive and to educate clients in specific trauma-related areas.

The most fragile survivors may leave therapy prematurely or may need to reenter

counseling several times before attaining the level of trust and affect regulation that

is required to work through their traumatic past.

Chronically traumatized clients, due to an abusive past, may have a strong need to

control the therapist. At times, they may be disrespectful and act out emotionally or

reenact aspects of past traumatic relationships; at such times, they may need further

stabilization before they can continue to process their traumatic past.

Due to the client’s paucity of interpersonal resources, a decision to focus on skills

training may be the preferred path of treatment, and trauma processing thus would

not be a focus of treatment or postponed for a more appropriate time.

Treatment Approaches

Several treatment approaches have been identified as best practices for use with

survivors of trauma, including eye movement desensitization and reprocessing,

dialectical behavior therapy, cognitive behavioral therapy, and psychodynamic.

Treatment for complex trauma needs to incorporate and recognize the attachment

problems that are so apparent in this population.

Eye movement desensitization and reprocessing

EMDR is an eight-phase treatment approach developed by Francine Shapiro in 1989

that focuses on the brain’s information processing system and the way memories are

held.

EMDR additionally includes an adaptive information processing (AIP) model that is

based on the ways that trauma affects the brain and on the way that healing may

occur.

Research has indicated that bilateral stimulation (BLS)—left or right tapping, auditory

tones, specifically recorded music, or certain movement—is not just limited to eye

movement; hence, BLS that activates the right and left hemispheres of the brain may

access traumatic memory.

EMDR processes many aspects of the images, thoughts, body sensations, and

emotions associated with the traumatic memory.

EMDR is a structured approach and uses a past, present, and future template.

The dual attention has the client focusing on the distressing material and

simultaneously on the BLS. Between sets of BLS, clients use free association to grasp

further information and make sense of associated memories. The client processes

the overwhelming material and is able to integrate new information.

This approach to the treatment of trauma disorders is evidence based and requires

extensive training on the part of already experienced therapists.

EMDR is used for strengthening the client’s internal resources and is thought to bring

about fast and long-lasting change.

Dialectical behaviour therapy

DBT is a relational skills treatment approach developed by Marsha Linehan.

Since its conception, DBT is used along with other trauma-related disorders such as

substance abuse, eating disorders, and anxiety.

Many clients who have issues with affect dysregulation and relationship problems or

who thrive on crisis also have complicated trauma histories; for this reason, DBT or

selected components of DBT may be useful in helping adult survivors of trauma in

the healing process.

DBT includes a series of structured group sessions consisting of skills training; these

are not process groups. The DBT approach requires that for this to be effective,

clients must work simultaneously with an individual therapist.

DBT covers four skill sets with a focus on affect regulation, mindfulness,

interpersonal interactions, and distress tolerance.

The affect regulation skill set offers clients adaptive methods to develop and

maintain better control over reactive emotions associated with trauma or distress.

Mindfulness teaches clients to be in the present moment in a nonjudgmental

manner, and at the same time, encourages body awareness.

The third skills set provides clients with ways to interact more effectively with people

in their lives, and the final set emphasizes the development of better coping

strategies intended to improve affect regulation.

This approach encourages clients to stay in the present and to pay attention to what

is helpful. It can aid in decreasing anxiety levels and self-destructive behaviours like

self-injury, which then can assist in decreasing the overreactive responses often

displayed by this population.

Cognitive behaviour therapy

CBT operates on the premise that clients can learn to regulate their feelings by

changing their thoughts and behaviours, and that new ways of thinking, behaving,

and feeling can affect change.

CBT is a structured therapy approach, incorporating skills training, which can lessen

the client’s level of anxiety as it helps in preparation for future intensive work.

In CBT, the sessions have agendas with goals and offer predictability about what

happens next when there are target aims.

Distortions in thinking or catastrophizing are addressed, and clients are taught to

reframe such distortions to more adaptable and accurate ways of thinking.

Homework is used in this therapeutic approach; clients keep a journal of their

thoughts, feelings, and behaviours and process this information with their

counsellors.

This approach encourages telling the trauma narrative, and the therapist titrates the

pace and intensity, so that the client effectively can manage thoughts, feelings, and

behaviours.

This approach has a strong emphasis on containing affect, thereby allowing clients to

experience more intense affect during stage two of trauma processing, when they

are more ready because they are safer.

Psychodynamic approach

Psychodynamic therapy is an insight-oriented treatment approach that focuses on

the interpersonal relationships of a client, including the therapeutic relationship with

the therapist.
 The psychodynamic therapist uses the therapeutic alliance to assist the client in

gaining insight about relationship issues by making interpretations that are related

to the client’s past childhood and current life experiences.

Counselling Implications

It is essential to keep in mind that trauma therapy needs to be multidimensional and

that “one size does not fit all.”

It is widely held that problems with affect regulation are right brained, and

therefore, nonverbal in nature. This offers a partial explanation as to the relevance

of why verbally based talk therapies alone often fail; they are unable to restore

normal affect regulation and ignore the neurobiological aspects of trauma.

Expressive arts, dance, yoga, meditation, and music are additional aspects of

treatment.

In working with trauma, it is important to consider that information processing is

multidimensional and occurs on cognitive, emotional, and sensory levels.

In closing, in the final stages of trauma treatment, clients can begin to comprehend

that the events they endured have not changed, but the negative effects on mind

and body have been transformed.

Not only is dealing with and healing from trauma transformational for clients; the

healing process also has an impact on clinicians.

 Intimate Partner Violence

Definitions

IPV (a relatively new term) is an area that has been the subject of copious research

under a variety of names, including domestic abuse, wife beating, and domestic

violence .

Recent IPV research has begun to include studies of female violence against male

partners; however, most partner abuse victims have been, and continue to be,

overwhelmingly female.

The historic roots of spousal abuse run deep. Women have been bought, sold, and

traded as chattel for centuries, denied education, land ownership, and are not yet

considered fully independent human beings in many cultures.

Politically, even in the industrialized West, women’s rights have been nominally

granted but continue to be undermined or ignored by certain male groups, and often

in their own homes by their partners.

Tjaden and Thoennes (2000) studied the prevalence and consequences of male-to-

female and female-to-male IPV, finding that women experienced higher rates of

violence by marital/opposite sex partners than did men.

Women reported more frequent, longer lasting violence, as well as more threats and

fear of bodily harm.

Women victims of IPV were significantly more likely than men to report that they

had been injured, had received medical care and mental health counselling, had lost

time from work, and had sought legal intervention.

 Thus, male and female experiences of violence at the hands of an intimate partner

appear to differ both quantitatively and qualitatively.

Intimate partners are defined as current or former spouses, boyfriends, and

girlfriends, and the term assumes that the partnerships may be either heterosexual

or homosexual.

The U.S. Department of Justice lists the following crimes in their description of IPV

statistics: homicide, rape, sexual assault, robbery, aggravated assault, and simple

assault.

Other studies have expanded the definition to include psychological violence, defi

ned as “put-downs, name calling, and controlling behaviour”.

Traumatic Consequences of IPV on Individuals

Physical effects

The physical effects of IPV are often first discovered in medical settings, such as

emergency rooms, physicians’ offices, or clinics. These effects can manifest as poor

health status, poor quality of life, and frequent use of medical care for a wide variety

of physical injuries.

According to Campbell (2002), battered women are more likely to have been injured

in the head, face, neck, thorax, and abdomen than women hurt in non-battering

incidents.

Campbell also describes the long-term consequences of battering, such as fear and

stress that can result in chronic conditions like headaches, neck pain, and back

problems.
Large-scale research conducted by Felitti et al. (1998) establishes the connection

between adverse childhood experiences (ACE Study) and problems in adulthood,

ranging from chronic physical health issues to long-term psychiatric disorders.

Studies show that battered women report higher than average gastrointestinal,

cardiac, and immune system symptoms and disorders. Further research is warranted

to establish a cause-and-effect relationship.

Campbell’s findings among heterosexual women are extended by Heintz and

Melendez (2006), who report an increased risk of HIV/STDs among gay, lesbian,

bisexual, and transgendered (GLBT) individuals as a result of forced sex by intimate

partners.

Members of sexual minorities also report a higher incidence of battering as a direct

consequence of asking their partners to practice safe sex.

The identification and treatment of IPV-related injury and illness often is hindered by

the reluctance of victims to report their partners’ violence to medical personnel.

They fear that police and legal intervention may follow, further jeopardizing their

physical safety and financial security.

In addition, the shame and social stigma attached to being battered by a partner or

spouse prevent many victims from seeking medical help for all but the most severe

injuries, which then, often, are attributed to falls or other accidents.

If the victim is also a member of a minority population, the personal experience of

racism and prejudices realistically may contribute to an individual’s reluctance to

seek help for physical problems associated with IPV.

Psychological effects

A meta-analysis of studies of the psychological effects of IPV (Golding, 1999) reveals

that depression and PTSD are the most prevalent mental health problems associated

with intimate partner trauma, with the occurrence of PTSD in battered women

statistically much higher than in nonabused women.

Diez et al. (2009) observed psychological health indicators such as antidepressant

intake, sleep disorders, lack of concentration, loss of energy, and difficulties making

decisions to be higher in abused women.

Coker et al. (2002) confirmed that behaviours that may have an adverse effect on

mental well-being, such as alcohol consumption and drug use, tend to be more

prevalent in female victims of IPV.

Historically, the relationship between intimate partners has been considered private,

particularly in cultures that tacitly or overtly condone men’s domination of women.

In many heterosexual marriages, women are subject to the control of their

husbands; a situation that is often supported through selective interpretation of

religious teachings.

Law enforcement personnel have been reluctant to intervene in domestic violence

situations because attempts to separate the abuser from the victim often result in

the formation of a united front against the police.

Misunderstanding of the complex dynamics involved in IPV relationships has led to

general scepticism about the abused person’s status as a victim or as a sufferer of

traumatic stress.

Ochberg (1988) has proposed that victims of deliberate cruelty such as IPV are likely

to suffer from symptoms from the following list, which represents “victimization”
 rather than “traumatization”—a distinction that recognizes the perpetrator’s

behaviour rather than the victim’s reaction as the source of deleterious effects

associated with IPV

 Shame: embarrassment, humiliation.

 Self-blame: exaggerated feelings of responsibility.

 Subjugation: feeling belittled, dehumanized.

 Morbid hatred: obsessions with vengeance.

 Paradoxical gratitude: positive feelings toward victimizer.

 Defilement: feeling dirty, disgusting, or evil.

 Sexual inhibition: reduced capacity for intimacy.

 Resignation: a state of broken will or despair.

 Second injury or second wound: revictimization by legal, medical, or mental

health systems.

 Socioeconomic status downward drift: reduction of opportunity or lifestyle.

Consequences of IPV on Society

The cycle of violence

In discussing the cycle of violence, it is important to recognize that most individuals

who have been abused as children do not go on to become abusers as adults.

However, it is equally important to know that studies have clearly identified

childhood abuse as a crucial risk factor for later violence.

These seemingly contradictory statistics are more easily understood if we are able to

picture victims of abuse as a relatively large group of individuals, while recognizing

that victimizers represent only a small number of those who have been abused and
may not belong to the victimized group at all, but generally victimize more than one

person.

Among victimizers, however, as stated earlier, studies have shown that a large

percentage of this group has been victimized, thus implicating childhood

victimization as a risk factor for becoming a violent adult.

Widom’s (1989) review of research on the impact of observing and witnessing

violence between parents cites studies reporting that 53% of habitually violent

offenders had observed their parents engaged in physical combat.

Similarly, Lewis, Shanok, Pincus, and Glaser (1979) noted that 79% of the violent

children they studied reported having witnessed extreme violence between their

parents.

Heyman and Slep (2002) found that frequency of family-of-origin violence predicted

adulthood child and partner abuse.

Whitfield, Anda, Dube, and Felitti (2003) confirmed that girls exposed to family

aggression and violence have a substantially higher risk of becoming victims,

whereas boys have a substantially higher risk of becoming perpetrators as adults.

Along with its multigenerational aspects, the notion of a cycle of violence also

characterizes perpetrator/victim dynamics that can be expressed as three phases

including tension, abuse, and relief or “honeymoon” phase.

During the tension phase, the abuser may become tense or irritable, prompting the

victim to “walk on eggshells.”

In the abuse phase, the perpetrator acts violently (physically, sexually, and/or

emotionally) toward the victim, during which time the victim may leave home or

seek help.
 The relief or honeymoon phase is characterized by abuser behaviours that include

apologies, remorse, and promises to change, all of which serve to keep the victim

hopeful for the future and enmeshed in the relationship.

Social costs and multiple losses

Societal resources are required to evaluate and treat the victims of violence; these

resources include victim service organizations, child welfare agencies, mental health

services, and medical facilities. The willingness of taxpayers and governments to

fund resources is not commensurate with the need.

The most damaging effect of IPV is its impact on succeeding generations of human

relationships and its profound reduction of quality of life.

Lisak and Beszterczey (2007) reviewed the life histories of 43 death row inmates,

finding that more than 80% of the men had witnessed IPV in their childhood homes

and 100% had experienced some form of neglect, along with other forms of abuse.

The authors also found that subjects who had been abused were likely to have come

from families with multigenerational histories of abuse.

Although the study sample represented the extreme end of the continuum of long-

term effects of familial violence, the consequence for the lives of the participants

gives us a glimpse of the pervasive effects of IPV.

The losses suffered by victims of IPV include and exceed those of individuals who

have been traumatized by non-IPV events (Koss et al., 1994). Loss of health, financial

security, home, children, pregnancies, and even life itself are tragic legacies of

victims of IPV.

Less easily observable losses can include decreased ability to assess one’s situation

caused by shock, grief, and despair.

 Koss et al. (1994) point out that as victims deploy more internal coping strategies

(e.g., denial, dissociation, numbing), there is often a decrease in external activity that

would be more likely to change the IPV situation.

Symonds (1978) speculated on a “state of terror” experienced by victims, which can

contribute to a sense of loss of control or agency within one’s life and seriously

impair the victim’s ability to appraise her own situation.

Theoretical contexts for Understanding IPV

Early literature on the subject of IPV tended to speculate on possible

psychopathological characteristics of the victims rather than social contributions to

the problem or perpetrator characteristics.

Women’s verbal and emotional aggression against their partners was seen as a

precipitant to male violence, whereas other studies sought to evaluate IPV from a

gender-neutral standpoint, asserting that males were victims of IPV as often as

females.

However, the vast majority of IPV incidents are perpetrated by males on their female

partners, with altercations identified as “mutually assaultive” far more likely to be

damaging to women than to men.

Feminist theory

Feminist theories of IPV originated with the upsurge in attention brought to the

victimization of women in the 1970s, defining IPV as primarily a social problem to be

corrected by empowering women and re-educating men.

 Feminist theories identify gender-based power differentials as central to the issue of

IPV, citing the domestic relationship’s structure as a parallel process mirroring the

patriarchal pattern of society’s organizational structures.

Treatment programs for batterers were established as a result of feminist activism

and focused on changing sex role attitudes, which claim that women’s behaviour

provokes men’s violence.

Support for the feminist model comes from observations that most batterers are

able to control their violent behaviour when “provoked” by authority figures such as

bosses, police officers, and judges.

Some theorists have claimed that feminist theory relies too heavily on a social model

of IPV to the exclusion of other factors, such as childhood abuse and personality

disorders.

According to critics, feminist theory fails to predict which men will become violent,

assuming that all men are exposed to similar patriarchal values.

Family systems theory

The family systems theory assumes that all individual problems are a manifestation

of the dysfunction present in the family unit, with each family member contributing

to the problem.

This theory predicts that either partner may resort to violence if conflict escalates

beyond verbal and emotional abuse.

Partners are seen as neither victim nor perpetrator of IPV, even if only one partner

becomes violent, because it is the interaction that is deemed to be violent rather

than the person.

 Family systems theory promotes a treatment strategy that includes improving

communication rather than focusing on the individual pathology of either partner.

The family systems theory provides a treatment framework for IPV couples who may

want to remain together while working to eliminate the violence from their

relationship.

The model’s emphasis on relationship strengths rather than pathology is cited by

some as a useful approach, particularly in light of statistics indicating that more than

half of IPV couples remain together.

Predictably, most criticisms of the model’s use with IPV couples cite concern for

victim safety, speculating that speaking honestly in the presence of the batterer is

inherently dangerous, particularly if the couple continues to live together.

Other critics note the potential for victim blaming while the victimizer is not held

responsible for the violent act.

The biomedical model

The biomedical model is a framework in which victims’ psychological symptoms are

catalogued and the individual is then assigned a diagnosis.

The connections between symptoms displayed and antecedent trauma are deemed

secondary, if not irrelevant to patient treatment.

Treatment is founded upon the assumption that many psychological disorders arise

from faulty brain chemistry that requires psychiatric medication for correction, with

or without adjunctive psychotherapy.

As a result of the identification of trauma-based disorders, particularly PTSD,

research into the origins of trauma as well as its connection to common mental
 health diagnoses has made a purely biomedical model less relevant in working with

IPV.

The primary utility of the biomedical model is its acceptance as the prevailing

paradigm by which diagnosable mental difficulties are understood, and upon which

insurance payments to providers are based.

The downside of this view is that medicalization of the symptoms suffered by trauma

survivors requires the sufferer to accept her symptoms as an illness rather than to

understand them as the natural outcome of traumatic experience.

The medical model may result in the secondary wounding and decreased credibility

of the victim.

Ecological developments and attachment models

Bronfenbrenner’s ecological development model and Bowlby’s attachment model

offer broader developmental and relational models for conceptualizing IPV.

Bronfenbrenner’s ecological development model, when applied to a framework for

understanding IPV, implies an acknowledgment of the biological characteristics with

which humans are endowed, along with developmentally mediated psychological

factors, as seen within a multifaceted social context.

Bronfenbrenner’s reference to micro-, meso-, exo-, and macrosystem structures in

an individual’s life acknowledges the impact of multiple layers of the relational

environment upon an individual’s experience at any given moment.

The ecological model, coupled with attachment theory, which focuses predominantly

on the impact of children’s early relationships with caregivers, provides a more

balanced view of the factors associated with IPV.

 Bowlby based his theory on his observations and belief that human infants have a

biologically driven developmental need to be cared for by a person who is older and

wiser for purposes of safety and survival as well as regulation of affect. The quality of

this initial attachment bond acts as a template for future adult attachments.

If early attachment is disrupted by separation, illness, or trauma, the child’s ability to

soothe herself in the presence of stress may be underdeveloped; this is a deficit that

has particular relevance to IPV because attachment-seeking behaviour continues

throughout the life span.

Studies on the neurobiology of attachment have provided support for attachment

theory by demonstrating the link between biological and psychological models of

development, thereby deconstructing artificial barriers that historically have existed

between the two.

Risk factors- the victim

The Stockholm syndrome pattern of attachment between captive and captor is

echoed in many IPV situations where the cycle of tension, abuse, and relief is lived

repeatedly, with the relief phase offering intermittent moments of hope and

optimism that may keep the victim in the relationship.

Dutton and Painter (1993b), in fact, cite the intermittency of abuse as a factor in the

level of stress experienced by women who chose to leave their batterers, with

extremes of negative and positive batterer behaviour associated with the most

postseparation distress.

In other words, women whose abusers were extremely violent, but who also

displayed the most kindness and remorse during the relief phase of the IPV cycle,

had the most difficulty separating from their batterers.

 Bornstein (2006) cites economic and emotional dependency as risk factors in the

aetiology of IPV relationships, for both women and men.

For women in particular, the cultural traditions of economic dependency and social

disempowerment contribute to the possibility of victimization by a male partner, as

does her partner’s excessive emotional dependency.

Most women in IPV relationships are looking for signs that the perpetrator is not all

bad. The woman has much invested in the relationship and hopes for a future, for

herself, and for any children she might have with the perpetrator.

Women’s interpersonal relational style, combined with attachment experiences and

viewed within an IPV context, may make them vulnerable to a pattern of coping

strategies that often is misunderstood by those outside the relationship who may

focus on the perceived shortcomings of the victim rather than the actions of the

perpetrator.

Risk factors- the perpetrator

Fonagy suggests that many men who commit violent acts against women lack the

ability to mentalize, that is, to imagine their attachment figure’s thoughts.

This is a state that Fonagy attributes to a childhood rendered so physically or

emotionally unsafe that the child copes by refusing to imagine the state of mind of a

parent who wishes to harm him.

This pattern, persisting into adulthood, may form the basis for IPV relationships

between batterers and their partners (who may also be attachment disordered).

Similarly, Meloy believes that men who fail to develop secure attachments in

childhood are at greatest risk for IPV, basing this hypothesis on a growing body of
 research that empirically supports the connection between insecure attachments

and adult (often intergenerational) relationship violence.

A study by Mauricio, Tein, and Lopez (2007) found that both antisocial and

borderline personality disorders were related to attachment styles that served as

mechanisms for both physical and psychological violence in a sample of male

batterers referred for treatment.

Heyman and Slep (2002) found that the frequency of family of origin violence

predicted adulthood child and partner abuse in a retrospective study of more than

6,000 participants in a national family violence survey.

Counselling Implications

Treatment for victims

Given that there are many forms, facets, and stages within the IPV cycle,

generalizations about victim interventions should be avoided.

Those still in physical danger will need physical safety, financial assistance, and legal

protection. Providers of these services include security specialists, the staff of

shelters, lawyers, victim advocates, and others with relevant experience and

resources.

It is only after basic needs have been met that the victim may be able to address the

effects of trauma and any self-defeating patterns of her own in therapy with a

trauma-competent counsellor.

Counsellors should be aware that shelters are often the safest refuges for victims

because the family of origin may represent another source of betrayal and abuse for

the battered individual.

 Careful discussion about what constitutes supportive behaviour can help counsellors

and their clients identify trustworthy contacts.

Once the client’s safety is established and the therapy process begins, it is important

for counsellors to use an empowerment approach, in which the client is given as

many choices as possible in determining the course of her own life.

Counsellors also need to be prepared to encounter the depression and often-

contradictory behaviour patterns of abused women. These behaviour patterns may

confuse the therapist that the client is frequently labelled “borderline,” due to the

frequent limit-testing and emotional demands.

Maintaining a professional relationship without implying friendship beyond

appropriate boundaries is the most helpful response.

Treatment for batterers

The Duluth model, a group model based on a sociocultural feminist perspective of

male patriarchy and relationship violence, once was considered to be the best

approach for treating batterers. More recent research studies have found this model

to be ineffective in decreasing male violence toward women.

What has been found to be more efficient is an approach that blends attachment

theory and cognitive behavioural therapy, taking into account the early childhood

risk factors.

Lawson, Barnes, Madkins, and Francois-Lamonte (2006) have reported significant

changes in abuser attachment styles as well as decreased violent behaviour in men

who participated in a 17-week course of integrated cognitive

behavioural/psychodynamic group treatment.

Regardless of the model applied in the treatment of batterers, true personal change

that generalizes into societal change can only be accomplished by holding batterers

and social institutions accountable for the damage they inflict or fail to prevent.