Journal of Aggression, Maltreatment & Trauma

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A Longitudinal Study of the Well-Being of Canadian

Women Abused by Intimate Partners: A Healing
Journey

Leslie M. Tutty , H. Lorraine Radtke , Wilfreda E. Billie Thurston , E. Jane

Ursel , Kendra L. Nixon , Mary Ruklos Hampton & Christine A. Ateah

To cite this article: Leslie M. Tutty , H. Lorraine Radtke , Wilfreda E. Billie Thurston , E. Jane
Ursel , Kendra L. Nixon , Mary Ruklos Hampton & Christine A. Ateah (2020): A Longitudinal Study
of the Well-Being of Canadian Women Abused by Intimate Partners: A Healing Journey, Journal of
Aggression, Maltreatment & Trauma, DOI: 10.1080/10926771.2020.1821852

To link to this article: https://doi.org/10.1080/10926771.2020.1821852

Published online: 01 Oct 2020.

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JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA
https://doi.org/10.1080/10926771.2020.1821852

A Longitudinal Study of the Well-Being of Canadian Women

Abused by Intimate Partners: A Healing Journey
Leslie M. Tutty a, H. Lorraine Radtkeb, Wilfreda E. Billie Thurstonc, E. Jane Urseld,
Kendra L. Nixone, Mary Ruklos Hamptonf, and Christine A. Ateahg
a
Faculty of Social Work, University of Calgary, Calgary, Canada; bDepartment of Psychology, University of
Calgary, Calgary, AB, Canada; cCommunity Health Sciences, Cumming School of Medicine, University of
Calgary, Calgary, AB, Canada; dDepartment of Sociology, University of Manitoba, Winnipeg, MN, Canada;
e
Faculty of Social Work, University of Manitoba, Winnipeg, MN, Canada; fDepartment of Psychology,
Luther College, University of Regina, Regina, SK, Canada; gCollege of Nursing, University of Manitoba
Winnipeg, MB, Canada

ABSTRACT ARTICLE HISTORY

This 2.5-year longitudinal, Canadian tri-provincial study (Alberta, Received 26 June 2019
Saskatchewan, Manitoba) of women abused by intimate part­ Revised 20 May 2020
ners examined the nature of the partner abuse, physical and Accepted 19 August 2020
mental conditions, disabilities, child abuse history, and quality KEYWORDS
of life (QOL). The women retained at 30-months (419 of 665) Intimate partner violence;
were identified as Indigenous (48.5%), White (46.6%), or visible violence against women;
minority (4.9%). Physical and mental health conditions were family violence; health and
noted by 62.3%; 41.8% of these were disabilities. Over half mental health; trauma;
(54.5%) reported histories of child sexual abuse, with 24.2% disability; ethnicity;
reporting other childhood abuse, and 21.3% were not abused longitudinal research
as children. Consistent with similar longitudinal studies, over
time the women significantly improved their QOL and had less
mental stress (SCL-10) and PTSD symptoms (PCL); however,
neither PCL nor SCL-10 scores were clinically problematic at
any time period. Depression symptoms (CES-D-10) remained
constant over time but were not in the clinical range over the
2.5 years. Only IPV severity and having a disability were asso­
ciated with more severe mental health/well-being scores at 30-
months. Implications for practice such as training IPV advocates
and counselors to better address disabilities and to avoid stig­
matizing women abused by partners as necessarily having men­
tal health issues are presented.

Intimate partner violence (IPV) against women has received world-wide

acknowledgment as a serious social issue (García-Moreno et al., 2013). The
considerable research literature on women, IPV and mental health conse­
quences is most-often documented when women are in crisis, having sought
assistance from violence against women’s shelters or counselors (e.g.,
R. Campbell et al., 1995; D. K. Anderson et al., 2003). It is important to take
a longer view, examining how women fare over time with longitudinal studies.
This paper provides a brief summary of research on the nature and

CONTACT Leslie M. Tutty tutty@ucalgary.ca Faculty of Social Work, University of Calgary, Calgary, Alberta
T2N 1N4, Canada
© 2020 Taylor & Francis
2 L. M. TUTTY ET AL.

consequences of IPV, the importance of adopting an intersectional perspective

and a review of longitudinal studies that assess women’s mental health over at
least three time periods. Our longitudinal study examines the mental health and
quality of life of 419 Canadian women over a 2.5-year period, considering the
seriousness of IPV, mental health and wellbeing, in intersection with ethnic
background, disability status, and child abuse histories.

The nature and consequences of IPV

The nature of IPV is often considered as primarily physical and potentially

life-threatening. While the risk of homicide in IPV remains of significant
concern, despite the fact that a relatively small number of women are mur­
dered by partners (Dawson et al., 2009), other forms of abuse in IPV are
concerning. Sexual assaults occur frequently and can cause considerable harm
whether by injuries or trauma (Boucher et al., 2009). Many women endure
years of psychological abuse that can devastate their lives (Ansara & Hindin,
2011). Notably, women can be at increased risk of serious IPV after having
separated from their partners (Brownridge et al., 2008).
The consequences of IPV include detrimental impacts on women’s physical
and mental health, which are interrelated. Physical effects include serious
injuries that may have long-term negative outcomes (Breiding & Armour,
2015; M. M. Cohen et al., 2005). Women who have experienced chronic and
ongoing IPV are often diagnosed with mental health issues such as depression
and anxiety (Bacchus et al., 2018; White & Satyen, 2015) and Posttraumatic
Stress Disorder (PTSD) (Coker, Weston et al., 2005; Perez & Johnson, 2008).
These are important as they may compromise women’s safety after leaving
abusive partners (Perez & Johnson, 2008).
Both physical and mental health difficulties may result in activity or
employment limitations, characterized as disabilities (Du Mont & Forte,
2014). Having a disability is also associated with being at risk of partner
abuse (Ballan et al., 2014; Yoshida et al., 2011). Further, victims of childhood
abuse, especially sexual abuse, are more at risk of IPV as adults (Barnes et al.,
2009; Widom et al., 2014).

Theoretical orientation: An intersectionality framework

Intersectionality is “a theoretical or analytical approach that simultaneously
considers multiple categories of identity, difference, and inequality (such as
gender, race, class, sexual orientation, disability, as well as others)” (Else-Quest
& Shibley Hyde, 2016, p. 155). An intersectional approach to studying IPV is
recommended because women’s lives are complex and health and mental health
are affected by more than just violence (Sokoloff & Dupont, 2005). For example,
Sutherland et al. (2001) examined poverty and IPV effects on women’s health,
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 3

concluding that IPV is particularly detrimental to the health of low-income

women. From an intersectional perspective, ethnic background has been linked
to the risk of IPV. In Canada, Indigenous women (this includes First Nations,
Métis, and Inuit peoples) are significantly more likely to experience IPV
(Brennan, 2011). In the U.S., Lacey et al. (2013) assessed the impact of racialized
background on physical and mental health in a nationally representative sample
of women, finding poorer perceived health for psychologically abused Hispanic
women and for physically abused Black women. White and Satyen (2015)
reported conflicting results with respect to IPV and depression across 11 studies
of women from diverse ethnic backgrounds, concluding that the differences
were mediated by help-seeking, cultural values, and racism.
While ethnic background and gender are the most often-considered
intersectional characteristics, others argue that disability (Ballan & Fryer,
2017; Lightfoot & Williams, 2009) and child abuse history (Damant et al.,
2008) also constitute intersectional variables of interest when studying IPV.
Authors such as Iudici et al. (2019) recommend conducting and interpreting
research on IPV with an intersectional perspective, consistent with the
current study.

Longitudinal studies of women abused by intimate partners

Examining the mental health consequences of IPV over time is important, yet
longitudinal studies (defined as at least three testing points) are relatively rare.
Across studies, researchers use similar mental health variables; depression
(Beeble et al., 2009; Bell et al., 2009; Campbell & Soeken, 1999; R. Campbell
et al., 1995; D. K. Anderson et al., 2003; C.B. Sullivan & Bybee, 1999), PTSD
(Bell et al., 2009), quality of life (QOL) (Beeble et al., 2009; Bell et al., 2009;
Bybee & Sullivan, 2005; C. B. Sullivan & Bybee, 1999), self-efficacy
(D. K. Anderson et al., 2003; Reisenhofer et al., 2019), and social support
(Beeble et al., 2009; R. Campbell et al., 1995; Goodman et al., 2005;
D. K. Anderson et al., 2003; Reisenhofer et al., 2019; C. B. Sullivan & Bybee,
1999; Suvak et al., 2013).
The context of the mental health variables differed such that some were
assessed only in relationship to other factors in the women’s lives. Rivera et al.
(2018) looked four times over one year at mothers’ depression and PTSD as
connected to partners’ threats to harm children. Whether women remained in
violent relationships as associated with her mental health was studied in
several investigations (Bell et al., 2009; Bybee & Sullivan, 2005; Goodman
et al., 2005; Reisenhofer et al., 2019). Due to the nature of the regression
analyses, which are appropriate to their research questions, these studies did
not directly report the scores of the mental health measures over the course of
the study.
4 L. M. TUTTY ET AL.

As mental health professionals, however, we were interested in a simpler

focus: Whether the mental health symptoms of women abused by partners are
within clinical ranges and whether they improved over time. These were
assessed in several longitudinal studies. R. Campbell et al. (1995) found that
128 women significantly improved depression symptoms from shelter exit to
10 weeks and 6 month follow-up, although about half of the depression scores
were still in the clinical range. J. C. Campbell and Soeken (1999) concluded
that depression in a sample of 98 women decreased over 3.5 years between
times one and two, but increased again at Time 3, regardless of abusive
relationship status. D. K. Anderson et al. (2003) reported that the most
seriously abused women had higher depression that either did not improve
or was significantly worse over two years. C. B. Sullivan and Bybee (1999)
evaluated the effects of an advocacy intervention on mental health symptoms
six times over two years. They reported significant improvements in depres­
sion and improvements in QOL for all, but better results for the women in the
advocacy condition, consistent with Beeble et al. (2009) who similarly assessed
depression and QOL. Suvak et al. (2013) found that belonging, an element of
social support, was the only factor associated with less depression over
4.5 years (although depression remained in the clinical range).
These studies focused primarily on depression; however, the women did not
routinely improve over time, suggesting the need for additional longitudinal
analysis. QOL improved in several studies (Beeble et al., 2009; C. B. Sullivan &
Bybee, 1999). Missing in longitudinal studies are other key mental health
variables associated with IPV such as PTSD and mental distress. Further,
intersectional moderating variables of interest including ethnic background,
disability status and child abuse history were not examined with respect to
mental health outcomes in the studies reviewed. Finally, most studies took
place in the United States (US); none were Canadian. The US and Canada have
very different health care systems, which could impact health outcomes.
The current study addressed several of these gaps with three major objec­
tives: (1) to assess the mental health/well-being (depression, PTSD, mental
distress and QOL) of 419 women who experienced IPV in the prairie pro­
vinces of Canada; 2) to consider these mental health variables over 30-months.
The third goal was to examine whether the outcomes interacted with the
intersectional variables of ethnic background, IPV abuse, child abuse, and
disability status (from baseline) and IPV from any partner at 30 months. This
analysis examined whether subgroups of women did better or worse, which
could have implications for practice and policy. Ethnic background, particu­
larly Indigenous background, is especially important in the Canadian prairie
context as Indigenous peoples make up a large proportion of the population.
Examining the extent to which the women might still be abused by partners
over time was also of interest, as continued IPV could exacerbate mental
health symptoms. Finally, given the correlations of IPV and child abuse history
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 5

and disability, it was important to assess whether these impacted the mental
health/well-being outcomes over time.

Method
“The Healing Journey” was a longitudinal, Canadian study with a convenience
sample of 665 abused women who had sought shelter and/or counseling in the
three prairie provinces of Alberta, Saskatchewan, and Manitoba. Both aca­
demics and community agency members of the research team assisted in
designing the research, recruiting participants, and interpreting the results.
The first wave (baseline) of data collection commenced in 2005, with six
additional waves collected every six months over 3 years. One wave specific
to an analysis of the economic costs of IPV (DeRiviere, 2014) is not considered
in the current article.
The research protocols were approved by the Ethical Review Boards of the
six associated universities (Universities of Calgary, Manitoba, Regina,
Brandon, Lethbridge, Winnipeg). An initial sample size of 600 participants
(200 women per province) was targeted, as this was both practically and
financially feasible and allowed for multivariate analyses. All three provinces
were over-sampled to minimize the impact of attrition. Power analysis indi­
cated that, with a sample of 600 women, we could detect large effects (SD’s of
0.8 or higher), moderate effects (SD’s of 0.5–0.7) or small effects (SD’s of
0.2–0.4).
A three province, nine-site (with key urban and rural locations) recruitment
strategy was adopted. The criteria to select sites were: (a) one or more agencies
providing services to abused women; (b) a working relationship or willingness
to develop a relationship between academics and community partners; and (c)
a university campus with interested academics and students. In Alberta, Peace
River (with no campus) was added to recruit women in the north of the
province.
Our primary community partners were the provincial VAW shelter asso­
ciations and their members (over 35 shelters and transition homes), as well as
local agencies for specific groups such as Indigenous women, women with
disabilities, immigrant/refugee women, lesbian women, and senior women
assisted with recruitment. In some cases, women were invited to attend
information sessions at these agencies, or agency staff provided with sealed
envelopes with study information. In the case of VAW shelters, a number of
women were no longer shelter residents but were recruited though their
continued contact with VAW shelter staff or post-shelter programs. Other
agencies preferred that only posters be used. Because the provincial recruit­
ment strategies differed, we did not note the numbers at information sessions,
nor did we link the recruitment strategy/agency to the women who ultimately
participated in the study.
6 L. M. TUTTY ET AL.

The criteria for research participants were: a minimum 18 years of age;

commitment to stay in the study for the full three years; and no debilitating
mental health issues. Honoraria of $50 CAN were provided to participants at
each wave. A final criteria, that the most recent incident of IPV no sooner than
three months and no longer than five years prior, was added because of
possible risks to women’s safety if they remained in a relationship with an
active and possibly volatile abuser.

Measures
Data were collected with respect to four major areas: demographic back­
ground and history of abuse; general functioning and service utilization;
health; and mothering (for the latter see Ateah et al., 2019; Nixon et al.,
2017) over three years. The surveys included standardized measures as well
as open- and closed-ended questions developed specifically for the study.
Demographic characteristics and the CAS were collected at baseline; QOL
was collected at baseline, 12 and 24 months and mental health symptoms
(SCL-10; CES-D-10; PCL) at 6, 18 and 30 months.

Intimate partner violence

The nature of the IPV was assessed by the Composite Abuse Scale (CAS)
(Hegarty et al., 2005). This screening measure consists of 30 items rated for
frequency in the past 12 months on a six-point scale from never to daily, with
a possible total of 150. The four subscales are: Severe Combined Abuse (8
items; possible score 0–40; suggested cutoff of 1), Physical Abuse (7 items;
possible score 0–35; cutoff of 1), Emotional Abuse (11 items; possible score
0–55; cutoff of 3), and Harassment (4 items; possible score 0–20; cutoff of 2).
The suggested clinical cutoff for the total score is 3 or 7 to minimize false
positives. The scale has demonstrated convergent and discriminant validity
(Hegarty et al., 2005). Cronbach’s alpha for the CAS in the current study is.93.

Child abuse, health and mental health conditions

Child abuse history was collected via structured questions with “yes/no”
answers: “Were you abused as a child or adolescent? a) physical, b) sexual,
c) emotional/psychological, d) witnessing abuse among family members (con­
sistent with Elias et al., 2012). We asked the women to self-report physical and
mental health conditions (whether or not diagnosed by medical personnel)
and, to assess disability, we asked whether these conditions affected their
employability or the kind or amount of daily activities.

Mental health and well-being

The Symptom Checklist Short Form (SCL-10) (Nguyen et al., 1983) is
a screening tool to assess global mental health functioning and psychological
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 7

distress in the previous week. Items (e.g., “In the past week, how much were
you distressed by feeling lonely?”) are endorsed with a 0 to 4 Likert scale
(0 = “not at all;” 4 = “extremely”). Higher scores indicate more distress.
Published clinical cutoffs for the 10-item version were not found. However,
since clinical cutoff scores are one standard deviation above the mean
(Jacobson et al., 1984), we used the Müller et al. (2010) data reporting an
mean score of 7.8 (SD of 6.3), resulting in a clinical cutoff score of 14.2.
Cronbach’s alpha in the current study is .89.
The CES-D-10 (Center for Epidemiological Studies – Depression) is a short
form of the CES-D-20 (Radloff, 1977) that documents depression symptoms
(Andresen et al., 1994). Ten items (e.g., “In the past week I was bothered by
things that usually don’t bother me?”) are rated on a 0 to 3 Likert scale, with
zero as “rarely or none of the time (less than 1 day),” and three as “all of the
time (5–7 days).” Internal consistency and test-retest reliability are good
(Björgvinsson et al., 2013). Cronbach’s alpha in the current study is .84. We
used the suggested clinical cutoff of 15 (Björgvinsson et al.).
The PTSD Checklist (PCL) (Blanchard et al., 1996) is a 17-item self-report
questionnaire that measures symptoms of PTSD in the past month. Items (e.g.,
“In the past month how much have you been bothered by repeated, disturbing
memories, thoughts or images of abuse or violence?”) are endorsed with a 0 to
4 Likert scale with zero meaning “not at all” and 4 meaning “extremely.” We
used a clinical cutoff of 44 (Blanchard et al.). The scale has good psychometric
properties (Cronbach’s alpha = .94; Blanchard et al., 1996). Cronbach’s alpha
in the current study is .92.
The original 25-item Quality of Life Questionnaire (Andrews & Withey,
1976) was shortened by C. B. Sullivan and Bybee (1999) to nine items
measuring satisfaction with her overall quality of life (e.g., “How do you feel
about life as a whole”) and satisfaction with particular areas (e.g., “How do you
feel about yourself; your personal safety; the amount of fun and enjoyment you
have”). Items are rated on a 7-point scale (1 = extremely pleased, 7 = terrible).
Higher scale scores indicate poorer QOL. Cronbach’s alpha for QOL in the
current study is .84.

Procedures
The questionnaires were administered face-to-face, with female interviewers
reading the questions and recording answers to ameliorate any literacy pro­
blems. The women chose where the interviews took place: their homes, the
agency/shelter from where they were recruited or the university campus. The
more than 50 interviewers were upper-level undergraduate/graduate univer­
sity students and professionals from the communities surveyed. The inter­
views lasted from one to two hours. To minimize attrition, RAs always
interviewed the same women, whom they contacted at least once between
8 L. M. TUTTY ET AL.

waves (Sullivan et al., 1996). When women did not respond in subsequent
waves, multiple contact attempts were made in the hopes of reengaging them.

Data analysis

Categorical descriptive data were analyzed using Pearson’s chi-square analysis

with effect sizes calculated with Phi or Cramer’s V. Standardized residuals
were calculated to identify the category differences responsible for the statis­
tically significant chi-square (Field, 2009). Effect sizes were interpreted using
Rea and Parker (1992) suggested benchmarks of under .10 as a “negligible”
association; between .10 and under .20 as “weak”; between .20 and under .40 as
“moderate”, and between .40 and under .60 as relatively “strong” (p. 203).
Numerical data were compared with independent t-tests and repeated
analysis of variance, with Bonferroni procedures as post hoc tests when
findings were statistically significant and effect sizes calculated as r-values
(Field, 2009). According to Cohen (1988), r’s of .2, .5 and .8 are the small,
medium, and large reference values, respectively. Because of potential inter­
actions between the key variables, the final analysis was a multivariate analysis
of covariance (MANCOVA) on the standardized mental health measures at
24/30 months post (yes/no), with the Composite Abuse Scale-Total score as
a covariate and ethnic group, disability status (yes/no), child abuse history
(yes/no) as independent variables (all from baseline) and abuse status (any
abuse by any partner) at 30 months.

Results
Comparison of healing journey completers and dropouts

Table 1 compares the demographic characteristics of the women who com­

pleted the 30-month data collection (N = 419) to those who were not retained
at 30 months (N = 246), to assess whether those who stayed differed from those
who dropped out. Six statistically significant demographic differences between
the attrition group and the completers were found (all with negligible or weak
effects). Those who dropped out were younger, had less yearly income, were
less likely to be working full-time, more likely to have children, had less
education, and were more likely to have stayed in a women’s emergency IPV
shelter.
Study completers reported significantly less severe combined abuse, physi­
cal abuse, harassment, and total IPV than women in the attrition group as
rated on the Composite Abuse Scale (all “small” effects) (see Table 2). CAS
subscale and Total scores were all in the clinical range, confirming that the
women had endured significant partner abuse. Importantly, scores on the
QOL and mental health measures did not differ between those who completed
Table 1. Women’s demographics at baseline: comparing dropouts to 30-month completers1.
1
Stars represent significant differences between categories based on standardized residuals (contact the first author for these statistics)
Dropouts Completers
Variable at Baseline (N = 246) (N = 419) Totals Sign. Effect size
Ethnicity (N = 657) White 99 (40.4%) 192 (46.6) 291 χ2 = 3.8;
(44.3%) p =.15 n.s.
Indigenous 127 (51.8%) 200 (48.5%) 327
(49.8%)
Visible Minority 19 (7.8%) 20 (4.9%) 39 (5.9%)
Age (N = 600) 34.9 (SD = 10.3) 37.3 (SD = 11.2) t= 2.58; r =.10
p =.004**
Income (N = 599) 18870 23298 (SD = 25616) t = 2.13; p =.03* r=.08
(SD = 22345
2
Population Size (N = 665) Rural (less than 999) 5 (2%) 10 (2.4%) 15 (2.3%) χ = 3.8;
Small (1000–29,999) 31 (12.6%) 47 (11.2%) 78 (11.75) p=.29 n.s.
Medium (30 K-99999) 42 (17.1%) 51 (12.2%) 93 (14%)
Large (100,000+) 168 (68.3%) 311 (74.2%) 479 (72%)
Partner relationship at Wave I Married/common-law 33 (13.4%) 53 (12.6%) 86 (12.9%) χ2 = 4.5;
Separated/divorced/ex 165 (67.1%) 262 (62.5%) 427 p =.34 n.s.
CL (44.2%)
Boyfriend/girlfriend 8 (3.3%) 28 (6.7%) 36 (5.4%)
Ex boyfirned/girlfriend 38 (15.4%) 72 (17.2%) 110
(16.5%)
Partner deceased 2 (1%) 4 (1%) 6 (0.9%)
Summary Current partner relationship (N = 565) No longer together 205 (83.3%) 338 (80.7%) 543 χ2 = 0.6;
(81.7%) p =.51 n.s.
Together 41 (16.7%) 81 (19.3%) 122
(18.3%)
Children? Yes 233 (94.7%) 370 (88.3%) 603 χ2 = 6.8; Phi =.11
(90.7%) p =.009**
No 13 (5.3%)* 49 (11.7%) 62 (9.4%)
Age of oldest child (N = 598) Children under 18 172 (74.1%) 246 (67.2%) 418 χ2 = 2.9;
(69.9%) p=.09 n.s.
Adult children 60 (25.9%) 120 (32.8%) 180
JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA

(30.1%)
(Continued)
9
 10

Table 1. (Continued).
Dropouts Completers
Variable at Baseline (N = 246) (N = 419) Totals Sign. Effect size
Highest Education Not complete HS 123 (50.2%)** 160 (38.2%)** 283 χ2 = 19.2 Cramer’s
(42.6%) p <.000*** V =.17
Complete HS or GED 54 (22%) 85 (20.3%) 139
(20.9%)
L. M. TUTTY ET AL.

Some Post sec-tech 41 (16.7%) 73 (17.4%)* 114

(17.2%)
Some Post sec-univ 27 (11%)** 101 (24.1%)* 128
(19.3%)
Currently working Full-time 35 (14.6%)* 102 (24.7%)* 137 χ2 = 14.9 Cramer’s
(21.0%) p <.001 V =.15
Part-time/Casual 34 (14.2%) 79 (19.1%) 113
(17.3%)
Not working 170 (71.1%) 232 (56.2%) 402
(61.7%)
Stayed in VAW shelter (N = 664) Yes 178 (72.4.%) 245 (58.6%) 423 χ2 = 12.1 Phi =.14
(63.7%) p =.001***
No 68 (27.6%)* 173 (41.4%) 241
(36.3%)
Where lived as a child? (N = 664) Biological/relatives 170 (69.1%) 305 (73%) 475 (71.5) χ2 = 0.96;
Child welfare/adoption 76 (30.9) 113 (27%) 189 p =.33 n.s.
(28.5%)
Child abuse history (N = 664) No abuse 51 (20.7%) 89 (21.3%) 140 χ2 = 0.8;
(21.1%) p =.92 n.s.
Any child sexual abuse 132 (53.7%) 228 (54.5%) 360
(54.2%)
Other child abuse 63 (25.6%) 101 (24.2%) 164
(24.7%)
Self-reported mental health and/or physical illness (N = 661) Yes 168 (68.6%) 259 (62.3%) 427 χ2 = 2.7,
(64.6%) p =.10 n.s.
No 77 (31.4%) 157 (37.7%) 234
(35.4%)
(Continued)
Table 1. (Continued).
Dropouts Completers
Variable at Baseline (N = 246) (N = 419) Totals Sign. Effect size
2
Self-reported mental health and/or physical illness linked to abuse? No/unsure 48 (28.7%) 89 (34.5%) 132 χ = 2.6;
(N = 425) (32.2%) p =.46 n.s.
Childhood abuse 9 (5.4%) 17 (6.6%) 26 (6.1%)
Partner abuse 54 (32.3%) 68 (26.4%) 122 (28.7)
Both child & partner 56 (33.5%) 84 (32.6%) 140
(32.9%)
Disability (N = 661) Yes 117 (47.8%) 174 (41.8%) 291 (44%) χ2 = 2.0;
No 128 (52.2%) 242 (58.2%) 370 (56%) p =.16 n.s.
Type of Disability (N = 660) No disability 128 (52.5%) 241 (57.9%) 369 χ2 = 3.8;
(59.9%) p =.28 n.s.
Physical 33 (13.5% 57 (13.7%) 90 (13.6%)
Mental health 34 (13.9%) 39 (9.4%) 73 (11.1%)
Physical & mental 49 (20.1%) 79 (19%) 128
health (19.4%)
JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA
11
12 L. M. TUTTY ET AL.

Table 2. Scores on standardized measures: comparing dropouts to 30-month completers.

Scale Dropouts (n= 246) Completers (n= 419) Total (N= 665) t-test Effect sizes
CAS Severe Combined 8.6 (SD = 7.5) 6.4 (SD = 6.1) 7.2 (SD = 6.8) 3.9; p <.000*** r =.15
CAS Emotional Abuse 29.1 (SD = 13.) 27.1 (SD = 13.5) 27.8 (SD = 13.6) 1.8; p <.077 ns
CAS Physical Abuse 14.4 (SD = 8.8) 11.5 (SD = 7.9) 12.6 (SD = 8.4) 4.4; p <.000*** r =.17
CAS Harassment 8.4 (SD = 5.3) 7.4 (SD = 5.1) 7.8 (SD = 5.2) 2.5; p =.014* r =.10
CAS Total Score 60.5 (SD = 29.6) 52.4 (SD = 26.8) 55.4 (SD = 28.1) 3.5; p <.000*** r =.14
QOL 32.3 (SD = 9.5) 31.6 (SD = 10) 31.9 (SD = 9.8) 0.9; p =.38 n.s.
SCL-10 13.4 (SD = 8.9) 12.6 (SD = 8.8) 12.9 (SD = 8.8) 0.9; p=.35 n.s.
CES-D-10 12.6 (SD = 6.3) 11.9 (SD = 6.3) 12.1 (SD = 6.3) 1.2; p =.22 n.s.
PTSD Checklist (PCL) 28.3 (SD = 14.6) 26.2 (SD = 14.3) 26.9 (SD = 14.4) 1.6; p =.11 n.s.

and those who dropped out. For the measures with clinical cutoffs (SCL-10,
CES-D-10; PCL), none were in the clinical (diagnostic) range for either group.
Further, the groups did not differ on the key intersectional variables of interest;
ethnic background, child abuse history and disability status.

Demographics of the final sample

With attrition of 246 (37%) women from baseline (N = 665) to 30-month

follow-up, the total sample was 419, with 160 from Manitoba (38.2%), 142
from Saskatchewan (33.9%), and 117 from Alberta (27.9%). The women were
from diverse, self-identified ethnic origins: 192 (46.6%) White (European
origins, White, or Caucasian), 200 (48.5%) Indigenous (First Nations = 150,
Métis = 350), and 20 visible minority (4%; the largest groups being African-
Canadian = 11, Latin American = 4 and South Asian = 5). At baseline, most
women (80.6% or 338 of 419) no longer lived with the partner who abused
them. At baseline, the total average yearly family income from all sources in
the last year was 23,298 USD (SD = 25616 USD).
The women were classified as reporting no history of being abused as a child
(89 or 21.3%), any child sexual abuse (228 or 54.5%), and child abuse excluding
sexual abuse (this included physical abuse and/or emotional/psychological/
verbal abuse and/or witnessing violence between parents or other family mem­
bers) (101 or 24.2%). Almost two-thirds (62.3%) of the women self-reported
serious physical or mental health conditions. A comprehensive list of the con­
ditions is beyond the scope of the current submission, especially since a number
of women disclosed multiple conditions. However, to highlight the serious and
life-threatening nature of the medical concerns disclosed by some, the most
often-mentioned physical conditions were Irritable Bowel Syndrome/Crohn’s
disease (n= 21), Chronic Fatigue Syndrome/Fibromyalgia (n= 22), Hepatitis
C and HIV (n= 12). Of the mental health conditions identified, the most
common were depression (n= 108), PTSD or anxiety (n= 71) and addictions
(n= 51). As well, eight women mentioned Bipolar Disorder and four disclosed
1
Stars represent significant differences between categories based on standardized residuals (contact the first author
for these statistics)
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 13

a diagnosis of Borderline Personality Disorder. Of those who identified long

term physical or mental health conditions, 65.6% (169 of 258) attributed these to
their abuse history: 6.6% to childhood abuse (n = 17), 26.4% to partner abuse
(n = 26.4), and 32.6% to both partner and child abuse (n = 84). As mentioned,
the self-reported physical or mental health conditions were coded as disabilities
if these affected employability and activities of daily life, resulting in 41.8%
(n = 174) being classified with a disability and 58.2% (n = 242) without. These
included both physical and mental health disabilities (79 women), only mental
health disabilities (39 women) or only physical disabilities (57 women).

Mental health and well-being over time

As can be seen in Table 3, mental distress (SCL-10), trauma symptoms
(PCL), and QOL all significantly improved over time (between baseline-
6 months and 12–18 months and between baseline-6 months and
24–30 months), while depression symptoms remained static but not clini­
cally significant. Similarly, scores on measures of mental health function­
ing (CES-D-10, SCL-10, PCL) were not in the clinical range for any of the
time periods.
Finally, to examine whether mental health was influenced by other impor­
tant factors in the women’s lives, a MANCOVA was conducted on the mental
health measures (24–30 months), with the Composite Abuse Scale-Total score
at baseline as a covariate; ethnic group, disability status and child abuse history
as independent variables; and abuse status (any abuse by any partner) at 30-
months, only the extent of the abuse and disability status were significantly
related to the 24–30-month-post mental health/wellbeing scores, such that
more severe IPV is linked to more severe general mental health and PTSD.
Having a disability was associated with a poorer QOL (8.7 versus 8.4;
t= 5.5***), more severe mental distress (12.3 versus 8.6; t = 4.8***), depression
(13.5 versus 10.6; t= 5.4***), and PTSD (23.9 versus 17.1; t = 4.7***). Regarding
abuse status at 30 months, 139 (20.9%) women reported being abused by
a previous or current partner. Notably, though, this was not associated with
poorer mental health scores.

Table 3. Repeated measures ANOVA on mental health/well-being scales over 2.5 years.
Scale Assessment 1 12–18 Months 24–30 Months F-test
QOL (N = 418)* 31.7 (SD = 9.9) 30.1 (SD = 9.5)a 29.5 (SD = 8.9)b 22.9; p =.000***
SCL-10 (N = 394)** 12.7 (SD = 8.9) 11.0 (SD = 8.7)a 10.2 (SD = 8.3)b,c 27.4; p =.000***
CES-D-10(N = 338)** 11.8 (SD = 6.3) 12.3 (SD = 5.0) 12.1 (SD = 5.3) 0.7; p =.40 n.s.
PTSD Checklist (PCL) (N = 376)** 25.9 (SD = 14.4) 22.6 (SD = 15.1)a 20.1 (SD = 14.9)b,c 34.5; p =.000***
* Collected at 12 and 24 months; ** Collected at 18 and 30 months
A superscript of “a” indicates a significant difference between Baseline and 12/18 months; “b” indicates
a significant difference between baseline and 24/30 months; “c” indicates significant differ
14 L. M. TUTTY ET AL.

Discussion
In summary, the 419 women made small but statistically significant improve­
ments over the 2.5 years with respect to mental distress, PTSD symptoms and
QOL. Improved QOL was also reported in Sullivan and Bybee (1999) and
Beeble et al. (2009). More serious IPV was associated with more serious mental
distress, depression, PTSD and worse QOL 24–30 months post, consistent
with D. K. Anderson et al. (2003) and Beeble et al. (2009).
The women constitute a large sample from the Canadian prairies with
almost half of Indigenous background, a group often not included in research,
but whose well-being is particularly important in Canada. This was the first
longitudinal IPV study to our knowledge to report on disability. Consistent
with the extensive literature on IPV, women in the study have complicated
lives with many reporting childhood abuse histories (78.9%), physical/mental
health conditions (62.3%), and disabilities (41.8%). They were also poor.
Poverty lines are complicated to calculate, however, in analyzing the economic
circumstances of the 36-month sample (N = 414), DeRiviere (2014) concluded
that half of the women (52.2%) were under the poverty line.
Depression is the most common outcome variable in IPV longitudinal
studies, but with inconsistent results. In our study, depression remained stable
but not in the clinical range at any point. In contrast, Suvak et al. (2013)
reported improvements in depression but scores were in the clinical ranges at
all ten time points (over 4.5 years). Others found significant improvements in
depression over two years (Beeble et al., 2009; D. K. Anderson et al., 2003).
However, while J. C. Campbell and Soeken (1999) found significant improve­
ments on depression between T1 and T2, depression became a clinical concern
again at 3.5 years. Understanding depression and the likelihood of recurrence
may be important to women who have made significant changes in their lives
and should not see a recurrence of depression as a personal failure.
Although the women reported significant partner abuse on the CAS, their
mental distress, depression, or PTSD scores were not in the clinical ranges at
any time-point. This may relate to the eligibility factors of the study, such that
the most recent abusive incident had taken place longer ago than three months
and, in some cases, as long ago as five years. The women were not recruited
when in the immediate crisis of an IPV incident, such as when in a VAW
women’s shelter, a common recruitment site for longitudinal studies (e.g.,
R. Campbell et al., 1995; D. K. Anderson et al., 2003; Sullivan & Bybee, 1999).
While living with an abusive partner is challenging, once no longer cohabiting
(the case for 80.7% of the women at baseline), the women themselves not only
generally do well, but statistically significantly improve their well-being over
time. In studies of IPV interventions for women such as therapy groups (Tutty
et al., 2015) or shelters (Meider-Stedman et al., 2006), mental health symptoms
improve significantly relatively quickly. Many women in the Healing Journey
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 15

study received advocacy or counseling during the research, so one could

anticipate some amelioration of mental health issues both when first inter­
viewed and afterward.
Several studies have examined resiliency in women abused by partners,
finding it was associated with improved mental health outcomes similar to the
Healing Journey (Fedina et al., 2017; Ford-Gilboe et al., 2009). K. M. Anderson
et al. (2012) studied resiliency and PTSD in 37 women formerly abused by
partners. As well as high scores on a resiliency scale, they also found non-clinical
scores on the PCL, identical to the current study. While we did not study
resiliency directly, the women’s improvements over time suggest its relevance.
Whether the women were still abused by previous or current partners at
30 months was not associated with mental health. Only 139 women (20.9%)
reported abuse, similar to Bybee and Sullivan (2005) who found 19% still in
violent relationships 2–3 years post-shelter. Whether women remained in
violent relationships was studied in several longitudinal studies (Bell et al.,
2009; Bybee & Sullivan, 2005; Goodman et al., 2005; Reisenhofer et al., 2019),
however, as IPV often continues post-separation (i.e. Brownridge et al., 2008)
and women may be involved with new partners who become abusive (i.e. Bybee
& Sullivan, 2005), relationship status per se was not the variable of interest here.
Abuse from any partner summarizes several issues (past vs. current partner
abuse), however, notably, it does not specify the severity of the abuse.
Further, with the substantial research literature on the mental health of
women abused by intimate partners, counselors and advocates are at risk of
assuming that their IPV clients necessarily suffer from mental health pro­
blems. Longitudinal studies, such as the current one, have the potential to
remind us that women are not necessarily depressed or traumatized and that
many remain resilient despite living with and through adverse circumstances.
Poorer mental health at 24–30 months was associated with a self-identified
disability at baseline but not child abuse history or racial/ethnic background.
A previous analysis of the baseline demographics also identified disability as the
sole background variable associated with poor mental health (Tutty et al., 2020).
Yet disability is not commonly identified as a factor in the IPV literature;
discussions of IPV and disability occur more frequently in the disability litera­
ture (e.g., Slayter, 2009). Much of the research on IPV and disability examines
IPV in populations of women with disabilities (e.g., Ballan et al., 2014; Barrett
et al., 2009; Cohen et al., 2005; Du Mont & Forte, 2014; Yoshida et al., 2011).
Several authors (Breiding & Armour, 2015; Coker, Weston et al., 2005) exam­
ined disabilities and IPV in general population studies. Few studies on women
and IPV discuss disability, an exception being Ford-Gilboe et al. (2015).
Focus groups with professionals (Lightfoot & Williams, 2009) concluded
that, while cultural competence regarding ethnicity was being promoted, this
was not the case for disability. Assessing whether a physical or mental health
condition constitutes a disability is important as it transforms a medical
16 L. M. TUTTY ET AL.

diagnoses into how well a person is functioning in their everyday lives. At

present, few services are specific to women with both disabilities and an IPV
history (Ballan et al., 2014; Lund, 2011). An exception is Ballan and Fryer
(2017) who provide trauma-informed counseling for women with disabilities
who have been abused by intimate partners.
Consistent with a lack of services, women with disabilities have estimated
that only 15% of health providers assess for IPV (Curry et al., 2011), and that
health care professionals often lack training in either IPV or disability (Ruiz-
Pérez et al., 2018). Clearly, this is a large gap in service provision. The current
study supports more research and recommends that IPV professionals should
be trained to assess for disability status and those working with women with
disabilities should assess for IPV.

Study limitations and strengths

Without random selection of either the agencies or the women, the results may
not be generalizable to other Canadian women from the prairie provinces who
were abused by intimate partners, particularly those who have not sought
assistance for IPV. We did not collect information specific to recruitment (i.e.,
what agency, or whether the women chose to be involved by attending informa­
tion sessions or receiving envelopes containing invitations). This might have
identified biases such as more recruitment from community versus VAW
shelters or more engagement with some agency types such as the mental health
sector. It also might have provided knowledge about how to better recruit and
prevent attrition in future studies. While the bulk of research on women and IPV
relies on convenience samples of women from VAW shelters or counseling
agencies, additional research in these sites and others on the variables of interest
in the current study, such as disability status, is recommended.
Although we were cognizant of the risks of attrition and used several strate­
gies to minimize this (e.g., re-contacting the women between waves) similar to
suggestions by Sullivan et al. (1996), 37% of the women had dropped out by
30 months. Attrition is to be expected in longitudinal studies, and our rate was
similar to the 30% in Campbell and Soeken’s 3.5 year study (Campbell &
Soeken, 1999), 36% in Suvak et al.’s (2013) 4.5-year study and 38% in
J. Campbell et al.’s (1998) 2.5 year study. The women retained at 30 months
were older, had more income and more were working, were better educated, had
fewer children, were less likely to have stayed in shelter and experienced less
severe IPV, characteristics suggesting they led more stable and functional lives.
Nevertheless, there were no differences between the women who dropped
out compared to those retained on mental distress, depression, PTSD (all in
the “normal range”), or quality of life. The two groups did not differ at baseline
with respect to the key intersectional moderating variables of interest: ethni­
city, child abuse history, or disability. This does not refute the fact that had the
 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 17

dropouts been retained the results might certainly have been different, how­
ever, does support that the groups remained similar on several key variables of
interest.
It would have been useful to compare our results with other longitudinal
studies, especially since most used similar outcome variables of depression,
PTSD, and QOL. Unfortunately, even when identical measures were used,
different versions of the scales (i.e., different numbers of items, different Likert
scales) made direct comparisons impossible. Further, some authors (Bell et al.,
2009) who used identical scales (PCL, QOL) did not report average scores
across time in their publications.
The physical and mental health conditions and disabilities were based on
women’s self-report rather than formal diagnoses. Recently, the disability
community has promoted self-identification as an accurate measure of dis­
ability (Owen & Ursel, 2018). Child abuse could have been measured more
comprehensively with standardized measures. However, the research instru­
ment was already long, and these were small concessions to feasibility and
reducing the burden for respondents.
Simply participating in longitudinal research can be positive. Burge et al.
(2017) speculated that the improvements in coping strategies, hope, mental
health, and increased readiness to leave their partners over 12 weeks of weekly
contact, were enhanced by being in their longitudinal study. We hope this was
true in the Healing Journey as well.

Conclusion
The women who participated in the Healing Journey study shared invaluable
and sensitive information about their private lives and personal journeys over
time in this complex and laborious project. Their diversity is apparent, not
only with respect to ethnic background, but also histories of physical and
mental health, and childhood abuse. Recent literature on women and IPV has
tended to highlight their mental health difficulties but disability as
a consequence of health outcomes is clearly important as well.
When this study was conceptualized, the research team named it “The
Healing Journey” somewhat optimistically since, while this was the hope, we
simply did not know how the women would fare over time. Given the small
but statistically significant improvements over time, as documented in the
current analysis, we may now, with more evidence, describe a healing journey
and offer women, professionals and advocates more hope for the future.

Acknowledgments
The CURA team (excluding the authors): Dr. E. Jane Ursel and Marlene Bertrand
(Manitoba Department of Family Services and Housing, MB) are the Co-Principal
18 L. M. TUTTY ET AL.

Investigators; Dr. Janice Ristock; Dr. Lori Wilkinson; Colin Bonnycastle; Dr. Jocelyn Proulx
(University of Manitoba); Dr. Johanna Leseho; Dr. Roberta Graham (Brandon University);
Dr. Linda DeRiviere; Dr. Michelle Owen (University of Winnipeg); Anna Pazdzierski
(Nova House, Selkirk, MB); Karen Peto (YWCA Brandon); Margaret Marin & Darlene
Sutherland (Osborne House, Winnipeg); Dr. Bonnie Jeffery; Dr. Darlene Juschka;
Dr. Wendee Kubik (University of Regina); Dr. Stephanie Martin (University of
Saskatchewan); Carol Soles (Prince Albert Emergency Shelter for Women); Debra George
(Family Services Regina); Dr. Karen Wood (Tamara’s House, Saskatoon); Maria Hendrika
(Provincial Association of Transition Houses Saskatchewan); Angela Wells (Family Support
Centre, Saskatchewan); Dr. Erin Gibbs Van Brunschot (University of Calgary); Dr. Caroline
McDonald-Harker (University of Alberta); Dr. Ruth Grant Kalischuk (University of
Lethbridge); Jan Reiner & Carolyn Goard (Alberta Council of Women’s Shelters); Brenda
Brochu (Peace River Regional Women’s Shelter); Kristine Cassie (YWCA Lethbridge); Pat
Garrett (WINGS of Providence, Edmonton).

Disclosure of interest
The author(s) declared no potential conflicts of interest with respect to the research, author­
ship, and/or publication of this article.

Funding
The study was supported by grants from the Social Sciences and Humanities Research Council
(SSHRC) Community University Research Alliance (CURA); Alberta Centre for Child, Family,
& Community Research; Alberta Heritage Fund for Medical Research; the Prairieaction
Foundation; and TransCanada Pipelines.

ORCID
Leslie M. Tutty http://orcid.org/0000-0003-3000-7601

Ethical standards and informed consent

All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation [Universities of Calgary, Manitoba, Regina, Brandon,
Lethbridge, Winnipeg, Canada] and with the Helsinki Declaration of 1975, as revised in 2000.
Informed consent was obtained from all patients for being included in the study.

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