Spousal / Partner Abuse

Prevalence and Nature of Intimate Partner Violence

Defining Intimate Partner Violence
Intimate partner violence (IPV) has also been referred to as domestic violence (DV) and spousal abuse. According to the Centers for Disease Control (CDC) (1998), IPV is a serious, preventable problem affecting millions of Americans. IPV refers to physical, sexual, or psychological harm caused by a current or former romantic partner or spouse in heterosexual or same-sex couples. The relationship may or may not involve sexual intimacy.

IPV varies across the continua of severity and frequency. Research is showing subtypes of violent and victim partners, the importance of context (the situation), the use of alcohol, mental and personality impairments, and other factors with clinical implications.

Saltzman et al. (2002) identifies four primary types of IPV. They are:

1. Physical violence: The intentional use of physical force where such force may cause death, disability, injury, or harm. This can involve acts such as "scratching; pushing; shoving; throwing; grabbing; biting; choking; shaking; slapping; punching; burning; use of a weapon; and use of restraints or one's body, size, or strength against another person." (CDC 1998)
2. Sexual violence: which occurs in three forms. a) physically forcing a person to engage in sex against their will (regardless of how far the sexual act progresses); b) attempting to have sex with a person who is unable to adequately understand it, to decline (for reasons such as intimidation, disability or the influence of drugs); and c) sexual contact that is abusive.
3. Threatening sexual or other violence through the use of words, gestures or weapons in a threatening manner.
4. Violence of a psychological or emotional nature. This traumatizes the victim through threats or coercion. This may include humiliation, control, withholding information, and isolation.
5. Stalking, defined by Tjaden and Thoennes (1998) as, "harassing or threatening behavior that an individual engages in repeatedly, such as following a person, appearing at a person's home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person's property."

Implications: IPV can occur in various forms of psychological, emotional, or physical abuse. It also occurs across a scale of severity. Thus, the clinician must recognize the nature and extend of IPV in order to provide relevant treatment. Additionally, the clinician must be sensitive to the complexities of abuse that involves various forms of boundary crossing and manipulation that are not overtly violent.

Statistics on IPV: Scope of the Problem

Rate of IPV

Statistics on IPV come from various surveys, research projects, and crime data. Justice system data such as arrest reports are not scientifically valid in that they cannot be used to draw strong conclusions about rates of IPV in the community. In order to draw effective conclusions, researchers look at as many surveys and research projects as possible. A major source of data is The National Crime Victimization Survey (NCVS), which has been collecting data on personal and household victimization of intimate partners from 1973, and uses nationally representative samples of residential addresses.

The NCVS is a primary source of data on characteristics of all forms of criminal victimization, including the number and types of crimes that are not reported to law enforcement authorities. The NCVS provides the largest forum for victims to tell of the impact crime has had on them, and of the characteristics of violent offenders.

Data is obtained semiannually from approximately 49,000 households and includes about 100,000 individuals. It is considered the most authoritative source on the reporting of crime victims. Advantages of the NCVS data are that it does not include arguments, pushing and shoving, or voluntary sexual activity that involves practices such as S&M.

Gaquin (1977-78) did the first analysis of domestic violence data from the NCVS. He found the rate of IPV to be 2.2 incidents per 1,000 households, or an incidence rate of 0.22%. Dugan (2003, p. 299) reviewed the NCVS data from 1992 to 1998 for 529,829 households. She reported that 2,873, or 0.5%, of the households reported at least one incident of IPV.

In research on repetition of violence that might relate to the cycle of violence model of IPV, Dugan (2003, p. 299) found that during the same time period, the NCVS data showed 3,508 incidents of criminal domestic violence in the 2,873 households reporting such violence. This means that up to 20% of households in which IPV occurred were reporting more than one act of domestic violence per year. This is less than 0.1% of the households surveyed. Extrapolation from the NCVS data suggests that there were roughly 340,000 cases of domestic violence in 1994 based on a total of 68.5 million total households. Extrapolation from Gaquin's analysis would yield a lower number of 150,000 cases. This extrapolation is based upon an estimate of 68.5 million households in the U.S. at the midpoint of the years discussed. (Statistical Abstracts of the United States, 1997, Table 66)

The above data also suggest that households experiencing more than one incident of IPV per year may constitute 20% of households reporting IPV. This would amount to from 30,000 to 68,000 cases, or 54,400 using only the more recent data. Some percentage of this group experience an ongoing pattern of violence.

If we take the more recent NCVS data on its own, rather than extrapolating from the 1994 to 2004 period, we have a lower figure by about 20% for domestic violence. This is because rates reported through NCVS are declining. These more recent data suggest that 4 per 1,000 households, or .4% experience at least one incident of IPV, including incidents between teens in relationships, and roughly .08% experiencing some repetition. A fairly small fraction of that percentage might experience a pattern of repeating violence.

Intimate terrorism: High levels of violence and psychological abuse and control are characterized as intimate terrorism. A very large Canadian study in 1999 revealed that approximately 3% of the women and 2% of the men had experienced this in the previous five years. The questions were somewhat biased toward terrorism that is more characteristically male. (Laroche, 1999)

Implications: Data from The National Crime Victimization Survey and total U.S. households suggests that IPV affects .22% to .5% of American households, and that repeating IPV occurs in as many as .08% of households. The most severe, repeated, and psychologically abusive IPV occurs in a subset of these homes, affecting possibly 2% to 3% of adults over a five-year span. It is important not to confuse an isolated incident with a pattern of abuse, or to confuse recurring incidents with intimate terrorism. Because psychological abuse exists on a continuum that ranges from normal irritability to extreme abuse, it should be carefully assessed.

Gender and IPV

Who is Violent? In contrast to decades of repeated messages about gender and IPV, a tremendous amount of information is accumulating that tells us that IPV perpetrators are fairly evenly split between males and females. It also tells us that there are differences between the sexes in IPV perpetration and its consequences.

The data is coming from diverse sources. A Philadelphia emergency clinic discovered that of 866 male patients over a 13-week period, 12.6% were IPV victims. Of these cases, 47% had been kicked, punched, bitten, or choked, while 37% had been attacked with a weapon. This did not include a period after midnight and did not include major trauma cases, so these results are lower than the actual incidence rates. (Mechem, Shofer, Reinhard, Hornig, & Datner, 1999)

In another emergency clinic study, 72% of men with IPV injuries had been stabbed. The majority of women victims (53%) had been assaulted. Burns were evenly split between men and women victims. (Vasquez, & Falcone, 1997)

For more research regarding gender and IPV rates, Appendix A offers many citations to the more recent scientific data, with annotations by John Hamel.

Resistance to data: When it comes to gender, IPV is a landmine of emotionally charged controversies. The struggles of feminism have led many women's movement and shelter advocates to take extreme umbrage at researchers who point to statistics suggesting that IPV is also victimizing men. The theoretical orientation of this subset of feminists describes patriarchy as the source of IPV. This orientations perceives nearly all IPV as male generated. It interprets female perpetrated IPV nearly exclusively as self defense.

The orientation excludes information suggesting that male abusers have mental health needs requiring treatment. Instead, the model calls for control and socialization. At the same time, some men on the fringes of the movement for men's rights and shelters are reactionary individuals who appear to justify the concerns of women's rights advocates.

Patriarchy as a flawed theory: According to Hamel (2009), "The causes of intimate partner abuse are far more similar between the genders than they are dissimilar." Examples of research that is eliminating patriarchy as a basis for or evidence of widespread IPV by men is provided in the following quote from Graham-Kevan (2006):



Early efforts to explain away female violence as being exclusively self defense are being undermined by a number of types of data. For example, Hamel (2009) states that, "Longitudinal studies have found that many partner-abusive women, like men, bring to the relationship a history of aggressive tendencies, thus undermining the notion that their violence is always reactive."

The source of the male batterer stereotype: The smaller population of perpetrators that have serious personality disorders, particularly with psychopathic traits, are highly likely to be persistent and dangerous, in spite of treatment and other intervention. This population is most concentrated in jails and is most likely to drive women to shelters. Because much early research and case reporting drew data from these populations, this highly sociopathic profile became emblematic of the IPV problem in the minds of early feminist theorists and subsequently became firmly embedded in the media, and in the minds of activists, legislators, and the public.

Historical basis, current concerns: Given the intensity and sacrifices involved in the struggle for women's rights, and given the long duration of the fight for things as basic as the right to vote, it is no wonder that there is great concern on the part of women's activists about anything that might erode this progress.

Two key concerns are 1) Resources devoted to men would threaten funding for women's services. This occurs in the context that, especially historically, men had greater resources than women and thus greater control over them. Thus, it less likely that men would be in need of shelter from abuse. 2) Manipulative male abusers would use the men's movement and related resources to inappropriately get control of children, blame women for violence they had not engaged in, and otherwise hide behind a smokescreen of men's rights.

Dynamics of change: Advocates for a more contemporary interpretation respond to these concerns with the following ideas: 1) Resources are needed by both genders, especially in the current economic environment. 2) Both males and females who manipulate the system will attempt to use it for inappropriate purposes, so this problem must be managed without reinterpreting it as a gender war. 3) Research is showing that modernizing batterer intervention programs with current clinical knowledge is yielding improved outcomes. The struggle, they say, is not between men and women, but for more, and more appropriate, services and legal system responses.

An outgrowth of the increased awareness of female-perpetrated violence is that women's advocates are coming to perceive IPV from a new vantage point. With an already existing humane perspective toward women and the needs of children, women's advocates have expressed more humane perspectives on IPV. For example, by looking at contextual and mental health issues that contribute to violent acting out, they are constructing a narrative that will support interventions that emphasize resources, case management, and treatment.

The early reaction to female violence was that it was exclusively a response to male violence. However, a number of sources, including that of law enforcement has painted a very different picture of violence, often fueled by alcohol, that is largely mutual, and otherwise is initiated by both males and females. Innovations in the justice system are taking place. These include alternative sentencing that considers the multi-problem nature of IPV. Specialized domestic violence courts have been created in some regions. They are based on a philosophy similar to that of drug courts and courts for people with serious mental illnesses and developmental disabilities. Such courts take the mental health and resource needs of individuals and families into consideration.

Increasing awareness of IPV in lesbian, gay, bisexual, and transgender (LGBT) relationship is also shifting perceptions of IPV. For example, authors studying LGBT violence added the category of "participant" to the victim and perpetrator roles, referring to bilateral violence. (Marrujo & Kreger, 1996) The recognition high levels of violence in lesbian relationships has required modifications of early theories. Post hoc rationalizations, such as the idea that lesbians had absorbed patriarchal attitudes, have not held up to scrutiny.

Wrong data, politicized interpretation, and manipulation: There has been much disagreement as to rates of male and female perpetration of IPV and psychological abuse. Problems include varying definitions of IPV, varying means of collecting data, diverse purposes of data collection, politics, and the dynamics of the urban myth.

Justice system data, particularly arrest data, sometimes shows a higher proportion of IPV violent men than that derived from scientifically randomized surveys. Critics say that this is due to a variety of factors that bias arrests and reporting, notably the tendency of men to underreport and not be willing to be perceived as a victim of female perpetrated violence.

Critics point to numerous inappropriate uses of data that include "cherry picking" (selecting only data that support a theory and ignoring other data that is just as credible). They point to statistical claims by the National Coalition Against Domestic Violence that is actually fabricated, but took on the scale of a pervasive urban myth through repetition.

Critics have also pointed out in some studies what appears to be deliberate manipulation of statistics through various means to exaggerate the percentage of male perpetrators. At best, much of the research showing a highly elevated percentage of male perpetrators of unilateral violence is highly flawed. (Hamel, 2008)

An example of this problem is discussed by Hamel (2008):



Criticism of Early Theories: High levels of male-only perpetration of IPV by many feminist theorists, activists, and authors have been called into question by critics who point to the highly politicized nature of the claims. They state that the political drive comes from a combination of advocacy for funds for organizations dealing with IPV, and a strong attachment to a very polarized view of gender. While patriarchy was considered the driving force behind IPV, current research does not support this contention.

Controversies regarding the effectiveness of various programs or treatment approaches are difficult to resolve for similar reasons. The widely used Duluth programs did not fare well in outcome research, however, many ostensibly Duluth-based programs are now integrating aspects of CBT. This makes it difficult to compare and contrast these two approaches. It appears, though, that the increasing movement to respond to IPV as a multi-problem matter is beginning to make the debate over the Duluth model obsolete. The primary shift lies in recognizing the mental health aspect of IPV, and the need for treatment.

Implications: IPV arouses strong feelings that are amplified by historical factors, politics, and stereotypes. Clinicians are ethically obligated to inspect their biases and rely on current information to take the most effective approach. While controversies regarding things such as the ratio of male to female batterers are intriguing and even inflammatory, clinicians must ensure that there are adequate services and that treatment is effective. Clinicians can better assist their clients by being aware of community resources and nuances to dealing with the justice system. By recognizing the limitations to early theories about patriarchal domination as the primary basis of IPV, clinicians will respond more effectively to victims, co-participants, and unilateral abusers.

Historical Roots, Current Consequences

Theorists point to historical cultural and legal roots to control and maltreatment of women as having repercussions in the present day. As we shall see in the section on changes to the law and police response, domestic violence was generally regarded as a private matter up until recent history.

British common law, inherited by America, held that husbands had the right to physically punish wives. (Dobash and Dobash, 1979). In a reform, British law limited the size of a rod used by the husband for such punishment to a diameter no greater than the husband's thumb. In American law, this legal beating did not begin to be outlawed until 1871, when an Alabama court revoked this right. Three years later, North Carolina merely made the punishment more humane by requiring that it not cause permanent injury or be delivered with cruelty or dangerous violence. (Leonard, 2002)

The transition from a private, sanctioned matter to a public issue with legal protections and punishment is an extreme contrast. However, because of factors such as shame, economic need, fear of intervention, love, hope, or psychological control, much IPV goes without clinical intervention, a legal response, or even family support.

Many of the statistics regarding IPV reflect abuse of women by males. As increasing research focuses on gay, lesbian, and straight male victims, these aspects of IPV are beginning to be better understood. The similar rates of IPV in lesbian and gay relationships to rates of IPV in straight relationships is calling into question the degree to which IPV results from patriarchal cultural roots. Research attempting to explore the relationship between patriarchy and IPV is not finding a strong association. Also, although the laws historically supported male violence, it is not known with certainty how much IPV was perpetrated by men or women, or how often men were killed by male proxies acting on behalf of a woman.

Men who cite patriarchal beliefs in justifying control tactics of violence against women may be rationalizing post hoc more than being driven by those beliefs in acting violently. The section on mental health issues in IPV will shed more light on this issue.

Implications: Patriarchal cultural roots have been blamed for IPV, but a variety of data do not support this contention.

Legal Precedents and Social Change

Historically, many police departments had passive and tolerant approaches to IPV. After a number of successful lawsuits and settlements and changes to the law beginning in the early 1980's, police departments came to respond much more effectively. The lawsuits were primarily based on the equal protection clause of the 14th amendment. They successfully conveyed that the police departments had a gender-biased response to domestic violence. Some of these cases involved shocking situations. (Kurst-Swanger & Petcosky, 2003)

Increased awareness of IPV and concern regarding lawsuits led to the institution of pro-arrest policies, in which the victim cannot convince the police not to arrest the violent individual. (Roberts, 2002) An unintended consequence of this kind of policy has been an increased awareness of bilateral or mutual violence and violence by females as increasing numbers of women are mandated to batterer intervention programs. (Mills, 2003)

In 1984, a project showed that arrest was a deterrent to IPV. (Roberts, 2002) However, subsequent research has shown that this deterrent is more true for employed, married abusers. Victims of unemployed abusers may experience increased risk as a result of the arrest. Also, they are less likely to cooperate with the prosecution and they may be less likely to call for help in the first place. (ibid) One reason for the lack of cooperation is that the cost of defense or conviction and subsequent program participation or incarceration may pose a grave hardship to a low-income family. Another can be fear of the reaction of the abuser. Ironically, a motive for mandatory arrests was to prevent anger against the victim, as the victim had no choice in the arrest. In a positive note, immediate safety concerns are handled, as the abuser is removed from the situation at a time that he or she is escalated.

The women's shelter movement created resources for women victims of IPV and acquired funding from various government sources in the United States. A key motivation for these services has been the financial vulnerability of victims and their children. In many cases, they had nowhere to turn and were at the mercy of abusive men. (ibid) However, services are generally very limited, and most women in need go un- or under-served. Waiting lists are commonplace.

Erin Prizzy began the first women's shelter in the U.K. in 1972. The women's movement and various researchers contributed a great deal to the growing recognition of child abuse and domestic violence from that period forward. (ibid)

Challenges, again based on equal protection, to the funding of such resources exclusively for women are beginning to result in the availability of services for men who are being victimized and who lack resources.

Implications: IPV is a changing mental health, public safety, and legal phenomenon that challenges us to stay current in our thinking and to understand the systems issues and contexts that affect our work and outcomes. Resources for women are inadequate, and resources for men, as of this writing, are far more limited.

IPV Dynamics and Demographics

Multiple Factors Contribute to IPV

IPV is a social and individual problem that can not be defined or explained by any one cause or factor. Violent and abusive behavior in relationships results from a combination of factors that vary from person to person. These include learned behavior, psychological factors and disorders such as trauma history, genetically derived temperament, level of stress and recent stressors, dynamics specific to the relationship, and cultural values. Hamel's (2009) review of research led to this list of causal factors:



Much research has pointed to the mental health issues shared by males and females in the etiology of IPV. For example, Hamel (2009) states:



Early theory explained female originated violence as nearly exclusively self-defense, battered woman syndrome, or part of an effort to escape. However, research such as the above is supporting a multi-problem etiology that applies to both genders. According to Hamel (2009), "A recent study by Graham-Kevan and Archer (2005b) of 358 female students and staff at an English university found no correlation between fear and a woman's use of severe violence. Significant effects, however, were found for reciprocal violence as a means of retribution or as the result of a desire to control one's partner."

Mandated treatment programs are tasked with accomplishing therapeutic aims as well as functioning as a legally approved and required process that individuals must complete. On one hand, clinicians must view the dynamics of IPV in order to craft effective interventions, on the other hand, short-term safety considerations and the requirements of the justice system dictate that accountability be squarely addressed. Critics of clinically-oriented approaches express the concern that perpetrators of violence may use psychological explanations for their behavior as excuses. They state that IPV is not caused by the victims' behavior, the use of alcohol or drugs, stress, or mental illness. However, the design of effective clinical outcomes, as outcome research is showing, must take these factors into account as contributing factors unique to the individual, and as targets of intervention.

Non-clinicians executing the priorities of the justice system can resolve the apparent conflict between accountability and clinical objectives. They can recognize that most of the individuals who are violent in their relationships must develop personal skills and resilience in order to eliminate violent behavior and adopt constructive alternatives, regardless of whatever punishment they must endure. Progress on clinical objectives contributes to the elimination of denial and the taking of responsibility.

Childhood exposure to violence in the home is a major risk factor for engaging in or being victimized by IPV as an adult. (Hotaling and Sugarman, 1986; Dutton, 1988) It is speculated that genetic inheritance, traumatization, and behavior modeling are key reasons for this correlation. Persons who engage in IPV tend to lack skills for appropriately coping with certain situations, conflicts, and feelings. Additionally, many lack affect regulation skills and have easily triggered emotional dyscontrol. This poverty of skills and inflammation of affect may be symptomatic of a multigenerational phenomenon that affects both the person's childhood family environment and their temperament.

To better understand IPV, research focuses on three levels: 1) The micro level (intrapersonal or psychological), 2) The mezzo level (interpersonal or social/psychosocial), and 3) The macro level (sociological/sociocultural). (Kurst-Swanger & Petcosky, 2003) All three levels are relevant to treatment. Interventions may involve psychotherapy, case management, justice system, social policy, social activism, and other methods. Family therapy largely perceives interpersonal problems, including violence at the messo level, looking at family or couple structure and dynamics. By the early 1960's, the psychopathological and psychiatric models in vogue were not sufficiently evolved to address IPV effectively. This compounded the experience and perception that male batterers were unlikely to change. This left social control of batterers and escape from them as the most reasonable options.

Implications: Treatment of IPV will often need to address cognitive deficits, personality disorder traits, dysfunctional attachment styles, developmental and current effects of trauma or post traumatic stress disorder, substance abuse, cognitive schema, and additional mental illnesses or disorders. While it is tempting for the clinician to focus on cognitive therapy of dysfunctional cognitions, this will often fall short. Certainly, embracing a polarized drama of good against evil or the oppressed against patriarchy will fail to produce meaningful outcomes. However, the smaller population of perpetrators that have serious personality disorders, particularly with psychopathic traits, are highly likely to be persistent and dangerous, in spite of treatment and other intervention. It is this population that is most concentrated in jails and is most likely to drive women to shelters. Therefore, this population had become emblematic of the IPV problem in the minds of early feminist theorists.

Demographics, Diversity, and Shared Traits

Violent partners can belong to any socio-economic, ethnic or racial group. They may be old or young, female or male, gay or straight. However, lower social class and education, and cognitive impairment or a history of head injury, increase the risk of engaging in IPV. (Cohen, Rosenbaum, Kane, Warnken, & Benjamin, 1999; Teichner, Golden, Van Hasselt, & Peterson, 2001) Alcohol abuse is a strong risk factor. A variety of mental health issues, notably borderline personality disorder and complex PTSD contribute to risk. Antisocial personality disorder is a risk factor that most closely resembles stereotypes of abusive men, particularly when it approaches psychopathy.

Victims of IPV are also diverse, but are likely to share traits of their violent partner, including social class, substance abuse, mental disorders, and aggressiveness. This may contribute to the high proportion of mutual combat in IPV.

Implications: While clinicians may be tempted to perceive a couple in which IPV is taking place as containing an abuser and a victim, cases are often more complex that this and require careful assessment as to contributing factors that require treatment.

IPV as an Expression of Pathologies and Attachment Style

Numerous surveys and studies tell us that the majority of IPV is bilateral, that is, mutual fighting. Often, this is exacerbated by alcohol.

Research suggests that violent and victimized, as well as mutually violent individuals who share the traits discussed above tend to couple. This is referred to as assortive mating. Many violent individuals also have a history of having been victims in violent relationships. This further supports the theory of assortive mating, because it describes individuals with traits conducive to IPV joining in intimate relationships.

This also helps explain the tendency of these couples to adhere to romanticized dreams regarding the relationship being one in which they can be understood in a way no one else has understood them. Persons engaging in IPV are likely to have dysfunctional attachment styles, such as anxious/avoidant style. With developmental attachment problems, these individuals have a heightened need for this romantic sense to be maintained, and have difficulty coping with disruptions. This is another way of saying that such individuals are highly dependent upon the relationship for their stability, and highly reactive to sensations of insecurity, jealousy, hostility, or abandonment.

These individuals also tend to attribute negative motives to their intimate partner such as unfaithfulness or hostility that are not necessarily actually taking place. This occurs because these individuals have impaired abilities to perceive social cues, and this makes them more likely to project their insecurity and be triggered into inflamed emotions. They are less able to de-escalate at these times, because they do not adequately perceive cues from their partner that would help them feel connected and secure.

Because they must manage themselves during their work day and in other social environments, they experience even more dependence on their partner as the one source of attachment that will emotionally rescue them or help them recover from their efforts to tolerate the world outside of their domicile. Alcohol or other drugs are also a means for tolerating life and managing their emotions through self-medication. However, despite its perceived value in self medication, it often fuels IPV.

Shared traits that are believed to result in assortive mating leading to IPV can include attachment problems, personality disorders with antisocial traits, alcohol and other drug abuse, lower social class, and a history of family problems including exposure to violence. Genetic research tells us that these historical factors are, to some degree, the result of shared genetics. This leaves open to question what extent of IPV is related to genetic factors as opposed to childhood family experiences of violence and other dysfunctional dynamics.

Implications: Clinical outcomes hinge upon treatment of existing problems from a biopsychosocial perspective. While domestic violence programs may or may not be mandated to complete an assessment or provide treatment from this perspective, clinicians are ethically obliged to offer informed consent. This means that clients are to be informed as to whether they are receiving treatment or an educational program. If they are receiving treatment, clinicians are legally and ethically obliged to provide it according to current knowledge and standards. This means that clinicians must be familiar with current literature regarding the effectiveness of treatment approaches.

Subtype Profiles, Implications for Assistance

Persons who engage in violence in intimate relationships are found to belong to some general subtypes.

Primary and secondary aggression: One view is that of primary and secondary aggressor. The primary aggressor is an individual who exhibits a pattern of physical or other forms of abuse. The secondary aggressor acts out less frequently, and as a reaction to the primary aggressors abuse. When the secondary aggressor is mandated to a domestic violence program, it may be helpful, but may cast the individual as a primary aggressor, and view them as being in denial if they don't play along. This model does not address the "participant" role of bilateral violence.

Trait-based abuser categories: Categorization that is more trait based tends to differentiate between traits that are predictive of the level of violence. The most violent individuals tend to have the most severe personality disorders, and are likely to have borderline personality disorder and antisocial traits. (Hines, 2008) This group is likely to display significantly dysfunctional attachment patterns with anxious/avoidant characteristics.

The more moderate group of violent individuals tended to have less severe personality disorders, if any. This group often has a dysfunctional attachment style, as above.

Trait-based victim categories: As with any category system, it speaks to general observations and not all individuals. Victims often have similar traits to batterers. This conflicts with the earlier view of passive and withdrawn victims. Many victims have been observed to participate vigorously in verbal conflict, defending themselves verbally. This profile conforms to what would be expected from two intimate partners with dysfunctional attachment patterns who become emotionally aroused by threats to their identity and sense of security. This leads to reciprocal and escalating verbal conflict. In the case of IPV, one or both parties cross the line into physical violence. The use of alcohol increases the likelihood of violence.

Victims who are significantly more functional than their violent partners may nonetheless develop some symptoms and coping patterns that overlap with those who are not as functional. This is because of the profound effects of living with a violent and emotionally dysfunctional individual. The section on effects of IPV addresses this.

Interviews and treatment of persons who were emotionally higher functioning before they became involved in an abusive relationship suggest that impairments such as ADD, mild dissociation, or drug/alcohol abuse may contribute to individuals becoming overly invested in a relationship with a dysfunctional partner. It appears that such individuals can become so occupied with the drama of the relationship that they lose their sense of having choices. Cognitive impairment makes them much more vulnerable to this loss of "choicefulness." The dysfunctional relationship creates additional impairment through factors such as stress, drug use, head injury, and psychological trauma. This leads to an even greater difficulty in thinking objectively and resourcefully about the relationship, safety, child welfare, and creating independence.

This is strong testimony for the importance of advocates, case managers, relatives, and therapists. These cognitively impaired individuals need help in regaining a sense of having options and personal power. It is important that clinicians not underestimate the challenge that these individuals face in completing tasks such as creating a safety plan and otherwise becoming independent. Independence can seem unachievable and intimidating to individuals who need to recover from cognitive impairment. Unfortunately, cognitive functioning is often unrecognized by clinicians, and most clinicians have no skills for consulting with people regarding coping with and recovering from such impairment.

Implications: Assessment and treatment planning must be relevant to traits and patterns that contribute to IPV. Recognition of the level of impairment of the victim highlights the importance of assistance in planning and utilizing resources. Most perpetrators of violence are amenable to treatment. Careful assessment is needed in order to ensure that appropriate treatment is provided. Because cognitive impairment often affects batterers and victims, clinicians must become skilled in recognizing and responding to it.

CBT Theory and Poor Affect Regulation

This perception of attachment style playing a role in IPV meshes well with CBT theory. This theory suggests that most cases of IPV involve dysfunctional and escalated efforts to manage anxiety and other uncomfortable feelings. These efforts take the form of an excessive focus on external situations and people. This can include various efforts to control an intimate partner. For example, a person who is highly sensitive to feelings of rejection may react violently to the perception that the partner has shown too much affection to a potential suitor.

This line of thought explains why so many violent individuals limit their violence to their intimate relationships. It puts forth that intimate relationships arouse the greatest feelings of vulnerability and anxiety in persons with disrupted attachment. This tells us that IPV is, for many individuals, largely a problem of poor affect regulation.

Key to this concept is that many violent individuals do not consciously experience the thoughts and emotions that lead to violence early enough to recognize that they are about to react violently. After the perception of a trigger, the impulse to violence is too swift for the violent individual to perceive the feelings aroused, and the thoughts or explanatory style as red flags or as an opportunity to make a different choice. Even after developing some awareness of the pattern, the individual may be too aroused to utilize this knowledge without additional treatment.

Unlike these unconscious reactors, other batterers are already quite aware and expressive of their thoughts and emotions, but are so invested in them that they fail to see the appropriateness and need for constructive alternative ways of handling their feelings, circumstances, and interpersonal conflicts.

Many of these clients are perceived as being sociopathic or psychopathic because of their apparent lack of empathy. However, when the dynamic discussed here is in play, the failure to experience empathy is more likely the result of temporarily distorted perceptions, rather than a trait of chronic absence of empathy (sociopathy). When this is the case, the lack of empathy stems more from a temporary misperception of the partner as a threat to their emotional well being (even though this perception is not necessarily conscious until the person has had some success in treatment and is able to recognize and express it).

CBT assists these individuals in developing sufficient self understanding that they are able to re-engineer their thinking and reactions, as well as develop plans for preventing violence by taking appropriate measures when life stresses reduce their tolerance of emotional triggers.

A key feature of CBT is that it helps the client make constructive choices instead of having automatic reactions. The client discovers the dysfunctional impressions and thoughts that turn situations into emotional triggers. With the help of the therapist, the client learns to experience these situations differently, thereby decreasing their reactivity. The client develops the ability to recognize situations that might trigger them, and prepare themselves ahead of time to respond differently.

When the client experiences other modalities such as reprocessing (e.g., through EMDR) and affect management and other self care skills (e.g., through dialectical behavior therapy) they respond even better to CBT.

Implications: Cognitive behavioral therapy is an appropriate and necessary treatment approach for most cases of IPV. However, it is essential to recognize that changing thought patterns may not be adequate or even possible without treatment of the state of arousal that results in violence. For this, medication, safety measures such as separation, treatment of factors such as PTSD, and somatic approaches to psychotherapy may be required.

Attachment to Violent Relationships

Understanding IPV involves accepting that there are no quick fixes or easy solutions. Abusive relationships are first and foremost relationships. Victims and perpetrators are likely to inhabit the same house, share in the care of children, and have the same circle of friends. There are many factors that help to determine whether the couple stays together and whether the abusive or controlling behavior can be changed or stopped.

Additionally, people bond around the positive aspects of relationships, even the majority of relationships that involve IPV. In most of these relationships, each party brings a variety of resources and sincere feelings that can support a constructive relationship, given proper treatment.

Implications: In the majority of relationships involving IPV, both parties, including those in relationships with unilateral IPV that abuses a victim, must be perceived in terms of their strengths and needs, and their relationship must be perceived in terms of its validity, not just dysfunction.

In order to mobilize clients and establish the rapport needed for effective treatment, the clinician must take care to join with clients in perceiving the relationship as involving more than abuse and violence. To observers who don't have this understanding, the victim appears to be staying in the relationship for no reason at all. Likewise, the abusive party appears to be evil and disposable. Such a perspective can engender helplessness and shame in both the batterer and the victim. People are generally highly responsive to how they are perceived by clinicians and authority figures. This superficial, shame-based perspective can also breach rapport between client and clinician. It reduces the clinician's capacity to produce an effective therapeutic relationship.

Control: Two Profiles with Very Different Implications

There has been a pervasive belief that the majority of IPV has served as a form of domination or control of females by males. However, research has only supported certain aspects of this perception. Overall, research tells us that there is a roughly even percentage of highly controlling and physically violent males and females. (Hamel, 2009); Graham-Kevan, 2007)

Numerous studies have looked at various aspects of the power and control theory of IPV. Studies focusing on sexual coercion or stalking have found much higher numbers of male perpetrators. All studies focusing on other aspects of the theory have not found that either gender is substantially more likely to engage in controlling behavior or violence, overall. (Felson & Outlaw, 2007) Expression of power or domination as an aspect of patriarchal culture appears to hold true in highly patriarchal cultures, but not in most of the Western world.

For both men and women, it has been found that individuals who engage in controlling behaviors are much more likely to assault their partners. Major studies including a major survey in the U.S. and a large international study of 32 nations (Straus, 2008) has shown the association between control and assault, and that men and women are similar in this regard.

Roughly speaking, there are two sources of the stereotype of the highly dominating and controlling perpetrator of domestic violence. One is that this profile exists, but is a small minority of the IPV population. This subtype is fairly evenly divided between males and females. This subtype tends to have strong psychopathic traits. Such traits are high in roughly 1% of the population, and this appears to hold true across numerous cultures and countries. (Hare, 1996)

This subtype has dominated the thinking of early advocates for domestic violence victims, because it fits with early feminist ideology. Another source of this perception is the profile discussed immediately above. Rather than expression dominance, the efforts to control stem more from emotional desperation. For this subgroup, the feeling is more one of lacking control. These individuals, in treatment, express a feeling of losing control when they are violent, and may experience much shame. Many, however, have highly engrained explanatory styles that externalize blame along with their externalized locus of control. These rationalizations may appear very unsophisticated to higher functioning individuals. In part, externalization such as victim blaming (she made me feel jealous the way she looked at that guy!) is part of the attachment to fantasies that support a very fragile sense of self, and that buffer against threats to that sense of self.

Nonetheless, this dependent and reactive profile is engaging in controlling behavior. The behavior may even resemble the former profile in that efforts to avoid insecurity and jealousy may involve some degree of attempt to alienate the intimate partner from friends or even prevent certain successful behaviors.

Implications: From a clinical perspective, it is important to distinguish between these two types of control. They each have very distinct clinical implications. Psychopathic individuals are very unlikely to benefit from therapy, and tend to use it in order to gain skills for more successful criminal and abusive behavior. The latter profile, with disrupted attachment and anxiety, is much more likely to benefit from therapy. These individuals are much more likely to bond with the therapist and to be motivated to achieve outcomes that will make them more independent and to have less disruptive emotional spikes. Medication may also play an important role in their stability and resulting improvements in behavior and skill acquisition. Unlike psychopaths, persons fitting this profile are likely to be motivated by the desire to act according to their values. Many of these clients are troubled by the fact that their abusive behavior is not in line with their values.

Forms of Control

While a minority of individuals who batter fit the profile of the highly controlling, antisocial type, those who are effected by their control tactics suffer a great deal of psychological harm. In assessing violent relationships, it is important not to confuse rationalizations with a full controlling profile. The pattern of behavior and its effects on the victim must be known before this assessment can be made. For example, a male may make a statement of male privilege in attempting to rationalize or justify violent behavior, but this same individual may not engage in sufficient controlling behaviors to isolate his victim from community resources, work, and other vital needs.

Also, if control tactics are used by an individual who better fits an attachment disorder profile than a sociopathic one, the batterer may be more amenable to treatment and behavior change with appropriate treatment. It can be challenging to view underlying motives of batterers objectively. There may be a mix of rational, meaningful motives and motives that stem from insecure attachment. There may be a temptation to view the batterer as being mindlessly bent on domination when the individual is actually more complex and accessible.

Further, if the batterer regresses because of involvement of the justice system (loss of control, great financial burden, loss of support, loss of contact with children, severe judgement from authority figures, hopelessness), therapists, social workers and others may only experience the batterer at their worst level of functioning and emotional intactness. This can lead to global judgements about the batterer that do not reflect the individual's potential, and that make it impossible to understand why the victim would return. It can also make it difficult to accept that there is mutual combat, when that is the case.

The following are power and control tactics noted in the literature on IPV.

1. Tight control of finances.
2. Forcing the victim to turn over money.
3. Not permitting the victim to work, or sabotaging efforts to maintain employment.
4. Threats of harm to the victim or other family members used to manipulate the victim.
5. Threats of legal actions such as turning the victim into immigration or the IRS.
6. Intimidation.
7. Threats of suicide.
8. Property destruction.
9. Displaying or brandishing or threatening with weapons.
10. Harming or killing pets.
11. Emotional abuse in attempting to undermine the victim's self esteem. Attempts to convince the victim that he or she is crazy. The victim may lose faith in their own independent thinking.
12. Pattern of humiliation, degradation. Can occur through name calling, insults.
13. Tactics that isolate the victim from sources of emotional, community, and financial support, or escape.
14. Tactics that place blame for violence on the victim.
15. Turning outside entities such as the police against the victim in order to evade blame and maintain control.
16. Using the children to maintain control over the victim. This may include threats of harm or kidnapping. The perpetrator may convince the victim that leaving will result in loss of parental rights.
17. Using guilt, accusing the victim of harming or breaking up the family.
18. Enforcing a subservient role upon the victim, treating him or her like a servant.
19. Being hypercritical of the victim's efforts to contribute, and using the imperfections as a reason to take over. Then the high level of responsibility is projected as the victim's fault for causing the perpetrator a great deal of stress.
20. Insisting that the victim adhere to the perpetrator's definition of male or female roles. Using deviations from these imposed norms as a justification for ridicule and other abuse.
21. Ability to skillfully reduce or escape responsibility because of having good interpersonal skills. Especially when the victim is not as effective at communicating.

The Cycle of Violence

Lenore Walker first described the cycle of violence in her 1979 work, The Battered Woman. This work was not empirically based, and has become widely adopted without much support or an understanding of how often this pattern actually occurs in relationships. The model is very simple, so it's utility is limited. Particularly where the tension building stage is concerned, much more detail needs to be known in order to provide treatment. When it occurs, the cycle may occur over a brief or longer period of time. Also, the buildup of tension that leads to violence may not occur in connection with the victim; for example, it could occur at work. As a result, the victim may be surprised by the unexpected escalation to violence.

The cycle of violence has three stages: The tension building stage, the violent episode, and the honeymoon stage.

1) Tension building stage: During the tension building phase there is increasing hostility and stress. Alternatively, tension may build within the batterer through a number of frustrations disappointments, or things that affect the batterers self esteem. These may or may not occur within the relationship with the victim. Arguments may occur more frequently, possibly along with relatively minor physical aggression.

2) Violent episode: The prior stage may escalate to a serious incident of violence. At this point, the victim may seek assistance.

3) The honeymoon phase: After the incident, the batterer may express remorse and redouble their efforts to refrain from violence and abuse. The victim may experience hope for change and forgive the batterer or rationalize their behavior. Except for a small percentage of the batterer population, the remorse is real. However, as evidenced by the cyclic nature of the problem, the batterer does not have the skills, impulse control, or perspective to prevent the cycle from recurring.

Why Victims Remain in Violent or Abusive Relationships or Don't Call the Police

There are numerous reasons that victims remain in these relationships. Each individual has a unique combination of reasons.

The reasons may include any of the following:

Positive Reasons



Practical Reasons and Disadvantages



Systems Problems



Abusive Interpersonal Reasons (May Result from Control Tactics)



Primitive or Less Rational Reasons, or impairment



Effects of IPV

Physical: The long term effects of IPV have not begun to be fully documented. Victims suffer physical and mental problems as a result of IPV. Battering is the single major cause of injury to women, more significant that auto accidents, rapes, or muggings. (O'Reilly, 1983) Many of the physical injuries sustained by women seem to cause medical difficulties as women grow older. Arthritis, hypertension and heart disease have been identified by battered women as directly caused by aggravated by IPV early in their adult lives. (Corrao, 1985)

Psychoemotional: The emotional and psychological abuse inflicted by batterers may be more costly to treat in the short-run than physical injury. (Straus, 1987) Psychological abuse has been shown to produce more severe depression and anxiety symptoms than physical abuse. (Erika, Jeungeun, Amie, & Eunyoe, 2008) According to surveys, IPV victims usually find it more difficult to recover from psychological abuse than from physical abuse. Research has shown that male and female victims reporting economic abuse, threats, intimidation, emotional abuse and isolation behaviors from their partners have more serious mental health problems such as depression, anxiety, hostility, and somatic symptoms, than those who report physical abuse. (Lawrence, et al., 2009)

Abusers who exert high levels of psychological abuse and control, as well as physical abuse, are known as "intimate terrorists." This term was coined by researcher Michael P. Johnson.

Until recently, instruments intended to measure psychological abuse were designed around women's concerns. The Controlling and Abusive Tactics Questionnaire (CAT) has been developed to capture psychologically abusive and controlling behaviors of both men and women. The instrument does not address the context of the violence or extent of injuries. Research with this instrument is showing very similar percentages and forms of aggression and abuse in men and women.

Practical: Victims may lose their jobs because of absenteeism resulting from illness, bruises, or court appearances. Battered persons may have to move repeatedly in cases of stalking. Battered persons may lose family and friends because of stigma, control tactics by the abuser, or self isolation as a result of shame. Smaller communities, cultural subgroups, or some religious groups may have dynamics that exact a toll through stress or loss of social support. Some religious groups do not allow divorce. In smaller groups, people may side with the abuser because of disbelief or personal gain.

Divorce proceedings and separation may pose a significant financial cost or eliminate financial security. However, the victim may see this as a necessary cost of escape. (Kurz & Coghey, 1989) As a result they may be impoverished as they grow older. (Marshall & Sisson, 1987)

Effects on Children

The anxiety and trauma associated with witnessing or overhearing violence may affect children in a variety of ways. Particularly where IPV is recurrent or associated with other problems such as alcohol abuse, children may have school problems, experience developmental regression, and various Axis I symptoms.

Victim denial may include the belief that the children are not aware of IPV or abuse, but this is unlikely to be true.

Exposure to IPV may be considered sufficiently abusive to warrant temporary removal.

Treatment of children may need to address a variety of problems. Family therapy may be appropriate when there is adequate stabilization of parents and child.

Parents may need to fulfill court requirements in order to regain the children, and these requirements must be fulfilled within a period of time set by the court, otherwise, parental rights may be loss. Addiction and other problems may challenge parents in regaining custody. Referral to a birth parent association may help them get additional services and training.

Mobilizing any extended family or social networks may greatly improve the security and anxiety levels of children. There may be additional mental health services through the school.

Well Being and Treatment of Children

The safety and well-being of children is directly related to the safety and well-being of the non-abusive parent. We need to challenge the widely held assumption that the non-abusive parent in a IPV situation should be held accountable for the actions of the abuser. The practice of blaming women who are victims of IPV for batterers' violence against them and their children belies the fact that most battered women care deeply about their children's safety and work hard to protect them both from physical assaults by a batterer and from the harm of poverty and isolation that may result from leaving or reporting a batterer.

Women's efforts to protect their children should be recognized and supported. Some existing IPV policies are inconsistent with this principle. For example, increasing penalties for perpetrating IPV in front of children may result in both parents being charged. Similarly, defining the commission of IPV in front of children as child abuse may discourage women from seeking help, may discourage providers from screening for IPV, and may place increasing demands on an already overburdened child protection system. IPV advocates/activists need to not only work directly with victims to improve their safety, but also need to work to change public policies that put mothers and children at risk (Groves, 2000).

Separation Violence

Some batterers become escalated when there are signs of or efforts to separate. There are several reasons for this. Batterers with poor mental health or serious attachment issues may regress and develop delusions or highly inflamed emotions. Highly antisocial batterers may use violence because it is how they get their way. Those with more complicated personality disorders may resort to stalking that may escalate to violence. The conscious interpretation of the batterer may be that they are being betrayed, that the separating partner is destroying the family, or other ideas that are experienced as justification for retaliation or attempts to control that unexpectedly escalate into violence. Violence or other dangerous acting out may become an issue during separation related events, even from partners who do not have a history of violence.

Diversity Issues

Cultural or Racial Issues

Although data is limited, it is likely that variations among racial groups in IPV primarily reflect socioeconomic issues and possibly cultural factors. Even cultural or national-origin subgroups of racial groups show variations in level and nature of IPV. Levels of alcohol use and enculturation into gang activity can be factors. A small cultural community, blaming attitudes, and mistrust of the police may impede help-seeking.

LGBT Issues

IPV has been shown to occur in non-heterosexual couples. Rates of IPV in same-gender relationships appear to be somewhat elevated, compared to the level in heterosexual couples, particularly in lesbian relationships. However, research is limited as of this writing. Because of potential stigma and side-taking within a small local LGBT community, and mistrust of authorities, there is increased risk of not seeking help. A call for help by a closeted individual would mean outing oneself. Threat of outing by a partner may inhibit seeking help. With higher cultural acceptance of violence against men or between men, people may be less mobilized by gay violence. When the larger or more aggressive-looking partner is abused, they are likely to face disbelief. An emotionally expressive male may be perceived as exaggerating the violence, abuse, or threat.

Treating Victims

Introduction

Treatment of IPV victims may occur as part of a domestic violence program when conjoint work is allowed and indicated. Otherwise, it is likely to take place through private therapists and various social agencies such as shelters that provide such services. It is very important that victims be treated by providers who have adequate training in domestic violence. As we have seen, there can be many changes in the victims perception of the abuser. There may be substance abuse, parenting and family issues, PTSD, borderline personality disorder, and numerous other problems. Long term abuse and codependence may have substantial long-term and developmental effects.

Boundaries

As we have discussed, there are many positive and negative reasons that victims return to their abusers. Therapists must carefully assess and have good contact with agencies involved so that missteps can be prevented. Therapists may become so charged with emotion that it becomes difficult to focus on clinical aspects over the drama of the decisions their client is making. Batterers may be highly manipulative in seeking out information regarding their partners, even long after separation and divorce. The agency must be cognizant of this and have measures in place.

Resources and Services

The therapist must ensure that their client is receiving adequate case management and consultation regarding community resources and practical steps needed to navigate the situation. Clients may need training in preparing to escape a violent relationship, in navigating the legal issues that are involved, and in acquiring the resources they need in order to gain independence if escape is an objective. Most communities have a variety of resources in these areas, such as Victim Witness programs.

The therapist should make sure that the client has a good understanding of the steps he or she will take. In many states, there are victim advocates available that can assist an individual in making a police report. This emotional and practical support can be tremendously valuable.

Barriers to utilization and access must be considered. For example, rural areas generally have substantial obstacles for victims:



Careful Assessment

Victims may have a variety of cognitive, neurological, orthopedic, and axis I problems that require treatment and other kinds of attention. The therapist must support the client in gaining needed care. Victims may have received head injuries that result in cognitive impairments. This can make efforts toward independence feel much more intimidating and even hopeless to the client. Adequate assessment and consultation regarding such problems provides the client with a map that can greatly reduce anxiety, and help to ensure that realistic plans are developed.

A full assessment must take place that is not limited to the problem of IPV or obviously related problems, and that does not assume that the client is a stereotypical victim. Substance abuse assessment must be included. The therapist must ensure that children are receiving appropriate services and treatment.

Complexities

Many victims enter their relationships with significant attachment problems or other emotional and mental health issues. This is because members of a couple select each other, in part, based on similar levels of functioning and needs. This can contribute a great deal to the volatility of relationships and explains why so much of IPV involves mutual combat. Long-term abuse may lead to complex PTSD. Any of these problems can be challenging to treat and requires specialized training. Many of the comments made about treatment of batterers below will also resonate to victims and mutual combatants.

Safety

Safety issues complicate treatment. The client, the children, and the therapist and agency staff may be targets of batterers. This is especially salient because batterers, particularly males, are most likely to escalate dramatically when separation is taking place or threatened. This is why escape plans, resources, and shelter locations are kept secret. TheAdvocacyCenter.org has a great deal of information on such matters, including detailed safety planning materials. Clients may be highly emotional when they escape or go for help after a violent incident. Having such materials and having mentally rehearsed the steps involved can greatly increase the client's ability to respond appropriately.

Treating Batterers

Introduction

Treatment of domestic violence takes the form of 1) domestic violence or batterer programs that are court-mandated (some of these programs allow voluntary participation as well), 2) private treatment programs or clinicians who are not necessarily bound by the court or by the regulatory requirements of the mandated programs. These are for individuals, couples, or families that enter treatment voluntarily. Clinicians should have specialized training in IPV because of the complexities and safety issues.

Typically, mandated programs have adhered to the Duluth model, which emphasizes the elimination of denial and the taking of responsibility by male batterers. Research on this model has not shown good outcomes. Research on emerging models, as of this writing, is not sufficient to draw solid conclusions. Unless the programs have sufficient funding to actually provide up-to-date treatment based on individualized assessment, the results of research on these programs will not really tell us about the potential of treatment for batterers.

Unless funding dramatically changes, the treatment needs of many batterers will continue to be underserved. As discussed earlier, individuals with complex PTSD and drug addiction may require a higher level of care such as an intensive outpatient program. Innovative courts may mandate such treatment in regions that set aside sufficient funding for innovative approaches, or may allow such treatment as an alternative to punishment, so long as the individual remains fully in compliance with the recommendations of the program.

Level of Care

Clinical assessment and treatment planning must determine: 1) the appropriate level of care, 2) the services required, 3) any referrals needed. Clients will require a broad range of levels of care, ranging from counseling to inpatient care. Court mandates may supercede clinical judgement. Clinicians must do their best to advocate for court orders that best support effective treatment and family preservation when appropriate.

PTSD

Post traumatic stress disorder (PTSD) greatly increases the risk of violent behavior. Research directly addressing the connection between PTSD and IPV is only beginning to take place. Early research is confirming the link. (Bell, & Orcutt, 2009). Clinical observation and treatment of IPV perpetrators and other aggressive individuals has stressed that this link exists. It appears that PTSD occurs at an elevated level in IPV perpetrators. Additional support for this concept comes from the very high rate of childhood trauma experienced by IPV perpetrators. IPV victims may experience PTSD as a result of fear induced by aggressive behavior and violence, and as a result of psychological abuse. Treatment for PTSD by clinicians trained in current, evidence-supported methods for PTSD must be available as part of treatment for IPV victims and perpetrators.

Complex PTSD

We are learning that complex PTSD may better resemble borderline personality disorder in some ways than it does simple PTSD. This means that treatment planning for persons with PTSD may be inappropriate for many individuals diagnosed with PTSD. It appears that anything less than multi-modal treatment will be considered inadequate for complex PTSD, particularly since there is a very high rate of substance abuse in this population, and alcohol abuse is very strongly associated with violence.

Cognitive Problems

There is an elevated rate of cognitive impairment in batterers. Such impairment can come from head injuries, small strokes, mental illness, and numerous other sources. Clinicians tend to overlook cognitive impairment and to have little, if any, training in responding to it. Clients with cognitive problems may need for interventions to be delivered in a manner that they can understand and in a manner that supports them in paying attention and feeling reinforced for participating. It should also ensure that they receive adequate assessment and consultation so that they can develop coping skills specifically for such impairment. Should the impairment rise to the level of a disability under the Americans with Disabilities Act, there may be additional assistance available such as accommodation and special classes that will help the individual succeed in college or vocational training.

Neurology and Mindfulness

Stress and mental disorders such as PTSD that can increase anger and impulsiveness are being shown in neurological research to be associated with brain and neuroendocrine dysregulation. For example, the regulation of the right prefrontal cortex by the left is diminished in people who experience hostility and negative moods. Mindfulness practices and interventions that support mindfulness skills are proving to improve mood and brain regulation.

Effective sleep is a key element of mental health and recovery from symptoms of PTSD. Evaluating for disordered sleep may be a life-saving move. Simply asking clients if they feel sleepy during the day and if they feel rested upon awakening will help determine if there may be a sleep problem. PTSD is associated with disordered sleep. Effective treatment of PTSD has shown to restore brain function and sleep.

Cognitive Behavioral Strategies

Cognitive behavioral therapy is a component of treatment for PTSD, IPV, and numerous other problems. The clinician must take care not to expect a narrow focus on cognitions to adequately treat most IPV clients. Thus far, research on programs using CBT-based approaches are showing substantial improvement in recidivism rates over earlier approaches.

Somatically Enhanced Therapy

Therapy influenced by body mind psychology can enhance PTSD recovery and expedite cognitive therapy. EMDR and body mind psychotherapy methods can be incorporated when appropriate. For clients who are dissociative or subject to chronic traumatic conditions, there may be a great deal of work necessary before such work is indicated, because of the potential for destabilization. Therapists trained in these modalities are also trained to assess for appropriateness. The initial work is likely to emphasize affect regulation and self care in such cases. Dialectical behavior therapy (DBT) may be highly valuable here.

Fundamental Resources and Multi-Problem Situations

The clinician should be familiar with community resources needed by multi-problem individuals and families. Any intervention or referral that can reduce stress on clients and their families can help to prevent violence and improve their ability to participate in treatment.

Conjoint and Family Treatment

Where safety issues do not contraindicate it, conjoint and family treatment can be a very important aspect of IPV treatment. IPV does not occur in a vacuum. There has been concern that attention to the interactional nature of IPV may reduce the responsibility for IPV on the primary perpetrator. This perspective presupposes that the clinician is unable to establish a sufficient working relationship with violent individuals to get them to take responsibility for appropriate participation in therapy. While there is a subpopulation of persons with severe personality disorders who will not participate in a sincere way, the response to this is to attempt to assess for and respond to such situations, rather than entertain the prejudice that all violent individuals are unwilling to alter their behavior. Clinicians using these modalities must have appropriate training.

Programs and Manualized Treatment

Various clinical populations are being treated, in part, through class-like group experiences. Linehan's dialectical behavior therapy approach has been modified for use with people recovering from severe mental illness and other problems. Some programs are beginning to work with this modality as a key element in IPV programs and treatment for batterers. Characteristics that distinguishes this from the Duluth approach is a stronger focus on skills for affect regulation, and a more positive approach to the batterers. This approach is believed to be particularly helpful for clients with complex PTSD and borderline personality disorder.

Coping with Authority and Systems

Clients may have highly dysfunctional responses to authorities and to staff of social agencies. There should be a strong focus on assisting clients in understanding the motives and objectives of these parties, and to refocus toward self-affirming goals.

Antisocial Personality Disorder

Antisocial clients can be treated, but care must be taken to distinguish them from clients who have a greater capacity for empathy and aspirations toward alignment with higher values. Many psychotherapy interventions are contraindicated for highly antisocial clients (psychopaths), because they use them to become more effective in manipulating others in criminal or sadistic ways. By taking a very non-confrontive and accepting approach initially, despite contradictory and unacceptable statements from the client, the therapist can gather information that helps to assess for antisocial personality disorder and psychopathy. However, if there is much history (particularly criminal history) available, it may already be fairly obvious. Treatment objectives for moderately antisocial clients can include ways to manage themselves so that they can successfully work their way through the requirements of the justice system. Co-occurring disorders are highly likely and can be treated. Safety issues for the therapist must be considered. Many antisocial clients are quite immature in attitudes and relationship skills. It is not possible to reliably predict who among the moderately antisocial clients will benefit from psychotherapy. However longer-term therapy is needed for such serious deficits in maturity.

Legal and Ethical Issues

Reporting

Generally speaking, there is no mandated reporting for IPV. Exceptions include abuse of children, people with certain disabilities, and the elderly, as well as credible threats that impose a Tarasoff condition. State laws are likely to specify a violent environment as causing emotional abuse that rises to the level of a mandated reporting situation. Programs contracted with the justice system have mandating responsibilities, but this is distinct from the mandated reporter issues. Staff are trained in these contractual issues by the appropriate agencies. If there is any doubt as to applicable laws or civil liability in your state, it is very important to consult an attorney through your national or state organization or your malpractice carrier.

Responsibilities to Referrers

Contracted domestic violence programs have various responsibilities to the referring agency. Clinicians will be oriented to the relevant policies before providing services. Of course, clients will release the program to release information because full participation and release of information will be part of their court ordered participation in the program. Termination of the release will constitute non-compliance with the program. This puts the onus on the justice system to determine what to do next.

The program depends for referrals upon the trust of the referring agency and the courts. This means that staff and clinicians of the program must adhere carefully to the contract and in a timely manner.

Safety and Clinical Decision Making

It is not possible to reliably predict dangerous behavior, but clinicians bear the responsibility to make informed decisions that support the safety of their clients, their clients' partners, and the community. One upshot of this is that IPV treatment providers establish detailed guidelines regarding safety issues. Such policies affect matters such as approval for conjoint counseling.

Appendix A: John Hamel's Annotated Citations on Gender in IPV

The following citations were listed and annotated by John Hamel, LCSW. They provide information on the proportions of males and females reporting various forms of interpersonal abuse and violence, including non-physical abuse and control.

The general conclusion is that representative samples from the general population studies or dating surveys in which males and females are asked the same questions, comparable rates of battering, intimate terrorism, control, and emotional abuse are found among men and women, with the following exceptions: According to Hamel, women suffer injuries at a twice the rate of men, men perpetrate far more rapes, and are more likely to engage in physical, confrontive forms of stalking, while women are more likely to make unwanted phone calls, spread malicious rumors and other less confrontive forms of stalking or harassment. College men surveyed indicated that they were exposed to surprising levels of sexual coercion by females. Of particular interest regarding non-physical abuse and control, according to Hamel, are the studies by Laroche and Graham-Kevan's that analyse the Canadian GSS, the data from New Zealand, and especially Felson's analysis of the National Violence Against Women Survey.

Straus et al. (1980); Straus & Gelles (1990). Both National Family Violence Surveys, with a combined sample of more than 8,000 respondents, reported comparable gender rates for not only physical assaults, but verbal abuse as well.

Rouse, Breen and Howell (1988). This survey of 130 dating and 130 married students found that women are more likely than men to engage in isolation behaviors, such as "monitors time," "discourages same-sex friends" and "discourages opposite sex friends."

Stets (1991). The male and female respondents in this study of dating students reported equivalent rates of controlling behaviors (e.g., "I keep my partner in line," "I am successful in imposing my will onto my partner"), as well as psychological abuse (e.g., "Said mean things," "Degraded him/her").

Kasian & Painter (1992). The authors surveyed a large sample (1,625) university students. Male respondents reported higher rates of received abuse, as measured by a modified version of the Psychological Maltreatment of Women Inventory, for control, jealousy/isolation, verbal abuse and withdrawal of affection. There were no gender differences in rates of received emotional abuse ("diminishment of self-esteem").

Feder and Henning (2005). In this study of 317 couples dually arrested for IPV, most of them African-American, criminal justice data revealed no differences between the partners in injuries inflicted or weapons use. Interview data revealed no differences in physical assault; women were more likely to use a weapon, but to suffer slightly higher rates of injuries (19.6% vs. 15.0%). There were no gender differences in overall psychological abuse or coercive control tactics.

Stacey, Hazelwood and Shupe (1994). Higher rates of victimization than perpetration were reported by the male subjects in this Texas study of men in batterer treatment on four of the thirteen items from the CSR Abuse Index: "deny rights to privacy," "deny access to family," "withdraw emotions to punish," and "withhold sex to punish." Although the men reported lower rates of victimization than females on the other items, the differences were usually not large (e.g., "deny freedom of activities" was cited by 71% of men and 72% of women; "deny access to friends" was cited by 57% of men and 63% of women, and "censor phone calls" was reported by 53% of men and 60% of women.) One would have expected much larger differences from this population, considering that the men had been arrested and deemed "batterers," while their female partners were deemed the "victims."

Tjaden & Thoennes (2000). The National Violence Against Women Survey (NVAWS), drawing on a sample of 16,000 men and women, reported that 0.2% of men are stalked each year by a current or former intimate, and 0.5% of women, a ratio of 2.5 women for each man victimized. In addition, .038% of the men reported to having been raped the previous year. Five times as many women (0.2%) said that this had happened to them.

Spitzberg and Rhea (1999). The authors examined a variety of stalking subtypes, collectively known as obsessive relational intrusion (ORI). Results from their sample of college students in Texas revealed a 54% rate of male-perpetrated ORI's, versus 46% for females.

Langhinrichsen-Rohling, Palarea, Cohen & Rohling (2000). In this college survey, respondents were asked to report on their own ORI behavior, as well as incidents of victimization. There were no overall gender differences in stalking rates. However, men made more unwanted visits to homes and apartments, whereas women left the greater share of unwanted phone messages. Women were also four times as likely to report having been physically threatened.

Meloy & Boyd (2003). The authors reported on 82 female cases from mental health clinics and some who came to the attention of law enforcement. The women were similar to male stalkers in having a history of failed intimate relationships and having cluster "B" DSM IV personality disorders (not antisocial). They were also similar in that 50% - 75% threatened and 50% - 55% assaulted their victim. But they were different in that they more often carried out threats and caused property damage.

Busby & Compton (1997). A large survey of 3,034 engaged couples reported that 6.1% men and 13.0% women had been sexually pressured by their partner.

O'Sullivan et al. (1998). In this survey of 433 dating university students, 18.5% of the men and 42.5% of women reported to having been sexually coerced by their partner.

Muehlenhard and Cook (1988). This college study revealed that men more often than women engaged in unwanted sexual intercourse, at rates of 63% versus 46%. Being taken advantage of when intoxicated was reported by 30.8% of the men, and 21.0% of the women. Among the men, 13.4% had been verbally coerced, and 11.5% of the women said that this had happened to them. The rates were 5.7% for men subjected to nonviolent coercion (e.g., blocking the door, holding the person down), compared with 5.4% for the women. Coercion involving physical assaults was experienced by 1.4% of the men and 2.7% of the women.

Waldner-Haugrud and Magruder (1995). The authors asked a dating population about a range of coercive sexual behaviors. In the previous year, the men had an average of 2.26 incidents perpetrated upon them, and the women 2.86. Persistent touching was reported by 51% of males and 70% of females. Men were twice as likely to report blackmail (8.5% versus 4.2%); women reported a higher incidence of manipulative guilt (30.1% versus 22.5%). The women were twice as likely as men to be restrained or detained, and more threatened with physical force (6.9% to 6.0%); but three times more men had weapons used against them (4.5% versus 1.4%).

Coker, Davis, Arias, Desai, Sanderson, Brandt and Smith (2002). A re-examination of data of 16,000 respondents from the National Violence Against Women Survey found lifetime male victimization rates of 10.5% for experienced verbal abuse and jealousy/possessiveness, and 6.8% for power/control, compared to rates of 5.2% and 6.9% for women.

Riggs, O'Leary and Breslin (1990). Found a strong correlation between having a dominant and aggressive personality and IPV for both men and women.

Cano, Avery-Leaf, Cascardi and O'Leary (1998). Found a significant correlation in high school dating study for boys and girls between the use of jealousy and dominance tactics and physical assaults.

Hines & Saudino (2003). Using the Revised Conflict Tactics Scale, this survey of 481 university students found comparable levels of physical aggression between the genders. Women were found to have engaged in higher levels of psychological aggression, and the two types of abuse tended to co-exist.

Graham-Kevan & Archer (2005). Drawing upon a community sample of university students and faculty in Lancashire, England, the authors found rates of 13% for female intimate terrorists and 9% for male intimate terrorists, based upon the same criteria as used by Michael Johnson (a combination of physical violence, control, and psychological abuse).

Laroche (2005), and Graham-Kevan (2007). Laroche analyzed a massive Canadian study, the 1999 GSS, involving 25,876 respondents. Respondents were asked about their victimization by a current or previous spouse in the past 5 years. In addition to questions on physical assaults, the survey also asked respondents about victimization from the following psychologically abusive and controlling behaviors by their partner, similar to those in the Duluth Power and Control Wheel: "Limits your contact with family or friends," "puts you down or calls you names to make you feel bad," "is jealous and doesn't want you to talk to other men/women," "harms or threatens to harm someone close to you," "demands to know who you are with and where you are at all times," "damages or destroys your possessions or property," and "prevents you from knowing about or having access to the family income, even if you ask." For the five year period prior to the study, approximately 3% of the surveyed women, and 2% of the men, were counted as victims of severe intimate terrorism (IT) - defined as having experienced severe and frequent physical violence and high levels of psychological abuse and control, and who would fit Ehrensaft et al.'s "clinical abuse cases" from injuries sustained, fear expressed, and use of police and other services. Graham-Kevan analyzed the results of the same survey, except that she focused on abuse reported for the past year only, and found very comparable rates of intimate terrorism between the genders. This is a remarkable finding, considering the study's methodology (akin to the NVAWS in that its questionnaire framed IPV in terms of personal safety rather than conflict, thus suppressing male victimization rates) and "the inadequate assessment of controlling behaviors suffered by men" (Laroche, 2005, p. 11).

Felson & Outlaw (2007). An analysis of data originally obtained through the NVAWS with a sample of over 15,000 currently married or formerly married adults found that: (1) women are just as controlling and jealous towards their male partners as other way around; (2) the relationship between use of control/jealousy and physical violence exists equally for both male and female respondents; (3) "Intimate terrorists" can be either male or female. (Controlling/jealous behaviors defined as: "Prevents you from knowing about or having access to family income even when you ask"; "Prevents you from working outside the home"; "Insists on knowing who you are with at all times"; "Insists on changing residences even when you don't want or need to"; "Tries to limit your contact with family and friends.") Regarding the extent to which men and women engage in "intimate terrorism," the authors write: "Both husbands and wives who are controlling are more likely to produce injury and engage in repeated violence. Similar effects are observed for jealousy, although not all are statistically significant. The seriousness of the violence is apparently associated with motive, although the relationship does not depend on gender" (p. 404). It should be pointed out that the National Violence Against Women Survey was designed, conducted and analyzed by feminist researchers, who sought to prove that violence against female intimate partners is much more serious than violence against male intimate partners.

Straus (2006). 7.6 % of the male respondents and 10.6% of the female respondents interviewed in the International Dating Violence Survey (sample of 13,601 university students in 32 countries) reported having perpetrated severe assaults, and both partners were found to be violent in 68.6% of the cases. Based on 9 items related to dominance on the PRP (e.g., "my partner needs to remember that I am in charge"), the survey found overall dominance scores to be equal across gender, although higher dominance scores were found for women in 24 of 32 countries. It was also found that dominance by either partner increases the probability of severe violence, and that dominance by females increases risk of severe female-only or mutual IPV more than does male dominance.

Appendix B: Handouts for Teens
Teen Dating Violence

Do any of these items describe the person you're dating?

• Is jealous and possessive, won't let you have friends, checks up on you, and won't accept breaking up?
• Tries to control you by being bossy, giving orders, making all the decisions, not taking your opinions seriously?
• Puts you down in front of friends, tells you that you would be nothing without him or her?
• Scares you? Makes you worry about reactions to things you say or do? Threatens you? Uses or owns weapons?
• Is violent? Has a history of fighting, loses temper quickly, and brags about mistreating others? Grabs, pushes, shoves, or hits you?
• Pressures you for sex or is forceful or scary about sex? Gets too serious about the relationship too fast?
• Abuses alcohol or other drugs and pressures you to take them?
• Has a history of failed relationships and blames the other person for all the problems?
• Makes your family and friends uneasy and concerned for your safety? If you answered "yes" to any of these questions your client could be the victim of dating abuse. Dating violence or abuse affects one in ten teen couples. Abuse isn't just hitting, it's yelling, threatening, name-calling, saying I'll kill myself if you leave me, obsessive phone calling, and extreme possessiveness.

Planning to Separate

• Tell your parents, a friend, a counselor, a clergyman, or someone else whom you trust and who can help. The more isolated you are from friends and family, the more control the abuser has over you.
• Alert the school counselor or security officer.
• Keep a daily log of the abuse.
• Do not meet your partner alone. Do not let him or her in your home or car when you are alone.
• Avoid being alone at school, your job, on the way to and from places.
• Tell someone where you are going and when you plan to be back.
• Plan and rehearse what you would do if your partner became abusive. Most teens talk to other teens about their problems. If a friend tells you he or she is being victimized, here are some suggestions on how you can help.
• If you notice a friend is in an abusive relationship, don't ignore signs of abuse. Talk to your friend.
• Express your concerns. Tell your friend you're worried. Support, don't judge.
• Point out your friend's strengths - many people in abusive relationships are no longer capable of seeing their own abilities and gifts.
• Encourage them to confide in a trusted adult. Talk to a trusted adult if you believe the situation is getting worse. Offer to go with them for help.
• Never put yourself in a dangerous situation with the victim's partner. Don't be a mediator.
• Call the police if you witness an assault. Tell an adult - a school principal, parent, guidance counselor.

Citations

Abbot, J. et al. (1995). Domestic Violence Against Women: Incidence and Prevalence in Emergency Department Population. Journal of the American Medical Association, 273, 1763-1767.

Bachman, R. (1992). Death and Violence on the Reservation: Homicide, Family Violence, and Suicide in American Indian Populations. CT: Auburn House.

Bell, K. M. and Orcutt, H. K (2009). Posttraumatic Stress Disorder and Male-Perpetrated Intimate Partner Violence. Journal of the American Medical Association, 302(5).

Bowker, L.H. (1988). On the relationship between wife beating and child abuse. In K. Yllo & M. Bograd (Eds.), Feminist Perspectives on Wife Abuse. Newbury Park, CA: Sage Publications.

Bureau of Justice Statistics (2000). Criminal Victimization in the United States, 1995, Chapter 2. Washington, D.C.: U.S. Department of Justice.

Cohen RA, Rosenbaum A, Kane RL, Warnken WJ, Benjamin S. (1999). Neuropsychological correlates of domestic violence. Violence Vict., 14(4):397-411.

The Commonwealth Fund (1999). Health Concerns Across a Woman's Lifespan: The Commonwealth Fund 1998 Survey of Women's Health.

CDC, 1998. Intimate Partner Violence. Retrieved from http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/definitions.html.

Council on Scientific Affairs (1997). Elder Abuse and Neglect, Journal of the American Medical Association, 257, 966-971. Delaware Health and Social Services, Division of Services for Aging and Adults with Physical Disabilities, Adult Protective Services Program and Long-Term Care Ombudsman Program.

Dobash, R.E. and Dobash, R.P. (1979). Violence Against Wives, New York: Free Press.

Dutton, D. (2007). Rethinking Domestic Violence. UBC Press.

Dutton, D. (1988). The Domestic Assault of Women, Boston: Allyn and Bacon.

Dugan, L., Domestic violence legislation: Exploring its impact on the likelihood of domestic violence, police involvement, and arrest, Criminology & Public Policy, 2, 2, p. 283-309, 2003.

Erika, L., Jeungeun, Y., Amie, L., & Eunyoe, R. 2008. Is Psychological Aggression as Detrimental as Physical Aggression? The Independent Effects of Psychological Aggression on Depression and Anxiety Symptoms. Violence and Victims, 24(1); 20-35.

Family Violence Prevention Fund (2000). Children and Domestic Violence, www.fvpt.org/kids/index.html.

Family Violence Prevention Fund (1999). Preventing Domestic Violence: Clinical Guidelines on Routine Screening.

Felson, R. B., Outlaw, M. C. 2007. The control motive and marital violence. Violence and Victims. 22(4): 387-407.

Feldhaus, K. et al. (1997). Accuracy of Three Brief Screening Questions for Detecting Partner Violence in the Emergency Department, Journal of the American Medical Association, 227: 1357-1361.

Frieze, I.H. & Browne, A. (1989). Violence in marriage. In L. Ohlin & M. Tonry (Eds.), Family Violence, Chicago: University of Chicago Press.

Gaquin, D. A., Spouse abuse: Data from the National Crime Survey, Victimology, 2, p. 632-643, 1977-78.

Graham-Bermann, S.A. (in press). Designing interventions for children exposed to adult domestic violence: Applications of research and theory. In S. Graham-Bermann & J. Edleson, (Eds.) Intimate Violence in the Lives of Children: The Future of Research, Intervention, and Social Policy. Washington, D.C: APA Books.

Graham-Kevan, N. (2007). Power and Control in Relationship Aggression, In John Hamel and Tonia L. Nicholls, Ed., Family Interventions in Domestic Violence. New York, USA: Springer Publishing Company. Pp. 87-107.

Groves, B.M. (2000). Children who Witness Violence: The Hidden Victims. NCJFCJ 8.

Groves, B.M. (1999). Mental health services for children who witness domestic violence. The Future of Children, 9(3), 122-132.

Groves, B.M. & Zuckerman, B. (1997). Interventions with parents and caregivers of children who are exposed to violence. In J. Osofsky et al. (Eds). Children in a Violent Society. New York: The Guilford Press.

Grusznski, R.J., Brink, J.C., & Edleson, J.L., (1988). Support and education groups for children of battered women. Child Welfare, 67(5), 431-444.

Hamel, J. (2009). Toward a Gender-Inclusive Conception of Intimate Partner Violence, Research and Theory: Part 2. New Directions. International Journal of Men's Health, 8(1), 41-59.

Hamel, J. (2007). Toward a gender-inclusive conception of intimate partner violence research and theory: Part I. Traditional perspectives. International Journal of Men's Health, 6(1), 36-53.

Hare, R. D. (1996). Psychopathy and antisocial personality disorder: A case of diagnostic confusion. Psychiatric Times, 13(2).

Hines, D. A. (2008). Borderline personality traits and intimate partner aggression: An International multi-site, cross-gender analysis. Psychology of Women Quarterly, 32(3), 290-302.

Hughes, H. & Luke, D.A. (1998). Heterogeneity in adjustment among children of battered women. In G.W. Holden, R Geffner, & E.N. Jouriles (Eds.), Children exposed to marital violence: Theory, Research and Applied Issues. Washington, D.C: APA Books.

Jacobson, W. (2000). Safe from the Start: Taking Action on Children Exposed to Violence. U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention.

Jaffe, P., Wilson, S.K., & Wolfe, D. (1986). Promoting changes in attitudes and understanding of conflict resolution among child witnesses of family violence. Canadian Journal of Behavioral Science. 4(18), 356-366.

Jaffe, P., Wolfe, D., & Wilson, S.K. (1990). Children of Battered Women. Newbury Park, CA: Sage.

Jaffe, P., Wolfe, D., Wilson, S.K., & Zak, L. (1986). Similarities in behavioral and social maladjustment among child victims and witnesses to family violence. American Journal of Orthopsychiatry, 56, 142-146.

Jouriles, E.N., McDonald, R., Stephens, N., Norwood, W., Spiller, L.C., & Ware, H.S. (1998). Breaking the cycle of violence: Helping families departing from battered women's shelters. In G.W. Holden, R Geffner, & E.N. Jouriles (Eds.), Children exposed to marital violence: Theory, Research and Applied Issues. Washington, D.C: APA Books.

Kaufman Kantor, G., Jasinski, J. L., Aldarondo, E. (1994). Sociocultural status and incidence of marital violence in Hispanic families. Violence and Victims, 9(3), 207-222.

Krugman, R. (1992). American Medical News, American Medical Association: January.

Kurst-Swanger, K. and Petcosky, J. L. (2003) Violence in the home: multidisciplinary perspectives. Oxford University Press.

Lawrence, et al. (2009). Is psychological aggression as detrimental as physical aggression. Violence and Victims, 24(1), 20-35.

Leonard, E. D. (2002). Convicted Survivors: The Imprisonment of Battered Women Who Kill. State University of New York Press.

Marrujo, B., and Kreger, M. (1996) Definition of roles in abusive lesbian relationships, in Renzetti, C. M. and Miley, C. H. (1996) Violence in gay and lesbian domestic partnerships. Routledge.

Mechem, C. C., Shofer, S.S. Reinhard, S. S., Hornig, S., and Datner, E. (1999). History of domestic violence among male patients presenting to an urban emergency department. Academic Emergency Medicine, 6, 786-91.

Muelleman, R. L. et al. (1998). How Often Do Women in the Emergency Department Without Intimate Violence Injuries Return with Such Injuries, Academic Emergency Medicine, 5: 982-985.

Malchiodi, Cathy A. (1997). Breaking the silence: Art therapy with children from violent homes. Bristol, PA: Brunner/Mazel, Inc.

Margolin, G. (1998). Effects of domestic violence on children. In P.K. Trickett & C.J. Shellenbach (Eds.) Violent Children in the Family and in the Community, Washington, D.C: APA Books.

McCloskey, L.A., Figueredo, A.J., & Koss, M.P. (1995). The effects of systemic family violence on children's mental health. Child Development, 66, 1239-1261.

Merchant, M. (2000). A comparative study of agencies assisting domestic violence victims: Does the South Asian community have special needs? Journal of Social Distress and the Homeless, 9, 249-259.

Mills, L. (2003). Insult to injury: Rethinking our responses to intimate abuse. Princeton, N.J.: Princeton University Press.

Muelleman, R.L.(1998). Non-Battering Presentations to the ED of Women in Physically Abusive Relationships, American Journal of Emergency Medicine 16 (2): 128-131.

Osofsky, J.D. (1995). Children who witness domestic violence: The invisible victims. Social Policy Report: Society for Research in Child Development. 9(3), 1-16.

Peled, E. & Edleson, J. (1995). Process and outcome in small groups for children of battered women. In E. Peled, P. Jaffe, & J. Edleson (Eds.), Ending the cycle of violence: Community Responses to Children of Battered Women, Thousand Oaks, CA: Sage Publications.

Pepler, D.J, Catallo, R. & Moore, T.E. (2000). Consider the children: Research informing interventions for children exposed to domestic violence. In R. Geffner, P. Jaffe, & M. Sudermann (Eds.), Children Exposed to Domestic Violence: Current Issues in Research, Intervention, Prevention, and Policy Development. Haworth Press, Inc: New York.

Perilla, J. L., Bakeman, R. & Norris, F. H. (1994). Culture and domestic violence: The ecology of Abused Latinas. Violence and victims, 9 (4), 325-339.

Puzone, C.A., Saltzman, L., Kresnow, M., Thompson, M., Mercy, J. (2000). National trends in intimate partner homicide: United States, 1976-1995. Violence Against Women, 6, 409-426.

Rand, M. R. (1997). Violence-Related Injuries Treated in Hospital Emergency Departments, U.S. Department of Justice, Bureau of Justice Statistics.

Rennison, C. M. (2001). Violent Victimization and race, 1993-98, NCJ 176354. Washington, D. C.: U. S. Department of Justice Bureau of Justice Statistics.

Rennison, C. M. & Welchans, S. (2000). Intimate Partner Violence Special Report, NCJ 178247. Washington, D. C.: U. S. Department of Justice.

Rimonte, N. (1989). Domestic violence against Pacific Asians In Asian Women. United of California (Eds.) Making Waves (pp. 327-337). Boston: Beacon.

Roberts, A. R. (2002). Handbook of domestic violence intervention strategies: policies, programs, and legal remedies. Oxford University Press.

Rodriguez, M.A. et al. (1999). Screening and Intervention for Intimate Partner Abuse. Journal of the American Medical Association, 282: 468-474.

Sanders, A. B., (1996). Emergency Care of the Elder Person. St. Louis, Mo.: Beverly Cracom Publications.

Schechter, Susan (1987). Guidelines for Mental Health Professionals, National Coalition Against Domestic Violence.

Schewe, P.A. (in press). Preventing Intimate Partner Violence: Developmentally Appropriate Interventions Across the Life Span. Washington, DC: APA Books.

Schoenwald, S.K., Brown, T.L., & Henggeler, S.W. (2000). Inside multisystemic therapy: Therapist, supervisory, and program practices. Journal of Emotional & Behavioral Disorders, 8(2), 113-127.

Silvern, L., Karyl J., & Landis, T. (1995). Individual psychotherapy for the traumatized children of abused women. In E. Peled, P. Jaffe, & J. Edleson (Eds.), Ending the cycle of violence: Community Responses to Children of Battered Women, Thousand Oaks, CA: Sage Publications.

Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2002.

Song, Y. I. (1986). Battered Korean Women in Urban America. The Relationship of Cultural Conflict to Wife Abuse. Unpublished Doctoral Dissertation, Department of Psychiatry, Ohio State University. Columbus, Ohio.

Statistical Abstracts of the United States, 1997.

Straus, M. A. (2008). Prevalence and Effects of mutuality in physical and psychological aggression against dating partners by university students in 32 Nations. Paper presented at the International Family Aggression Society Conference, UK: University of Central Lancashire.

Straus, M.A & Gelles, R.J. (1990). How violent are American families? Estimates from the National Violence Survey and other studies. In M.A. Straus & R.J. Gelles (Eds.), Physical Violence in American Families, New Brunswick, NJ: Transaction.

Sugg, N. and Inui, T. (1992). Primary Care Physicians' Response to Domestic Violence: Opening Pandora's Box. Journal of the American Medical Association, 267, 3157-3160.

Teichner G, Golden CJ, Van Hasselt VB, Peterson A. 2001. Int J Neuroscience. 111(3-4):241-53.

Tjaden P, Thoennes N. Stalking in America: Findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 1998. Publication No. NCJ 169592.

Torres, S., Campbell, J., Campbell, D., Ryan, J., King, C., Price, P., Stallings, R., Fuchs, S., & Laude, M. (2000). Abuse during and before pregnancy prevalence and cultural correlates. Violence and Victims, 15, 303-321.

Tjaden, P. & Thoennes, N. (2000). Full report of the prevalence, incidence and consequences of violence against women: Findings from the National Violence Against Women Survey (Publication 183781). Washington, D. C.: National Center Justice.

United States Department of Justice. (n.d.). Rural domestic violence and child victimization enforcement grant. From: http://www.usdoj.gov/ovw/rural_grant_desc.htm

Wagar, J.M. & Rodway, M.R. (1995). An evaluation of a group treatment approach for children who have witnessed wife abuse. Journal of Family Violence, 10(3), 295-306.

Walker, Lenore (1979). The Battered Woman, New York: Harper Collins.

Walker, Lydia. (1989). Presentation. Tennessee Task Force on Domestic Violence Conference, January.

Wilson, S.K., Cameron, S., Jaffe, P., & Wolfe, D. (1989). Children exposed to wife abuse: An intervention model. Social Casework: The Journal of Contemporary Social Work. March, 180-184.

Wolak, J. & Finkelhor, D. (1998). Children exposed to partner violence. In J.L. Jasinski & L. Williams (Eds.) Partner Violence: A Comprehensive Review of 20 Years of Research. Thousand Oaks, CA: Sage.

CLOSE [X]

CLOSE [X]

CLOSE [X]