Women, Domestic Violence, and Posttraumatic Stress Disorder (PTSD)*

Women, Domestic Violence, and Posttraumatic Stress
Disorder (PTSD)*

by


Margaret J. Hughes & Loring Jones


Department of Health and Human Services
School of Social Work
5500 Campanile Drive
San Diego State University
San Diego, CA 92182
Tel: (619) 594-6360

email: mhughes2@mail.sdsu.edu

January 2000






This report was produced with the help of a 1999 contract from the California State University Faculty
Research Fellows Program for the California Governor’s Office of Planning and Research. This program
is under the direction of Professor Robert Wassmer, Center for California Studies, California State
University at Sacramento. Visit our web page at http://www.csus.edu/indiv/w/wassmerr/facfelou.htm .
Kurt Schuppara and Lynelle Jolley, of the California Governor’s Office of Planning and Research, were
instrumental in the formulation of this report.






* We would like to thank Coretta Hazelton and Uri Unsterstaller (Graduate Assistants from the School of
Social Work) for their work in database searches and literature reviews; Teresa Grame (Graduate
Assistant from the School of Social Work) for her work in database searches, literature reviews, survey
mailings and phone contacts, and data processing. We would also like to thank those California Directors
of Mental Health Departments and their staff who took time out of their busy schedules to respond to our
questionnaire.

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TABLE OF CONTENTS

TABLES.......................................................................................................................................... 4
EXECUTIVE SUMMARY............................................................................................................. 5
POLICY AND PROGRAM RECOMMENDATIONS.................................................................. 6
SUMMARY OF EMPIRICAL GENERALIZATIONS FROM THE LITERATURE................. 7
SUMMARY OF ACTION GUIDELINES FOR INTERVENTION ............................................. 7
INTRODUCTION .......................................................................................................................... 9
RESEARCH QUESTIONS ADDRESSED BY THIS REPORT ..................................................10
METHODOLOGY ........................................................................................................................11
SYSTEMATIC RESEARCH SYNTHESIS ............................................................................................11
Steps in SRS .......................................................................................................................12
SRS Findings ......................................................................................................................13
Limitations of the Research.............................................................................................13
Empirical Generalizations ...............................................................................................15
Empirical Action Guidelines ...........................................................................................23
A General Statement about PTSD and Domestic Violence Intervention ...........................23
Macro Level Interventions ..............................................................................................23
Mezzo Level Interventions ..............................................................................................26
Micro Level Interventions ...............................................................................................27
Survey Findings ..................................................................................................................32
Limitations of the Survey ................................................................................................32
Recommendations for Mental Health Service Delivery Based Upon Survey: ...................33
Methodology...................................................................................................................33
Findings..........................................................................................................................34
Model Programs..............................................................................................................38
REFERENCES ..............................................................................................................................41
APPENDIX A ................................................................................................................................49
APPENDIX B.................................................................................................................................50
APPENDIX C ................................................................................................................................68







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LIST OF TABLES


Table 1: Additional Mental Health Problems in Victimized Women.................................................19

Table 2: Effect of Demographic Variables on Mental Health Symptoms Including PTSD.................21

Table 3: Mental Health Strategies Recommended in the Literature Reported Upon..........................29

Table 4: Domestic Violence Arrests, 1988-1998 .............................................................................31

Table 5: Cultural/Ethnic Diversity of Clients...................................................................................35

Table 6: Treatment Strategies Used by Programs ............................................................................36

Table 7: Effective Strategies for Treating PTSD Symptoms in Domestic Violence Victims ..............37


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EXECUTIVE SUMMARY

Domestic violence, if considered a disease, would be declared a national epidemic based on the
magnitude of its incidence. In the United States each year, intimate partners batter between two and four
million women of all ages, races and classes. Among women of different racial and ethnic backgrounds,
the difference in the prevalence of reported rape and physical assualt is statistically significant.

Posttraumatic Stress Disorder (PTSD)1 has been diagnosed most commonly in rape, child sexual
abuse, and war victims. More recently, studies have found battered women meet the criteria for PTSD.
The severity of the violence, the duration of exposure, early-age onset, and the victim’s cognitive
assessment of the violence (perceived degree of threat, predictability, and controllability) exacerbate the
symptoms.

The project had multiple objectives. The first was to compile and analyze data from professional
literature that was based on studies of battered women to determine (a) the correlation of domestic
violence and PTSD, (b) the best treatment strategies for PTSD, and (c) the evidence of PTSD treatment
effectiveness with battered women. The project used Systematic Research Synthesis (SRS), a meta-
analysis process, to analyze data collected from the most current literature on domestic violence and its
correlation with PTSD. A second objective was to determine what we know about the number of women
experiencing domestic violence in the State of California and what happens to these women in the
aftermath of their experience. A survey sent to all 58 Directors of County Mental Health Departments was
used to compile data about these women. A third objective was to identify model programs in the State of
California. The questionnaires to County Directors and information gathered from programs throughout
California were used to meet this objective. Lastly, the policy and program implications of the study were
concluded.

Analysis of reliable studies from the literature and survey results produced several important findings:
(a) symptoms of battered women are consistent with PTSD symptoms, (b) certain populations are at
higher risk of developing PTSD symptoms, (c) intensity, duration, and perception of the battering
experience is a significant factor in the severity of the women’s PTSD symptoms, (d) some demographic
variables have an influence on PTSD severity, (e) there is a need for standardized PTSD assessment by
trained professionals working with domestic violence women, (f) there is a need for greater public health
involvement for prevention, identification, and medical treatment of domestic violence and PTSD, (g)
certain treatment strategies have been found to be best practices in working with battered women with
PTSD, (h) few public agencies in California responding had programs specific to domestic violence
women, (i) most treatment is on an outpatient basis, and (j) assessment, emergency services, support
groups, substance abuse, and case management were the most commonly used treatment strategies.

1 The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines PTSD: “The essential feature of
Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme
traumatic stressor involving actual or threatened death or serious injury, or other threat to one’s physical integrity…”

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POLICY AND PROGRAM RECOMMENDATIONS

Ten policy and program recommendations emerged from the project. They are as follows:

Ø Most importantly, women experiencing domestic violence, PTSD, or both must be treated in
a way that validates their experiences (both past and present), validates their symptoms
through both individual counseling and support groups, and gives them problem solving skills
to overcome their battering and achieve a safe and healthy lifestyle for themselves and their
children.

Ø Whereas Battered Women Syndrome is subjectively defined and Posttraumatic Stress
Disorder is objectively defined by the Diagnostic and Statistical Manual (DSM-IV), justices
should be mandated to use the latter in determining cases in order to avoid wrongful
determinations in cases in which the victim retaliated, whether lethally or otherwise.

Ø Sentences that send a strong message to batterers need to continue and become standardized
as a protection for women and their children.

Ø A universally adopted instrument needs to be developed to assess for PTSD in
symptomology, severity of abuse, frequency of abuse and severity of symptomology.

Ø Additional funding is needed for shelters to allow them the opportunity to hire professional
staff with special training in PTSD and domestic violence assessment and treatment of
domestic violence victims.

Ø Programs should adopt treatment methods shown to be effective through scientific studies for
treating domestic violence victims with PTSD and investigation of model programs
throughout the state and nation.

Ø Local, state, and national programs’ record-keeping of women served needs to be
standardized so that better data can be collected for research.

Ø More funded research is needed to test specific treatments for PTSD in conjunction with
domestic violence women, and studies need to include cultural variables to determine if
women from different cultural/ethnic groups respond differently to treatment modalities.

Ø Given that child abuse is significantly correlated with domestic violence, more funding to
support home visitation programs, which treat the child (ren) as well as the battered women
in homes where domestic violence is occurring, is needed.

Ø The public health approach for PTSD and domestic violence should be proactive in
identifying domestic violence victims and offering information to women on a routine basis
about prevention and treatment of domestic violence.

Ø Cross-system training for effective multi-disciplinary practice and coordination of
services is needed since the problems of victimized women cross so many service
systems.



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SUMMARY OF EMPIRICAL GENERALIZATIONS FROM THE LITERATURE
1. Available research indicates that the symptoms exhibited by battered women are consistent
with the major indicators of PTSD as currently defined by the DSM IV. A consistent finding
across varied samples (i.e., clinical samples, shelters, hospitals, community agencies, etc.) is
that substantial proportions of victimized women (31% to 84%) exhibit PTSD symptoms.
2. The domestic violence shelter population is at a higher risk for PTSD than victimized women
who are not in shelters. Estimates of victimization among the shelter population range from
40% to 84%.
3. Having multiple victimization experiences (childhood abuse, particularly sexual abuse, and
adult sexual abuse) increases the likelihood of PTSD and many other types of psychiatric
disorders.
4. The extent, severity, and type of abuse are associated with the intensity of PTSD. Severity
refers to how life threatening the abuse is. The more life threatening the abuse is, the more
traumatic the impact. Sexual abuse, severe physical abuse, and psychological abuse are
associated with an increase in trauma symptoms among victims. Women need not experience
severe violence to experience PTSD symptoms; but experiencing severe violence exacerbates
symptoms. Psychological abuse may be as damaging as physical violence.
5. Other forms of emotional distress accompany PTSD, particularly depression and dysthymia,
are noted among domestic violence victims. A history of depression may be a risk factor for
victimization.
6. Suicide is a risk among domestic violence victims who exhibit PTSD symptoms. PTSD may
mediate the link between partner abuse and suicidal ideation.
7. Substance abuse was reported in a high percentage of victimized women. Women who
reported being victims of child abuse and adult abuse had significantly more lifetime drug
and alcohol dependence than women not reporting abuse.
8. In addition to PTSD, depression, and substance abuse, other mental health problems have
been noted in victimized women.
9. The empirical evidence does suggest that younger unemployed women, with a
relatively large number of children, with low income, and low levels of social
support, are more at risk to experiencing PTSD symptoms and other mental health
problems than women without those characteristics.








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SUMMARY OF ACTION GUIDELINES FOR INTERVENTION

1. The high numbers of victimized women experiencing PTSD suggest it is a useful construct
for use in treatment of battered women.
2. A public health prevention approach is needed for PTSD and domestic violence.
3. Screening for victimization should become a standard of mental health practice so referrals to
appropriate agencies can be made.
4. Mental health outreach to the shelters seems warranted.
5. The treatment of substance abuse ought to be an integral part of the recovery from battering.
6. In addition to mental health services women would need additional concrete assistance
(medical, financial, housing, child care, legal etc.).
7. Effective multi-disciplinary practice and coordination of services are needed with this
population.
8. Medical personnel must ask women directly whether they have been abused. Both asking and
reporting should be mandatory in all jurisdictions.
9. Low income and younger women, including teens, are especially vulnerable to abuse and
symptoms. This vulnerability suggests they need to be the targets of prevention and treatment
programs.
10. Support groups can provide a safe structure for the battered women.
11. Practitioners need assessment methods that accurately identify domestic violence, and they
need to know how to develop intervention strategy that addresses the safety needs of victims.
12. It is important to assess a battered woman's family background for a history of psychological
trauma and family dysfunction so that sources of potential vulnerability can be evaluated.
13. The research indicates that clinicians need to distinguish between severity (levels) and types
of violence since the psychosocial effects of domestic violence will vary according to severity
and type.
14. Skill training in alternative coping responses and problem solving is needed by abused
women whose fear, depression, cognitive problems, and lack of social support make it
difficult for the women to plan for their own safety.
15. Effective therapy for battered women offers a supportive relationship, focuses on the abuse,
validates the women's perceptions, encourages self-determination, and provides a safe setting
to work through the residue of years of trauma.
16. Domestic violence service providers, mental health staff, medical personnel and other
relevant professionals need to be sensitized to the increased suicide risk noted among abused
women with PTSD.
17. Cognitive-behavioral therapies are the most commonly recommended treatment strategies in
the literature for PTSD.


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INTRODUCTION

Partners are the predominant perpetrators of violence against women. In the United States each
year intimate partners batter between two and four million women of all races and classes (First
Comprehensive National Health Survey of American Women, 1993; Tjaden & Thoennes, 1998). It is
estimated that 21% of adult women suffered sexual abuse as children; 20-25% of women are raped as
adults; and 30-50% of married women suffer physical assaults by spouses (Plichta, 1996). Physical
assaults involve punching with a fist, kicking, biting, beating, or attack with a gun or knife (Straus &
Gelles, 1986). Current patterns predict that 50% of women will be victims of domestic violence at
some point in their lives (Corsilles, 1994).
Every year in the United States, between 1500 and 4000 people die as a result of partnership
violence (Corsilles, 1994; Straus & Gelles, 1988). Thirty-one to 42% of all female homicides are the
result of domestic violence (Corsilles; Gross, 1997). Corsilles also reported that domestic violence is
a primary reason for injuries to women. Assault by an intimate partner is the leading cause why
women visit hospital emergency rooms (Zorza, 1992).
In California, the number of domestic violence arrests and rate per 100,000 in the general
population has increased steadily from 1988 to 1997. The number of arrests declined 10.6% in 1998,
which may indicate society’s condemnation of this behavior and changes in how the legal system
views domestic violence, the victims, and what constitutes an appropriate response by law
enforcement and the courts (Lockyer, 1999).
The above statistics should indicate that domestic violence ought to be a major social policy
concern. Despite the published data, exact counts of the extent of domestic violence are difficult to
determine. Victims are often reluctant to report domestic violence due to a complex set of factors:
fear, hope that their partner will change, lack of options, financial concerns, cultural factors, or
pressure from others in their social network. Straus and Gelles (1986) asserted that only one in every


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seven victims report the domestic violence being directed against them. Cases not directly reported by
the victim are unlikely to be recorded elsewhere because medical, social service, and police personnel
may fail to identify domestic violence or respond appropriately when they encounter it (Nurius,
Hifrink, & Rifino, 1996).
The most common diagnosis by mental health professionals for battered women is Posttraumatic
Stress Disorder (PTSD) (Crowell, 1996). However, the typical treatment strategies for battered
women are not those developed for PTSD. Battered women are likely to be just treated for depression
or some other psychological disorder. The mismatch of treatment with disorder might not only be
ineffective but it may make matters worse.
This report examines previous research on this topic, and the actual treatment regimes employed
in the State of California in order to develop suggestions on how state government could better assist
in the treatment of PTSD that women experience after victimization from domestic violence.
RESEARCH QUESTIONS ADDRESSED BY THIS REPORT
1. What does the academic literature tell us about the PTSD syndrome for women as a result of
domestic violence against them? What are the best treatment strategies for this condition? What
evidence of treatment effectiveness (or lack thereof) is there for treating Posttraumatic Stress Disorder
for women?

2. What do we know about the number of women experiencing domestic violence in the State of
California, and what do we know about what happens in the aftermath of this experience?

3. What federal, state, or local government programs are currently designed to provide mental health
services to women who have experienced domestic violence? Do any of them recognize
Posttraumatic Stress Disorder and treat it? How might these be improved?

4. What mental health strategies are currently prevalent in treating these women? What evidence of
treatment effectiveness do we have?

5. What do we know about mental health strategies that are effective in treating women who have
experienced domestic violence? Are there model programs in California?

6. What are the policy and program implications of this work? Could the state design and implement
policy that would assist in the more effective handing of this issue?


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METHODOLOGY

Three separate means of data collection were utilized to answer the research questions. These
were:
1. Systematic Research Synthesis (SRS) is a form of structured inquiry that uses structured
protocols reflected in meta-analysis together with the integrative qualities of the traditional literature
review. Meta-analysis is a quantitative form of the traditional qualitative literature review. It seeks to
arrive at a common metric that incorporates multiple studies into a single statistic signifying the
influence of an intervention on an outcome or dependent variable (such as PTSD).
SRS is used to “make sense” of massive and disorderly research evidence. The outcome is to
create a conceptual synthesis of disparate research findings. The synthesis identifies where the
consensus is in the literature on how to treat a particular phenomenon such as domestic violence. The
goal of the synthesis is to develop empirical statements that would aid in the development of practice
strategies as well as to accumulate new knowledge (Rothman and Thomas, 1994).
2. Existing on-line computer databases were used to gather data.
3. A mailed, self-administered survey was conducted of 58 County Mental Health Directors to
answer some of the research questions concerning California.
Systematic Research Synthesis

SRS was used to answer the following sets of research questions:
Ø What does the academic literature tell us about the PTSD syndrome for women as the result
of domestic violence against them? What are the best treatment strategies for this condition?
What evidence of treatment effectiveness (or lack thereof) is there for treating post-traumatic
stress syndrome for women?
Ø What mental health strategies are currently prevalent in treating these women? What
evidence of treatment effectiveness do we have?


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