PTSD: National Center for PTSD

Addressing the Stress and Trauma of Experiencing Intimate Partner Violence

Katherine M. Iverson, PhD

This article addresses the public health problem of intimate partner violence (IPV). Increased public attention to IPV and growing likelihood of survivor disclosure stimulated interest in integrating IPV screening and intervention practices into routine health care (1). Although early research focused on elucidating IPV against women at the hands of male partners, more recent studies highlight the occurrence and impact of IPV experienced by men and the lesbian, bisexual, transgender and queer or questioning (LGBTQ) community (e.g., 2-4).

Despite decades of foundational research on IPV and its health effects, studies suggest that practitioners often don't know how to address IPV in ways that are consistent with the research findings—this is true across disciplines and services, including mental health (5). It is therefore important that clinicians, health care leaders and policy makers are knowledgeable about IPV, including its definition, prevalence, health consequences and best clinical practices for screening and intervention. This article summarizes the current knowledge to guide clinical care for individuals who experience IPV, as the need for effective dissemination and implementation is urgent for this population.

Defining and Understanding IPV

While domestic violence includes IPV (and the terms are sometimes used interchangeably), domestic violence is a broader term that refers to any violence that occurs in the domestic sphere (e.g., child abuse, elder abuse, sibling abuse). IPV is a specific form of domestic violence that refers to violence and aggression between past and current intimate partners (e.g., spouse, girlfriend/boyfriend, dating or sexual partner). Although individuals of any gender identity may experience IPV, women are disproportionately affected with elevated prevalence, chronicity and severity of IPV and more pronounced physical, mental and social health impacts (6). IPV is the most common form of violence against women worldwide and includes physical violence, sexual coercion and abuse, psychological abuse (including coercive and controlling behaviors), and stalking by past or current intimate partners (3).

Prevalence

The CDC's National Intimate Partner and Sexual Violence Survey (NISVS) indicates that 1 in 4 women and 1 in 10 men experience physical violence, rape or stalking by an intimate partner that results in health-related impacts such as injury, need for medical care or posttraumatic stress symptoms (3). Women are three times as likely as men to be injured by IPV (41.6% vs. 13.9%) and are much more likely than men to experience severe forms of physical violence at the hands of an intimate partner (e.g., being strangled, beaten, assaulted with a weapon; 24.3% vs. 13.8%) (3). Findings from the NISVS indicate that sexual minority respondents experience IPV at rates equal to or higher than those of heterosexuals (4). For example, 44% of lesbian women and 61% of bisexual women experience physical violence, rape and/or stalking by an intimate partner in their lifetime compared to 35% of heterosexual women. Following a similar pattern, 26% of gay men, 37% of bisexual men and 29% of heterosexual men experience physical violence, rape and/or stalking by an intimate partner during their lifetimes. These troubling numbers do not even include psychological IPV, which is difficult to measure with precision.

Further, research on stigmatized topics like IPV often underestimates prevalence since individuals can decline to report or respond "do not know" to survey items, which may reflect ambivalence to acknowledge or discuss IPV. Individuals experiencing the most severe IPV may not feel safe responding to research. It is also important to remember that individuals of all gender identities can be reluctant to disclose IPV due to stigma and societal stereotypes about who experiences IPV, and, men in particular, are likely to experience more barriers to IPV disclosure as a result of stigma.

Prevalence rates vary by age, race/ethnicity, income levels and military service. For example, younger individuals are more likely to experience IPV as are women who previously served in the military (7,8). Individuals who experience IPV have higher health care utilization across a range of services, with the volume of health care use increasing with increases in frequency and severity of IPV (9).

Psychological IPV

Public perception and discussion of IPV often focus on physical forms and impacts of violence (e.g., contusions and bruising). Yet, nearly half of women and men in the U.S. will experience some form of psychological IPV during their lifetime (10). Much of the research on psychological IPV, especially coercion and control, has focused on women. The majority of women who experience physical or sexual forms of IPV also experience psychological IPV that includes verbal aggression, threats, intimidation, coercion and controlling behaviors (11,12). Some women experience psychological IPV without physical or sexual violence, but the reverse is rare (12,13). Women, in particular, have frequently reported that psychological abuse, including social isolation, tactics to reduce self-esteem and cruel manipulations (i.e., gaslighting; "I'm not lying, you are imagining things") is the worst part of their IPV experience (11).

In sum, research has long noted, and continues to substantiate, that psychological IPV can have particularly adverse impacts for women and men (e.g., 13,14). It is also possible that men may experience more stigma and additional barriers to acknowledging and discussing psychological forms of IPV. Thus, in addition to sexual and physical violence, it's critical to address and not minimize the effects of psychological IPV on clients' and patients' lives.

Biopsychosocial Consequences and Correlates of IPV

More than three decades of research have established the significant biopsychosocial consequences of IPV. There is indisputable evidence that IPV can cause and exacerbate acute and long-term physical, mental health and social problems (see 9,15). Physical health conditions associated with IPV include direct injuries, chronic pain, and chronic illnesses, as well as gastrointestinal, musculoskeletal and neurological problems (14-16). Among women, gynecological, reproductive and adverse pregnancy-related outcomes have been found (15-17). A rapidly growing body of evidence indicates traumatic brain injuries from head-blows and strangulation-induced anoxia from IPV is common among abused women and has strong implications for physical and psychosocial health (18). The psychological toll of IPV on women's and men's health is pervasive. IPV is strongly associated with PTSD, depression, anxiety, substance misuse and mental health multi-morbidity in community and clinical populations (13,19-21). IPV is also associated with increased risk of eating disorder pathology and suicide attempts as well as social health needs like housing instability and unemployment (21-23).

Screening and Education

Consistent with the multitude of health issues associated with IPV, men and women who experience IPV have increased health care utilization across a range of services, including mental health care (9,24). Thus, health care encounters, regardless of purpose, present opportunities to identify, support and connect patients with services related to IPV impacts. Although clinicians are theoretically well-positioned to effectively address IPV with patients, they often avoid asking about it or ask in ways that aren't conducive to open disclosure (e.g., "You're not a victim of domestic violence, are you?") (25). It's critical that practitioners across disciplines know how to ask questions in ways that make it easier for patients to disclose this stigmatized experience. It's also critical for practitioners to avoid minimizing psychological IPV—the stereotypical "it's not like he's hitting her or anything like that"—simply isn't consistent with research indicating that psychological IPV can be just as traumatic as, and often more debilitating than, physical IPV.

Clinicians should evaluate psychological IPV in addition to sexual and physical IPV, as each of these forms of violence contribute to health needs for women and men (14,19,24). Additionally, clinician knowledge of the different forms of IPV allows them to better understand their patients' experiences and tailor their interventions to their needs. Examples of gender-neutral screening questions for psychological IPV include "Does your (ex)-partner keep you from seeing friends or family?," "How often has a past or current partner put you down or called you names," and "Are there times when you do not express your opinion because you are afraid your partner might punish you in some way?"

The U.S. Preventive Services Task Force (26) recently updated their IPV screening recommendations, supported by a systematic review (27). The USPSTF concludes that appropriate screening is effective in identifying IPV in women of reproductive age and that screening does not cause adverse effects. The USPSTF concluded there is insufficient data to support universal screening of women beyond child-bearing age or men (26). Nonetheless, it is critical that clinicians adopt, at minimum, a case finding approach with these populations.

The USPSTF identified several brief and accurate tools for screening or past-year IPV (e.g., Hurt, Insult, Threaten, Scream [HITS] and the Humiliation, Afraid, Rape, Kick [HARK]). The USPSTF recommends providing or referring women who screen positive for ongoing support services. Despite this evidence and support for screening among both patients and providers (28,29), there is slow and incomplete integration of universal IPV screening programs into routine care (30). Moreover, there is a need to evaluate the clinical utility of specific screening tools in identifying IPV among men. Nonetheless, there is evidence of the impact of recent and increased national media coverage on sexual abuse, harassment and IPV against women, which further legitimizes, and in some cases, prioritizes IPV as a primary health issue for identification and intervention among health care patients (1).

But it's important to note that even the most effective screening methods won't capture every case. Even when asked directly by trained providers, individuals may choose not to disclose IPV for various reasons, including, but not limited to, distrust, lack of comfort with the provider, mandated reporting concerns, shame, privacy and safety/retaliatory violence concerns (25,28,29,31). There are likely additional barriers experienced by men, including but not limited to stigma. Thus, while screening increases identification of IPV, experts in the field call for universal education about the health impacts of IPV and available resources and services even in the absence of IPV disclosure (15). When conducted sensitively, even individuals who screen negative or decline referrals may benefit from universal IPV education.

Referral, Documentation and Follow-Up

Whether screening occurs routinely or through case finding (i.e., inquiry based on clinical presentation or suspicion), it is an ethical imperative that individuals who disclose IPV are offered follow-up discussions, resources and referrals. A practitioner's non-response or minimization of disclosures could be harmful to patients by contributing to their self-blame or giving the impression that their experience is normative and acceptable. As stated by a woman who participated in focus groups on IPV screening and counseling preferences, "You can't make the woman answer...but if she tells you and you don't follow up, then in the back of her mind, she's saying, "Well, I told them and they don't seem to care...I guess it's just like he says. I deserve it." (31).

Research offers several practical tips for responding to IPV disclosures and providing possible interventions (15). Although most of this research has been conducted with women, many of the principles and strategies are applicable to men and individuals of other gender identities. Individuals with IPV experiences want sensitive acknowledgement and supportive statements, and they prefer open-ended follow-up questions to determine personal circumstances and service preferences (28). They want practitioners to respect their autonomy in what, when, why and how much they disclose (31), as well as information about relevant resources, appropriate referrals and shared decision-making about what is documented in the electronic health records (28,29,31). Documentation in the era of electronic medical records is tricky for patients and providers alike as there can be safety concerns regarding documentation of IPV if an unsafe partner were to access their medical records, as well as concerns about other providers viewing this sensitive health information (29,31). However, discussing issues around documentation and honoring individual's preferences for documentation is a feasible trauma-informed practice (1).

Since privacy concerns or partner interference with health care may limit peoples' ability to make and keep clinic appointments, providers should be aware of alternative resources that provide information and safety planning. For example, myPlan is a free and private interactive decision-support aid, available as a mobile app and secure website, which guides individuals experiencing IPV in clarifying their priorities, weighing risks and benefits, evaluating their safety risk and making informed decisions about safety planning and resources (www.myplanapp.org). This tool has been shown to increase safety behaviors and reduce psychological and sexual IPV for some women (32). Providing individuals with information about this and other accessible tools could benefit not only those who disclose, but also those who aren't comfortable disclosing, or aren't even sure if they are experiencing IPV. Such tools may be particularly helpful to people whose abusive partners interfere with their ability to access health and social services through controlling and manipulative tactics (33).

Appropriate referrals for IPV should be tailored for individual's specific circumstances, so practitioners should have consolidated lists of potentially relevant resources and referrals. Interventions to support healing, empowerment and safety among those experiencing IPV can include advocacy, legal support, emergency shelter and transitional housing, social services and counseling. Research indicates that multifaceted programs rooted in institutional support can improve IPV screening practices and increase disclosure rates (34). Successful health care-based IPV assistance programs address practitioner competency and self-efficacy by including ongoing training, multi-level leadership support, evidence-based tools embedded within the electronic health records to facilitate trauma-informed IPV screening, structured assessment and response practices, immediate access to IPV experts and/or co-located social work and mental health services well-equipped to provide follow-up care such as safety planning, advocacy and mental health services (1,35).

Evidence-Based Psychotherapies

Currently there is no gold-standard psychotherapy or "one-size-fits all" intervention for individuals dealing with IPV, because individuals experiencing IPV are heterogeneous in their priorities, circumstances and mental health needs. While IPV is not itself a mental health condition, there are several promising evidence-based psychotherapies for individuals who experience IPV-related distress (36).

PTSD is one of the most common consequences of IPV and can persist years after abuse has ended. PTSD treatment related to past IPV can be accomplished with front-line trauma-focused PTSD psychotherapies, such as Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing (EMDR) (37). Among interpersonal trauma survivors, including those who have experienced past IPV, such treatments appear to have the added benefit of reducing risk for future IPV (38). Each of these front-line psychotherapies for PTSD have been validated in randomized controlled trials (RCTs) that have included IPV survivors within their samples. However, there is a critical lack of research to understand how well these treatments work in the context of current and severe abusive relationships. It is especially important to understand the effectiveness and implementation of these trauma-focused psychotherapies for treating IPV-related PTSD when the person is in an ongoing relationship with the abusive partner who caused the PTSD.

Treatments for IPV-related PTSD

To date, two psychotherapies have been developed specifically for IPV-related PTSD and rigorously evaluated in RCTs. They are described next. It is notable that both treatments have been developed for and tested with women, but it may make sense to apply the key elements of these treatments with men and individuals of varying gender identities.

Cognitive Trauma Therapy for Battered Women (CTT-BW): Kubany and colleagues developed Cognitive Trauma Therapy for Battered Women (CTT-BW) for women with PTSD secondary to IPV who are no longer in abusive relationships. CTT-BW is delivered in 8-12 individual therapy sessions that include psychoeducation about PTSD, exposure and cognitive therapy techniques and four modules specific to IPV (trauma-related guilt; other trauma histories; managing ongoing contact with abusive ex-partners; and, risk for revictimization). A randomized controlled trial of CTT-BW with 125 ethnically diverse women who had been out of IPV relationships for an average of 5 years found that the majority of treatment completers (87%) experienced significant reductions of PTSD symptoms (to nondiagnostic levels) and depressive symptoms (39). These improvements were maintained at 3- and 6-month follow-up, and CTT-BW worked equally well when delivered by clinically vs. non-clinically trained interventionists. This finding has implications for enhancing the reach of CTT-BW in non-clinical settings such as community IPV programs, social service agencies and shelters. Indeed, there is preliminary data demonstrating promise for delivery of this treatment in diverse settings (40).

Although CTT-BW is a promising intervention for women dealing with PTSD from past IPV, this treatment has not been evaluated with women still involved in abusive relationships or who are separated but considering reconciliation. Future investigations should assess whether adaptations are required for effective delivery of CTT-BW with a broader population of IPV survivors. In addition, investigations are needed to understand how to adapt and apply the treatment effectively to men and individuals of diverse gender identities who experience PTSD and sub-threshold PTSD from IPV relationships.

Helping Overcome PTSD through Empowerment (HOPE): Johnson and colleagues developed Helping Overcome PTSD through Empowerment (HOPE) with women residing in IPV shelters (41,42). HOPE is an empowerment-based cognitive-behavioral therapy targeting PTSD symptoms and concurrent clinical needs of women residing in shelters. HOPE is delivered in up to 12 individual sessions that include psychoeducation, cognitive restructuring, empowerment strategies including prioritization of individual goals, assertiveness with safety planning, self-care skills, and accessing resources.

In a randomized controlled trial of HOPE with 70 women assigned to HOPE plus standard shelter services versus standard shelter services alone, HOPE was associated with significant improvements in depressive symptoms, empowerment, social support and lower likelihood of IPV 6 months after leaving shelter (41). However, HOPE did not produce greater reductions in PTSD symptoms than the control group except that women who received HOPE reported fewer emotional numbing symptoms. At post-treatment, nearly half (46%) continued to meet full or partial criteria for PTSD. Given these modest outcomes, the treatment developers expanded HOPE to a 16-session intervention that continued in the 3-months after leaving the shelter (42). Expanded HOPE sessions included:

• re-evaluation of goals and safety after leaving the shelter
• ongoing case management
• expanded modules on substance relapse
• emotional numbing and two booster sessions

In a sample of 60 women, expanded HOPE had significant effects for PTSD as well as depression symptoms, empowerment, employment and resource gain. Additionally, results showed the acceptability and feasibility of adding IPV-related treatment to standard shelter services. This intervention holds promise for use in other settings where women who experience IPV are commonly seen, such as community-based IPV programs. Future research should evaluate both the effectiveness and implementation of HOPE in other settings, as well as explore its clinical utility with men and individuals of varying gender identities.

Summary and Future Directions

Patients are entering a range of health care settings with IPV experiences; clinicians are treating individuals who are experiencing or have experienced IPV whether they know it or not. Thus, practitioners across disciplines need to be knowledgeable about the impact of IPV in order to ask the right questions at the right time, thoughtfully refer to evidence-based services and follow up appropriately. Appropriate screening should occur at least in preventive care, primary care, mental health, social services and emergency settings. Research indicates what individuals want in terms of provider response to IPV disclosure: listening without judgment, validation, providing options without pressure and tailored referrals.

Psychosocial and mental health interventions can play an important role in helping individuals recover from the psychological wounds of IPV. Although there is no universal approach to address IPV, two cognitive-behavioral psychotherapies have demonstrated efficacy specifically for women with IPV-related PTSD. Future research should evaluate the dissemination and implementation of CTT-BW and HOPE in routine care settings as well as their applications to men and to individuals within the LGBTQ community. Additional IPV-specific psychosocial interventions are currently being developed and evaluated (36), but we must accelerate the protracted timeline between intervention testing and implementation into routine care. There is also a need for systematic research to identify how to best apply front-line trauma-focused treatments for PTSD in the context of ongoing IPV, especially in situations of IPV-related PTSD.

Although there is significant knowledge about the health and social consequences of IPV, and a number of promising practices for IPV screening intervention, the translation of IPV research into routine practice remains significantly under-developed. There is a need to study and effectively apply best practices for patients and clients who do not identify as a woman, as IPV affects individuals of all gender identities. Furthermore, as sexual minorities experience IPV at rates equal to or higher than heterosexuals, it is critical to effectively address IPV with lesbian, gay, and bisexual clients. In particular, there's a need to better understand how to increase integration of evidence-based screening and intervention practices into routine care. There is also a need for researcher-practitioner collaborations and more stakeholder engagement (including the voices of diverse individuals who experience IPV) during the development, evaluation and scale-up of IPV programs.

For more information, see the author's PTSD Research Quarterly issue: Practical Implications of Research on Intimate Partner Violence Against Women (PDF).

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