COMMENTARY

Domestic Violence Awareness

Domestic or intimate partner violence is alarmingly preva- Finally, disclosure represents a potential threat to the contin-
lent, and, for victims, a major contributor to depression, uance of a romantic relationship, which, though abusive,
anxiety, and other forms of mental illness. Psychological involves emotional investment. Without experience handling
problems and psychiatric syndromes often are the antecedents domestic violence situations, clinicians can feel ill-prepared and
of domestic violence for the perpetrator and also can be risk deskilled, lacking knowledge about referral sources, emergent
factors for becoming a victim. Remarkably, the two dominant threats of bodily harm, and the accompanying legal and ethical
mental health fields, psychiatry and clinical psychology—the obligations. This lack of presentation in clinical settings con-
ones charged with investigating and attending to the mind, tributes to a “don’t ask” scenario (8). Since 1986, numerous
brain, and behavior—are largely absent from domestic violence medical institutions have advocated for domestic violence
research and intervention. screening in routine medical care (16, 17); in 2001, the American
More than one in three women and at least one in four men Psychiatric Association followed suit. That same year, the
have been the victim of rape, physical violence, or stalking by an American Psychological Association’s Intimate Partner Abuse
intimate partner (1). However, women are far more likely than and Relationship Violence Working Group launched
men to experience severe sexual and physical violence from a curriculum on domestic violence but appears to have done
a partner or to be killed by one (1, 2). In the United States, intimate little to foster relevant training in clinical interventions.
partner homicides make up between 40% and 50% of all murders Domestic violence is an exceptionally challenging clinical
of women (3). Domestic violence crosses geographic and so- situation. Those in domes-
cioeconomic stratification, although studies indicate that lower- tic violence relationships One in three women and at
income women in rural communities experience higher rates of are at risk for repeating this least one in four men have
violence and, specifically, sexual abuse (4, 5). Victims suffer from experience, and likely have been the victim of rape,
dramatic rates of depression, anxiety, and posttraumatic stress abuse or exposure to it in physical violence, or stalking
disorder, as well as substance abuse and suicidality (6–8). A recent their backgrounds (11, 18), by an intimate partner
study based on a representative U.S. sample of more than 25,000 adding immense complex-
adults indicated that new onsets of major mental health problems ity to treatment. The work presents unique challenges, including
were more than twice as common among those exposed to safety planning and patients’ minimization of abuse, which may
domestic violence in the past year than among nonvictims (9). induce feelings of helplessness in the context of significant ur-
Millions of children—as many as 15 million, according to some gency and danger (19–21). There now are targeted treatments for
estimates—witness domestic violence each year (10). For domestic violence intervention, such as Seeking Safety (22) and
male children there is a 1,000% greater risk of reproducing Child-Parent Psychotherapy (23), though few psychologists
this violence in their own spousal relationships (11). A recent and psychiatrists are trained in them. Of course the question
epidemiologic study found prior domestic violence victimi- of how clinically to respond to perpetrators is a complicated
zation to be more strongly associated with domestic violence one, independent of the necessary legal consequences. However,
perpetration than any other factor (12). treatment and prevention programs are emerging, such as the
Despite its prevalence in the general population, domestic Melissa Institute for Violence Prevention and Treatment.
violence is underrepresented in our consulting rooms in part Beyond the “professional counter-transference” is possi-
because victims, and especially perpetrators, rarely voluntarily bly a more personal one. Aggression is a fundamental human
self-identify or seek treatment (8, 13, 14). Shame, guilt, and denial impulse, and violence a socially unacceptable manifestation
are obvious deterrents. These factors are often compounded by of it. Underlying any violent interaction is the universal
a sense of futility resulting from learned helplessness, and human struggle with aggression and its myriad complex
a profound unraveling of self-esteem (15). More practical antecedents: family and developmental history; self-esteem;
considerations include fears for personal security, economic power dynamics; fear of abandonment and humiliation;
codependence, and the concerns that disclosure will trigger emotional regulation; impulse control; and the capacity for
social services engagement, particularly child protection (8). empathy, guilt, and remorse. The possibility that domestic

See related feature: Clinical Guidance (Table of Contents)

944 ajp.psychiatryonline.org Am J Psychiatry 172:10, October 2015

violence exists at the far end of a continuum of aggression 7. Golding MJ: Intimate partner violence as a risk factor for mental
that includes our own moments of intense anger is difficult disorders: a meta-analysis. J Fam Violence 1999; 14:99–132
8. Rose D, Trevillion K, Woodall A, et al: Barriers and facilitators of
to accept. That we all may have something in common with
disclosures of domestic violence by mental health service users:
perpetrators encourages our disengagement. qualitative study. Br J Psychiatry 2011; 198:189–194
Our counter-transference to victimization is similar; it is 9. Okuda M, Olfson M, Hasin D, et al: Mental health of victims of
threatening to empathize with the shattering paradox of do- intimate partner violence: results from a national epidemiologic
mestic violence victims, experiencing violence at the hands of survey. Psychiatr Serv 2011; 62:959–962
10. McDonald R, Jouriles EN, Ramisetty-Mikler S, et al: Estimating the
someone they love and whom they are unable to leave. And yet
number of American children living in partner-violent families. J
this paradox—experiencing a depth of attachment that super- Fam Psychol 2006; 20:137–142
sedes most basic self-preservative drives—is consistent with 11. Knapp JF: The impact of children witnessing violence. Pediatr Clin
what John Bowlby theorized, what recent child development North Am 1998; 45:355–364
research has demonstrated (24), and what data from rodent 12. Okuda M, Olfson M, Wang S, et al: Correlates of intimate partner
violence perpetration: results from a national epidemiologic survey. J
models have characterized on a neurobiological level (25).
Trauma Stress 2015; 28:49–56
Evoking deep, psychological concerns, we retreat from do- 13. Tjaden PG, Thoennes N: Full Report of the Prevalence, Incidence, and
mestic violence, drawing a line in the sand between “our” Consequences of Violence Against Women: Findings from the Na-
behaviors and “theirs.” With this dichotomizing orientation, tional Violence Against Women Survey. Atlanta, National Center for
moral judgment replaces a psychological perspective. We tend Injury Prevention and Control, Centers for Disease Control and
Prevention, 2000. http://hdl.handle.net/2027/pur1.32754071818946
to pity and disdain the victim, and vilify the abuser, abdicating
14. Eckhardt CI, Samper RE: Anger disturbances among perpetrators
our roles as clinicians and researchers. It is the mandate of the of intimate partner violence: clinical characteristics and out-
criminal justice system to punish people for violent actions, and comes of court-mandated treatment. J Interpers Viol 2008; 23:
of social services to support victims. As the leading fields in 1600–1617
mind, brain, and behavior, it is our mandate to understand and 15. Bargai N, Ben-Shakhar G, Shalev AY: Posttraumatic stress disorder
and depression in battered women: the mediating role of learned
rehabilitate all human behavior, without prejudice.
helplessness. J Fam Viol 2007; 22:267–275
16. Domestic Violence: Position Paper of the American College of
Physicians, 1986. http://www.acponline.org/acp_policy/poli-
AUTHOR AND ARTICLE INFORMATION
cies/domestic_violence_acp_position_paper_1986.pdf
From the Department of Psychiatry, Weill Cornell Medical College, New 17. de Boinville M: Office of the Assistant Secretary for Planning and
York; and the Department of Psychiatry, Columbia University Medical Evaluation Policy Brief: Screening for Domestic Violence in Health
Center, New York. Care Settings. U.S. Department of Health and Human Services, 2013.
Address correspondence to Dr. Monk (cem31@cumc.columbia.edu). http://aspe.hhs.gov/hsp/13/dv/pb_screeningdomestic.cfm
The authors report no financial relationships with commercial interests.
18. Whitfield CL, Anda RF, Dube SR, et al: Violent Childhood Experi-
ences and the Risk of Intimate Partner Violence in Adults: Assess-
Accepted August 2015. ment in a Large Health Maintainance Organization. J Interpers
Am J Psychiatry 2015; 172:944–945; doi: 10.1176/appi.ajp.2015.15070853 Violence 2003; 18:166–185
19. Bogat GA, Garcia AM, Levendosky AA: Assessment and psycho-
therapy with women experiencing intimate partner violence: in-
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