Though there has been limited focus on the problem of domestic violence by
the field of psychiatry, there is a high prevalence of domestic violence in
mental health settings, according to psychiatrists who are experts in treating
From left: Carole Warshaw, M.D., Graeme Hanson, M.D., and Sandra Bloom,
M.D., were presenters at an annual meeting session on how to help victims of
At APA's annual meeting in New York City last month, they discussed how
best to address the mental health needs of patients who are victims of
Domestic violence and mental health problems are often intertwined,
according to Carole Warshaw, M.D., director of the Domestic Violence and
Mental Health Policy Initiative in Chicago and a member of APA's Committee on
Family Violence and Abuse. For example, studies show that from 42 percent to
46 percent of women in outpatient mental health settings have experienced
physical abuse, and 29 percent to 38 percent have experienced sexual abuse as
For women patients with serious mental illnesses, these rates are twice as
high. Further, studies of women enrolled in domestic violence programs have
shown high prevalence rates of mental illness, according Warshaw.
In 2000, researcher Jacqueline Golding, Ph.D., found that mean prevalence
rates of posttraumatic stress disorder (PTSD) among women in these settings is
61 percent. About 50 percent of these women experienced depression symptoms,
and 20 percent exhibited suicidal behavior.
Complicating matters is the fact that women with severe mental illness who
reveal that they are victims of domestic violence may not be taken seriously
by the medical community.
"Not infrequently, reports of abuse are attributed to
delusions," Warshaw said, adding, "but we know that an episode of
abuse often precipitates psychotic decompensation."
Warshaw also pointed out that "the symptoms and stigma associated
with mental illness can increase women's vulnerability to being controlled by
an abusive partner."
The partner may tell the woman and others that she is crazy, for instance,
or have her committed to a psychiatric hospital and then speak on her behalf,
Warshaw noted. After an episode of violence, it is not uncommon for abusers to
rationalize their behavior by saying they were just trying to restrain a
partner who was "out of control," Warshaw pointed out.
Psychiatrists should be aware that symptoms related to trauma resulting
from domestic violence may look similar to symptoms of serious mental illness,
Warshaw said. For instance, flashbacks may be confused with hallucinations,
and emotional lability and affect dysregulation associated with complex trauma
may be mistaken for symptoms of bipolar disorder. Some women may have symptoms
related to ongoing trauma plus one or two comorbid psychiatric disorders,"
but there has not been much written about how these conditions
intersect," she said.
Some symptoms of PTSD—avoidance and dissociation, for
example—can hinder an abused woman's ability to get out of a dangerous
situation, Warshaw pointed out. The symptoms "can prevent women from
mobilizing the resources they need to stay safe or to protect their children
from danger," she said, by increasing a woman's chance of being isolated
and controlled by an abusive partner.
According to Sandra Bloom, M.D., a Philadelphia psychiatrist and president
and CEO of Community Works, an organization focusing on reducing the potential
for conflict and violence in a number of settings, women who have endured
abuse can develop a wide-ranging set of maladaptive behaviors including
substance abuse, aggression, criminal behaviors, and self-harming behaviors
such as cutting "that are all ways to cope with unmanageable
Abuse can disrupt a person's ability to form normal attachments with
others, Bloom noted, resulting in problematic relationships for the person who
has been abused. In these relationships, "there may be no sense of
boundaries because [the abused person's] boundaries have been repeatedly
violated," she said.
Psychiatrists who work with those who have been abused "will see
people who have learned to be helpless because they cannot master the
violence" and feel powerless to stop it, Bloom said, but at the same
time are often controlling "because their lives are so out of
Those who have endured years of abuse may tend to feel demoralized and
profoundly hopeless, she said. A patient's basic assumptions about "the
world and self" have been shattered.
When treating patients who are victims of domestic abuse, Warshaw said,
psychiatrists should first determine whether their patient is safe. Some of
the questions psychiatrists should ask during a safety assessment include
whether the abuse is escalating in frequency, what is the nature or severity
of threats, whether the patient is being stalked, whether the abuser is
depressed or suicidal, and whether the abuser exhibits pathological jealousy
and has access to a weapon.
In addition, it's important to determine whether the patient is planning to
leave her abusive partner and whether the partner is aware of the plan.
Together, psychiatrist and patient can work to identify the risk factors
for escalating violence and strategies to reduce this risk. It's also a good
idea for psychiatrists and patients to develop a safety plan for the patient
to use when violence erupts in the home, Warshaw said. Determining a safe
location to which the patient can escape in an emergency and teaching children
how and when to call 911 may be part of that plan.
Psychiatrists can also refer abused patients to local domestic violence
programs or hotlines for additional information about the problem, she added.
Many domestic violence programs provide legal assistance, job training, and
In addition, psychiatrists should focus on patients' strengths and skill
development during treatment, Warshaw said. "Helping women access
aspects of themselves that have been lost after years of abuse" is
critical, she added.
More information about addressing the mental health needs of
domestic violence victims is posted online at<www.dvmhpi.org>.▪