Domestic violence: the psychosocial impact and ...

Domestic violence: the psychosocial impact and perceived health problems Gayle Brewer Lecturer, School of Psychology, University of Central Lancashire, UK

Mark Roy Senior Lecturer, School of Psychology, University of Central Lancashire, UK

Yvonne Smith Postgraduate, School of Psychology, University of Central Lancashire, UK

ABSTRACT Self-reported health (and the extent to which this was associated with partner abuse or psychosocial variables) was investigated in 132 women recruited from a domestic violence service. The survey instrument included abuse disability, life event and daily stress exposure, social support, anger expression style, and perceived health status. The prevalence estimates for this sample were significantly higher than standard estimates across a range of health problems. Regression models demonstrated that whilst the extent of partner abuse predicted the prevalence of three conditions, psychosocial factors were more substantial predictors of health and well-being in domestic violence victims. Of these, life event frequency and anger expression were the most significant. These findings provide important information about the health of domestic violence victims as they seek support from domestic violence agencies, with relevance for practitioners working with victims who have terminated a violent relationship and for those supporting victims who remain with a violent partner.

KEY WORDS Domestic violence; perceived health; stress; victimisation.

Introduction Domestic violence is the single most common cause of violence-related trauma in women (Rand, 1997). Despite underreporting (Smith, 1989), domestic violence accounts for 16% of UK violent crime, and has more repeat victims than other crimes (Nicholas et al, 2005), highlighting the threat posed to a substantial proportion of the population. Although domestic violence raises important concerns about victims’ safety, its effects are more extensive, with serious implications for the physical health and psychological well-being of sufferers. The severity of the relationship between domestic violence and health status (both physical and

psychological) is reinforced by the finding that victims generate 92% more lifetime healthcare costs than non-victims (Wisner et al, 1999). For example, sufferers are more likely to visit the accident and emergency department, visit primary care practitioners and contact mental health agencies than normative populations (Bergman et al, 1992). Women from violent relationships are more likely to judge their health status as poor or fair than women who have not experienced this form of abuse (Ratner, 1998). These judgements do not simply reflect a bias towards negative reporting, and in fact appear to

10.5042/jacpr.2010.0137

4

Journal of Aggression, Conflict and Peace Research • Volume 2 Issue 2 • April 2010 © Pier Professional Ltd

Domestic violence: the psychosocial impact and perceived health problems

underestimate the extent to which the victim’s health is affected. Sutherland et al (2002) report that the domestic violence victims describing their health status as good, actually attended health centres several times in one month and reported at least 21 symptoms, including pain, fatigue, sleep problems, headaches, and musculoskeletal and back-pain difficulties. Mental health is also compromised among those experiencing domestic violence, and the incidence of depression and post-traumatic stress disorder is greater amongst female victims than those experiencing childhood sexual abuse (Golding, 1999). Highlighting the severity of this association, victims of violent relationships are also more likely to attempt suicide (Stark & Flitcraft, 1991). The extent to which mental illness is a consequence of domestic violence or a factor that increases the vulnerability of an individual remains unclear. As outlined, there is a clear relationship between the experience of domestic violence and poor health status. However, the degree to which health status (with the exception of direct physical injury) is linked directly to the extent of partner abuse (abuse disability) itself remains unclear. A number of variables, such as additional life stressors and health-related coping behaviours, may influence this relationship. The current study investigates the health status of domestic violence victims in conjunction with other important variables, such as the experience of stress, anger and social support. Domestic violence victims experience stress both during an actual episode and when anticipating its onset (Mitchell & Hodson, 1983). Whilst public concern focuses on the direct physical trauma experienced by victims, the importance of the subsequent stress should not be underestimated. Adler & Matthews (1994) indicate that stress indirectly contributes to 80% of victims’ health problems. Among the health problems most prevalent are gastrointestinal problems, eating disorders, viral and heart problems (Coker et al, 2000), consistent with the experience of chronic fear and stress. According to Cohen & Herbert (1996), stress can affect the individual’s health through direct physiological disturbance of neuroendocrine and immune systems, leading to increased susceptibility through processes such as allostatic load. It can also affect health through the reduction of adaptive coping responses and the increase in maladaptive coping behaviours such as smoking

or drinking. Thus, the relationship between stressful environments, such as a violent relationship and poor health, could develop on a number of levels. Domestic violence is related to a number of negative health-related behaviours or coping strategies. Experience of domestic violence is the strongest predictor of alcoholism in women (Miller, 1990). Increased alcohol intake may have a direct influence on a victim’s physical or mental health; it may also reduce a person’s ability to comprehend their situation or make effective decisions regarding their future. Domestic abuse may also have an impact upon women’s health through the suppression of emotional states perceived to risk engaging threat or disapproval. In particular, domestic violence may inhibit the expression of anger. This is consistent with previous research outlining the extent to which fear of rejection and violence inhibit assertive expression (Cox et al, 2004). The abusive environment may therefore restrict the extent to which a person can act on their feelings (Lerner, 1985), with victims becoming more fatalistic about their ability to manage anger productively (ModcrinMcCarthy & Tollett, 1993). Women suppressing anger or subject to high levels of anger are more prone to cardiovascular illness, headaches, asthma, arthritis, high blood pressure and heart disease (Emerson & Harrison, 1990). Consequently, the abusive environment may compromise victim health by the suppression of emotional expression. As a psychosocial resource, social support has been shown to modulate psychobiological responses to stress (Roy et al, 1994) and has a greater influence on positive adaptation to a stressor than any other coping behaviour (Lu & Chen, 1996). Domestic abuse can be an isolating experience in which the perpetrator seeks to restrict the activity and social network of the abused partner, and may contribute to the poor health of domestic violence victims (Landenberger, 1989). Whilst the availability of social support represents an important predictor of morbidity differences (eg. Berkman & Glass, 2000), a robust social network may ameliorate the impact of stressors upon health (Todd & Worell, 2000). The previous literature clearly documents both the extent to which physical injury is endured by domestic violence victims, and the poor long-term health of individuals previously


5


in a domestic violence relationship. However, less is known about the health and health behaviours of women as they seek support from outside agencies. As women engage with domestic violence services, the emphasis is (appropriately) placed on the immediate safety of the victims and associated practical support, such as the gathering of evidence. Therefore, a more detailed understanding of the health of domestic violence victims at this stage could provide the basis for future support, encouraging the practice of positive coping strategies and health behaviours. Whilst the termination of a violent relationship may address physical safety, the negative health behaviour displayed by victims may continue. In fact, the introduction of novel stressors such as involvement with the judicial system or searching for new accommodation may exacerbate these activities. Consequently, poor quality of life and general health, together with an increased use of healthcare, continue for a considerable period after leaving the abusive relationship (Jones et al, 2006; Sutherland et al, 2002). This study explores the pattern of selfreported health in women recruited through a domestic violence support service. In the survey, participants were asked about their general perceptions of health, estimates of their utilisation of healthcare resources, and the prevalence/frequency of a range of symptoms. The extent to which the self-reported health was associated directly with the extent of the abuse (abuse disability) or associated psychosocial variables, such as the availability of social support, was investigated.

Method Participants Participants were recruited through a domestic violence service (DVS, Keighley), following a thorough risk assessment to ensure that contact would not constitute a threat to their safety. A total of 132 women (response rate 27%) consented to the study after the initial briefing, and returned the survey instrument. Participants were aged from 18 to 56 (Mean = 33 years, SD 7.7 years). The research was conducted in accordance with APA ethical standards and the research procedure was authorised by the host institution ethics committee.

6

Instruments The survey instrument comprised a number of questionnaires: The Abuse Disability Questionnaire (ADQ) (McNamara & Brooker, 2000; McNamara & Fields, 2001) is a 30-item measure depicting global impairment resulting from domestic violence, as well as specific areas of impairment. Items in this study were scored on a binary scale (0 = disagree and 1 = agree) with potential scores ranging from 0 to 30. Scale reliability was very high ( != 0.9). An example of the items is: ‘I feel trapped in my intimate relationships’. The Life Events Questionnaire (LEQ) (Roy et al, 1994) was derived from the Interview for Recent Life Events (Paykel, 1983), and asked about life event occurrence for the last 12 months from an inventory of 36 items. The frequency of events is used here rather than event impact severity, as it is regarded as more reliable and less susceptible to recall/affect bias (Turner & Wheaton, 1995). Reliability was not computed for the LEQ as it is an inventory of quasi-random events for which there is no expectation of association. An example of the items is: ‘Serious argument with someone living in the same house as you’. The Daily Stress Inventory (DSI) (Brantley et al, 1987) is a 58-item assessment of minor stressful event frequency over the last 24 hours. Again, as severity is potentially confounded by affect, only event frequency is used here. For the DSI, as with the LEQ, reliability estimates were not computed as items are independent of each other. An example of the items is: ‘Criticized or verbally attacked’. The Health Status Assessment Questionnaire (HSAQ) (Roy, 1994) has three sections: General Details, including age and perceived general health; Personal Health History, used to assess prevalence and symptom frequency across a range of health areas (eg. migraine, asthma, sleep problems and bowel disorders); Health Behaviours, including frequency of primary healthcare consultations, diet, smoking, alcohol and physical activity. For the HSAQ, as with the LEQ, reliability estimates were not computed as items are independent of each other. An example of items is: ‘What best describes your health generally? (Excellent, Good, Fair, Poor or Very Bad)’. The Social Support Network Inventory (SSNI) (Flaherty et al, 1983) is a measure of



perceived social network support. Overall SSNI scores (potential range 0–60) were computed from five support subscales (availability, practical support, emotional support, reciprocity and event-related support). The scaling of responses is from 1 = not true at all to 5 = very true. Sub-scale reliability was high for support availability ( = 0.74), practical support ( = 0.89) and reciprocity ( = 0.78), but low for emotional support ( != 0.35) and event-related support ( = 0.40). An example of the items is: ‘This person is available when I need them’. The State-Trait Anger Expression Inventory (Spielberger et al, 1985), a widely used measure of the propensity to express anger, it has three sub-scales measuring: Anger-In (suppression); Anger-Out (expression of anger toward other people/objects); and Anger-Control (the tendency to control the expression of anger). An overall Anger-Expression score is a general index of experiencing anger. The scaling of responses is from 1 = Almost never to 4 = Almost always, so that each subscale score can range from 8 to 32. Sub-scale reliability was moderate for the Anger-In subscale = 0.58, and the Anger-Control subscale = 0.70, but high for the Anger-Out subscale = 0.82. An example of the items is: ‘I express my anger’.

Results Descriptive statistics Abuse-related disability The proportion of global impairment reported by participants was 20/30 (SD = 6.3), and while binary item scoring made it impossible to directly compare scores with those in McNamara’s studies (109/180 in McNamara & Brooker, 2000, and 107/180 in McNamara & Fields, 2001), the proportion of disability would appear to be roughly comparable. Exposure to stress The mean frequencies of both stressful life event frequency over the previous 12 months and Daily Stress Inventory events are shown in Table 1, overleaf. One sample t-test showed that reported levels were significantly lower than for comparison groups in both cases. This suggests a tentative conclusion that exposure to domestic violence, at least in this study, rather than being associated with a greater frequency of stressful events, was associated with a lower

frequency than for individuals for whom there was no a priori expectation of either high or low levels of stress exposure. Furthermore, within the current sample, severity of abuserelated disability was uncorrelated with either measure of stress exposure frequency. Social support Social support presented an unexpected dilemma when it came to the analysis. The mean number of important providers of support reported was 1.4 (SD = 1.63, range 0–5). But 45.5% of the sample did not or could not identify anyone when asked to ‘identify by age and relationship up to five important people’. This imposed an effective dichotomy between support identifiers (non-zero responders) and non-support identifiers (zero responders). Therefore, subsequent analyses dichotomised participants into two groups: nonzero responders and zero responders. When the non-zero responders’ overall SSNI score was compared using a one-sample t-test to a pooled/heterogeneous reference sample, the results indicated a significantly lower level of social support in this sample (Table 1, overleaf). Anger expression Across the three subscales (Anger-In, AngerOut and Anger-Control), as well as the overall likelihood of experiencing feelings of anger (Anger-Expression), the sample means were significantly lower than for a matched normative sample of adult women (see Table 1, overleaf) and, in the case of Anger-In and Anger-Out, the sample mean fell into the tenth percentile range of the normative sample distribution. Self-reported health and symptom prevalence Responses regarding general health quality and patterns of health behaviours were compared to normative data, where age and gender matched comparisons were available, and z-tests performed to determine the significance of differences between study and normative samples (Table 2, overleaf). The proportion of participants reporting their health as good or excellent (Table 2, overleaf) was significantly lower than for either women in Census 2001 (Office for National Statistics, 2006) or in the European Community household panel (European Communities, 2004). Participants reported a much higher rate of primary


7


Table 1: Descriptive statistics and normative comparisons for psychosocial questionnaires Scale

Mean (SD)

Comparison data

Mean (SD) Significance

Exposure to stress and social support LEQ

4.7 (3.2)

90 male firefighters (mean age 25)1 80 mixed sample college age and retired African Americans2

7.7 (4.1)

t = 10.6, p