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Intimate Partner Violence: Practical Issues for Psychiatrists

Intimate Partner Violence: Practical Issues for Psychiatrists

  • Contrary to accepted wisdom, women may be frequent aggressors.
  • Intimate partner violence has been found to take 2 separate forms: severe with significant risk of injury to the victim and mild or reciprocal with low risk of injury.
  • To treat a couple with intimate partner violence with couples therapy, guidelines to exclude severe violence should be followed and the couple screened for comorbid substance abuse/dependence, depressive disorders, and posttraumatic stress disorder.

The term “domestic violence” emerged in the United States with the rise of the women’s movement in the 1970s. Before that, violence between partners was considered a private matter. A specific type of domestic violence, intimate partner violence, refers to violence between intimate partners. Public awareness campaigns help us identify one type of intimate partner violence in which one partner, typically the male partner, is the aggressor, and the other partner, typically the female, is the victim. Educational programs encourage female victims of intimate partner violence to seek help by calling hotlines and, if necessary, going to safe houses or shelters. Twenty-five percent of women report being victims of partner violence during their lifetime, and 1.5 million women and 835,000 men report physical or sexual assault annually.1

In recent years, researchers have identified different types and patterns of intimate partner violence. Two discrete populations of intimate partner violence are now well recognized; one population coming to attention through the court and shelter system and the other distinct population existing in the community. The first population consists of the male batterer and female victim: the picture of domestic violence that is now well recognized as a significant social problem. The second population consists of couples in which intimate partner violence is less severe and in which violence is usually reciprocal or bidirectional, with both partners acting as perpetrators and experiencing victimization. In this type of intimate partner violence, serious injury generally does not occur, and the couple may not consider the violence to be a major relational problem.

Heyman and Slep2 have designated these 2 populations as partner abusive with impactful assaults and partner abusive with non-impactful assaults. Partner abusive with non-impactful assaults is recognized by other researchers as well. Johnson3 designated this non-impactful form of intimate partner violence as common couple violence, which is differentiated from patriarchal or intimate terrorism. Common couple violence occurs in 90% of violent couples and is found in surveys of the general population. Intimate terrorism occurs in 10% of couples who experience intimate partner violence and is found among the female victims who have sought refuge in women’s shelters and among men referred by the courts for anger management.

Reciprocity of violence, meaning that both partners act as aggressors and are victims of violence, has been reported by respondents in community surveys. In the US National Comorbidity Survey, 6.5% of women and 5.5% of men reported reciprocal physical violence.4 In the 2001 National Longitudinal Study of Adolescent Health, which assessed subjects aged 18 to 28 years, violence was reported in 24% of relationships, with half of these (12%) showing reciprocal violence.5 In cases of non-reciprocal violence (ie, 12% of relationships), women were the perpetrators in 70% of cases. Men were more likely to inflict injury than women, and reciprocal intimate partner violence was associated with injury more often than no reciprocal intimate partner violence.

The fact that women are frequent aggressors has also been identified in a meta-analysis of 82 studies.6 In fact, women are slightly more likely than men to report using physical aggression in intimate relationships, according to Archer.6 These findings are also reported in a study of couples seeking outpatient treatment, in which 61% of husbands and 64% of wives were classified as aggressive.7 Of concern, in a sample of 272, presumably happy couples planning on marrying, 44% of women and 31% of men reported having been physically violent toward their partners.8

What is the relationship between these 2 types of intimate partner violence? Are there truly 2 distinct types, partner abusive with impactful assaults and partner abusive with non-impactful assaults, as suggested by Heyman and Slep,2 or is there a continuum, with milder reciprocal intimate partner violence at one end of the spectrum and severe intimate partner violence at the other end? Heyman and Slep2 state that partner abusive with impactful assaults is associated with aggressive males; a history of developmental risk factors, such as parental conflict; frequent chronic acts of violence; and use of power and control tactics. There is more belligerence and contempt expressed during conflict, and the female partner is fearful.2 Syndromes such as battered woman syndrome, a type of posttraumatic stress disorder (PTSD), are consequences of partner abusive with impactful assaults.9 Little is known about the characteristics of couples who experience partner abusive with non-impactful assaults because they are not generally well recognized.

Most agencies and health care providers are urged to screen and assess female patients for intimate partner violence and to refer appropriately. What changes should be made to the recommendations about screening based on these new findings? What should the general psychiatrist know about screening and about treatment referral? Should the psychiatrist look for reciprocity? If couples request couples treatment, what should the psychiatrist advise? The following discussion attempts to answer these questions.


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