What I did not see was any comment on Dr Walker’s claim that battered woman syndrome (BWS) is a subcategory of PTSD. This should be news to the psychiatric community for 2 reasons.3 First, no DSM even mentions BWS, let alone lists it (or any other stressor) as a subtype. It might be argued that domestic violence is listed as a possible stressor (precipitant) to PTSD, but then so is a car accident. No one would presume to proffer a car accident subtype to PTSD. The symptoms are not trauma- specific. Second, the whole BWS research paradigm is based on convenience samples without appropriate control groups.
Battered women deserve better.
— Michael McGrath, MD
Webster, NY
Dr Walker Responds
It is interesting that both of these commentators focus on the use of the term Battered Woman Syndrome rather than the issue of recognizing and properly intervening with women who have experienced domestic violence and who come to their doctors for help—which was the major point of my article.
My research put a name on a group of signs and symptoms commonly seen by both researchers and clinicians that fill the psychological literature. The term Battered Woman Syndrome was first recognized from a National Institute of Mental Health (NIMH) funded study in which I was principal investigator from 1978-1981. Some continue to question the adequacy of the methodology because there was no experimental and control group. However, statistical advances have made it possible for computerized programs to hold variables constant while manipulating those to be studied so our virtual control groups will suffice statistically. Some of your readers may not realize that every funded study by NIMH (now part of SAMHSA) is carefully critiqued by an interdisciplinary panel of scientists who awarded me the grant and then carefully monitored our progress and actually recommended further funding (which, unfortunately, was not available in 1981 when we were supposed to continue our research). Fortunately, my university had some support for me to continue these investigations. The NIMH documents are available from the Freedom of Information Act for anyone who wishes to review the committee’s deliberations and decisions. Nonetheless, the term Battered Woman Syndrome has appeared in the psychological and medical literature since the early 1980s.
Dr McGrath comments that Battered Woman Syndrome cannot be a legitimate category because it is not listed by name in the DSM-IV-TR, which is true. However, it is listed in the World Health Organization’s International Classification of Diseases (ICD-10) as a medical disorder. ICD-10 apparently has decided to break with the DSM-V and produce its own psychiatric nosology for the ICD-11, looking toward psychological research for its scientific basis. I was an official representative of the American Psychological Association to the DSM-III-R and DSM-IV and know first hand the politics that compete with science to produce those nosologies. Interestingly, the DSM-V Task Force has apparently become even less transparent in their deliberations, sacrificing scientific scrutiny perhaps to protect from politics.
Publication in that nosology does not make the final decision in the health community about whether a disorder does or does not exist. In fact, Battered Woman Syndrome and its research appeared as early as 1977 in the psychological literature. A complete bibliography can be found in the latest edition of the Battered Woman Syndrome (Third Edition) published by Springer in 2009.
Dr Robbins comments that there is no support for the fact that I report that our society trains men to dominate and control women. Again, the psychological and sociological literature is replete with references to empirical studies about the different gender socialization of men and women, girls, and boys. Thirty years of attempts to reach equality in all areas of society still bring women only about $0.80 on the dollar in pay for equal work, and still keep women out of the top echelon in our nation’s corporations. As Hillary Clinton so eloquently stated, we have cracked some of the glass ceilings, but we still keep some women dependent on their husbands for fear of being alone.
As the Washington State Supreme Court stated in the Wanrow decision, the long and unfortunate history of sex role socialization has taught men to use parts of their bodies as weapons necessitating women to equalize their need for safety with guns and knives. No one is advocating for women to arm themselves against men, but the truth about domestic violence is that women are far more likely to experience physical injuries than are men. Even those who have attempted to study the impact of domestic violence on men have provided risk assessments that permit health professionals to help protect women from further abuse.
Finally, I’d like to address the comments about children who witness domestic violence. Although there was insufficient space in my article to discuss the damage that is done to these children psychologically, I do devote an entire chapter to the subject in my Battered Woman Syndrome book, and I have just completed a chapter in the soon-to-be-published Oxford University Press book on child abuse and neglect. Dr Robbins omits the fact that mothers are most likely to be found guilty of neglect while fathers are most likely to be the perpetrators of severe physical abuse that causes death of children. Further, the data show that boys are most likely the victims of physical abuse and girls are most likely to be sexually abused. Even more frightening are some statistics that suggest that up to 60% of men who batter women also physically or sexually abuse their children. The strongest risk factor for a boy to use violence in his life is witnessing his father battering his mother. Further, boys who witness their fathers battering their mothers were found to be 700 times more likely than those who were not exposed to domestic violence to batter in their own homes. If those boys were also abused themselves, it raised their risk to 1000 times the norm.
If domestic violence was considered a disease, those who spread violence would be quarantined. Let’s all learn how to work together to eradicate domestic violence in our lifetime. We know what to do. Let’s stop arguing over language and who does what to whom and offer the help that these families need from us.
—Lenore E. Walker, EdD, ABPP-Cl & Fam
Board Certified in Clinical and Family Psychology
Professor & Coordinator
Clinical Forensic Psychology Concentration
Nova Southeastern University
Center for Psychological Studies
Fort Lauderdale, Florida
Dr McGrath responds:
Dr Walker presents a trauma syndrome (Battered Woman Syndrome, BWS) based on her research, which she claims is diagnosable and treatable. However, criticism of her research methodology is deflected by appealing to her good intentions in wanting battered women to be identified and treated. Dr Walker fails to appreciate that one can empathize with victims of domestic violence, and advocate for their identification and treatment, yet not accept her BWS paradigm.
I will address her response to my 2-point critique1 of her work:
1. Asserting that BWS is a subtype of the DSM diagnosis of PTSD without indicating that the DSM has never condoned or even mentioned BWS is both misleading and factually incorrect.
2. The BWS research paradigm suffers from the fact that it is based on convenience samples without appropriate control groups.
What follows is a synopsis of Dr Walker’s response to my critique of her Psychiatric Times article.2 I have included further commentary and critique. (W= Dr Walker and M=Dr McGrath.) When Dr Walker refers to more than one commentator, she is referring to Dr Arnold Robbins3 and me. I felt the need to respond to Dr Walker’s response because she misunderstood an aspect of my first point and I was concerned a reader might think she had adequately addressed my second concern.
W: “It is interesting that both of these commentators focus on the use of the term Battered Woman Syndrome. . .”
M: This aspect of the criticism is hard to understand, because BWS is the term Dr Walker created and continues to use to describe the purported syndrome.
W: “. . . rather than the issue of recognizing and properly intervening with women who have experienced domestic violence and who come to their doctors for help—which was the major point of my article.”
M: I focused on what I believed required critique. It is interesting that Dr Walker deals with criticism of aspects of her article by appealing to the totality of her article, rather than the specific criticism. By this rubric, it would be acceptable to include inaccurate or misleading information in an article, as long as your intentions are good and most of what you write is acceptable.
W: “My research put a name on a group of signs and symptoms commonly seen by both researchers and clinicians that fill the psychological literature.”
M: There is also much critique filling the literature of the group of signs and symptoms being espoused for BWS.
W: “The term Battered Woman Syndrome was first recognized from a National Institute of Mental Health (NIMH) funded study in which I was principal investigator from 1978-1981.”
M: This is an appeal to authority and by itself proves nothing about the results of the study.
W: “Some continue to question the adequacy of the methodology. . .”
M: I would argue that over the years many have questioned the adequacy of the methodology.4
W: “. . . because there was no experimental and control group. However, statistical advances have made it possible for computerized programs to hold variables constant while manipulating those to be studied so our virtual control groups will suffice statistically.”
M: Statistical advances notwithstanding, this does not change the fact that there were and are no appropriate control groups. Certainly this omission could have been rectified during the 30-some-odd years of research. Why settle for statistical acrobatics when an appropriate control group would be so much better? Surely there must be some non-battered women in the world. Also, not addressed is the fact that the population from which the “virtual” control groups was selected is a convenience sample that may or may not represent the true population of domestic violence victims.
W: “Some of your readers may not realize that every funded study by NIMH (now part of SAMHSA) is carefully critiqued by an interdisciplinary panel of scientists who awarded me the grant and then carefully monitored our progress and actually recommended further funding (which, unfortunately, was not available in 1981 when we were supposed to continue our research).”
M: If I am reading this correctly, as well as chapter 3 of the latest edition of BWS by Dr Walker, NIMH funded her study of 400 women in 1977, or thereabouts. Obtaining such funding is clearly something to be proud of. It does not, however, prove the validity of BWS. That would be up to the completed research itself, as published by Dr Walker, as well as replication by others. Dr Walkers BWS research has been consistently criticized with no convincing (in my opinion) rebuttal. That an institution such as NIMH funded a study does not guarantee the study is without flaws. For example, an NIMH funded study of suicidal behavior and antidepressants has been criticized on many levels, one of which was not having appropriate control groups.5 Interestingly, a Department of Justice Report,6 partially funded by NIMH, had significant critique of BWS as promulgated by Dr Walker. Which NIMH are we to rely on: the one that funded the initial study, or the one that funded a critique of it?
W: “Fortunately, my university had some support for me to continue these investigations. The NIMH documents are available from the Freedom of Information Act for anyone who wishes to review the committee’s deliberations and decisions.”
M: As noted, that NIMH funded the research now, or as in this case, several decades ago does not prove the research findings are valid.
W: “Nonetheless, the term Battered Woman Syndrome has appeared in the psychological and medical literature since the early 1980s.”
M: Critiques of BWS have appeared in the psychological and medical literature since the 1980s. Assuming we must allow for a lag period before critics can uncover and address concerns, the criticism has consistently followed the work. The fact that there is literature, medical or otherwise, dating from some date is not prima facie evidence of validity. If it were, then the pseudoscience of chiropractic must be accepted by mainstream science, as it dates from the 1890s. It also has many adherents, and practitioners can become licensed to practice it in this country. But it is still pseudoscience.
W: “Dr McGrath comments that Battered Woman Syndrome cannot be a legitimate category because it is not listed by name in the DSM-IV-TR, which is true.”
M: I did not claim it could not be a legitimate category because it does not appear in the DSM. What I did do was point out that Dr Walker’s claim that BWS is a subtype of the diagnosis of PTSD as found in the DSM is an opinion, not a fact. While I do not think BWS is a legitimate diagnosis for many reasons not included in my original critique, this is not based on its not appearing in the DSM. Making the claim that BWS is an accepted subtype of the DSM-listed PTSD is (in my opinion) an attempt at legitimacy by association.
W: “However, it is listed in the World Health Organization’s International Classification of Diseases (ICD-10) as a medical disorder.”
M: Note that the inclusion is “as a medical disorder.” ICD-10 lists: T-74.1 Physical Abuse: Battered: Baby or child syndrome NOS and Spouse syndrome NOS. Regardless, the fact that ICD-10 lists some form of a battered person or syndrome does not make it a factual psychological syndrome as proposed by Dr Walker. It should not go unnoticed that the ICD-10 “battered spouse syndrome NOS” is not included in the ICD-10 Classification of Mental and Behavioral Disorders, but is only available as a medical diagnosis and no diagnostic criteria are listed. How could it be inferred that the ICD-10 listing of a medical battered syndrome be support for Dr Walker’s BWS? This also appears to be an attempt at legitimacy by association.
W: “I was an official representative of the American Psychological Association to the DSM-III-R and DSM-IV and know first hand the politics that compete with science to produce those nosologies.”
M: We have no disagreement here.
W: “Interestingly, the DSM-V Task Force has apparently become even less transparent in their deliberations, sacrificing scientific scrutiny perhaps to protect from politics.”
M: Yes and no. The sacrificing of scrutiny reduces political influence, but can also reduce input from informed and concerned practitioners and other behavioral scientists. Lack of outside scrutiny does not protect from internal political influence. But what does this have to do with BWS? Is Dr Walker suggesting that BWS was kept out of the DSM for political reasons? As an official representative of the American Psychological Association to the DSM-III-R and DSM-IV, surely she would have raised an alarm.
W: “Publication in that nosology does not make the final decision in the health community about whether a disorder does or does not exist.”
M: Dr. Walker and I agree. This comment is a misunderstanding of my position.
W: “In fact, Battered Woman Syndrome and its research appeared as early as 1977 in the psychological literature. A complete bibliography can be found in the latest edition of the Battered Woman Syndrome (Third Edition) published by Springer in 2009.”
M: See above. The fact that there is literature dating back to 1977 on BWS does not prove it is a valid diagnosis.
W: “If domestic violence was considered a disease, those who spread violence would be quarantined. Let’s all learn how to work together to eradicate domestic violence in our lifetime. We know what to do. Let’s stop arguing over language. . .”
M: Language is and always has been important to science. In the scientific arena, one is responsible for what one publishes.
W: “… and who does what to whom and offer the help that these families need from us.”
M: This is a recap of the appeal to motivation. Because Dr Walker’s motivation is presumed to be above reproach (ie, identifying and helping battered women), others (presumably who will not share her humanitarian ideals) should not critique her research.
I would like to close by making something very clear. My critique is of BWS, not battered women. I believe that victims of domestic violence suffer and need help. I believe that PTSD or other diagnosable mental conditions develop because of domestic violence.
Michael McGrath, MD
Webster, NY
REFERENCES
1. McGrath M. More on battered woman syndrome: news to the psychiatric community? With response from Dr Walker. Psychiatric Times. October 26th 2009.
2. Walker LE. Battered woman syndrome: key elements of a diagnosis and treatment plan, Psychiatric Times. 2009;26(7): http://www.psychiatrictimes.com/display/article/10168/1426560
3. Robbins A. Battered patient syndrome? Psychiatric Times. September 22nd 2009.
4. McGrath M. Psychological aspects of victimology. In: Turvey B, Petherick W, eds. Forensic Victimology: Examining Violent Crime Victims In Investigative And Legal Contexts. New York; Elsevier: 2009; 229-264.
5. http://www.ahrp.org/cms/content/view/94/55/
6. USDOJ/DHHS. (1996). The Validity and Use of Evidence Concerning Battering and Its Effects in Criminal Trials (No. NCJ 160972). Washington, DC: USDOJ, OJP, NIJ and DHHS, NIMH.
Dr Robbins responds:
I think Dr McGrath's reply is masterful and superb. I can add little to it except my complete agreement with it.
I might again point out that numerous recent, carefully done and controlled studies have shown clearly that being a victim of battering is NOT gender-specific. Even the lay press has been full of the reports regarding the murder of Steve McNair and the battering of Tiger Woods. Dr Walker’s strict focus on BWS thus is likely to have a strong political agenda, which may to some degree explain its lack of scientific integrity.
Arnold Robbins, MD
