Trauma therapy helps a woman understand that she is not “crazy” and that she is not the only one dealing with the psychological symptoms that come from exposure to trauma. Without the use of trauma-specific therapy techniques, a woman may be unable to move past psychodynamic barriers that make it more difficult for her to deal with her situation. Thus, focusing on the external “trauma triggers” rather than her own internal issues will help heal BWS symptoms.
Briere and Scott10 have outlined the various steps that need to be followed during trauma therapy with abuse victims. Changing her part in the family system, even if it is dysfunctional, may be dangerous.
Trauma triggers that cause PTSD and BWS symptoms need to be identified and behavioral techniques need to be used to reduce their potency. Behavioral techniques that are useful during this phase include relaxation training, guided imagery, and successive approximation with high arousal incidents. These behavioral and cognitive-behavioral techniques may also help the woman develop cognitive clarity over time.
Some women benefit from a description of the autonomic nervous system that regulates many of PTSD symptoms.
Typical trauma triggers include the memory of the way the batterer’s face or eyes look when he begins his abuse, the curse words he shouts, a particular phrase he uses to demean or humiliate, or even the aftershave he uses or other odors he emits during the abuse. Startle responses and hypervigilance to cues of violence are the last symptoms of BWS to be extinguished. In many women, these cues or trauma triggers never totally go away. This sensitivity can interfere with new relationships. It is often necessary to help a new intimate partner develop patience and understanding to save the new relationship, provided that it is nonabusive. Despite the myth that women often go from one abusive relationship to another, data suggest that fewer than 10% of all battered women do so.8
The STEP is a formal application of the combination of feminist and trauma therapy.16 This 12-unit program has been empirically validated with clinic and jail populations, and it is useful for women with substance abuse as well as for those with interpersonal violence issues.8 When STEP is used in institutions, such as jails or substance abuse treatment centers, a shorter, adapted version of the 12 topics listed in Table 3 is generally used. In clinics and in private practice, each STEP unit may be developed over several sessions. When asked about their satisfaction level after each session, all of the women who participated in this program gave positive comments that were highly correlated with the reduction in their scores on the Beck Anxiety Inventory.
DVDs of feminist therapy with a domestic violence victim17,18 and of a model 2-year treatment of a battered woman19 are available from www.psychotherapy.net.
Many battered women are involved in legal issues and need the attention of the psychotherapist to help them get through the stress and help them understand what they need to do and to help them provide information their attorney needs. The Federal Violence Against Women Act (US Congress, 2005) provides numerous legal remedies, including declaring abuse as a violation of a woman’s human rights with subsequent opportunity for a federal lawsuit under the civil rights statutes.
Litigation frequently involves child custody and access to children. Each state has its own laws regarding parental responsibility, but they all usually presume that it is in the best interests of the child(ren) to have equal access to both parents. Unfortunately, batterers often use the children to continue their control over their ex-wives, so that it is difficult, dangerous, and usually impossible to share parental responsibility. Nevertheless, the parent whom the family court judge considers most likely to facilitate a friendly relationship with the other parent is often given greater access to the children. Mothers who try to protect their children from fathers who lack good parenting skills or who are actually abusing the children20,21 are frequently seen as engaging in “hostile and aggressive parenting,” “parental alienation syndrome,” “psychological Munchausen by proxy,” or other similar nonempirically based disorders. They often lose custody and sometimes even all access to their children. (See http://www.Leadershipcouncil.org for more information on the danger to children after separation and divorce.)
Mothers who have lost their children frequently become depressed in addition to their trauma symptoms and are unable to fight the legal system without money or psychological energy to do so.22 Their children may end up physically, sexually, and psychologically abused by the batterer—regardless of whether he has custody, and especially if the children do not follow his orders.20
In rare cases, battered women will kill their abusive partners rather than be killed themselves. As cited by the Bureau of Justice Statistics, fewer than 1200 battered women kill their batterers, while over 4000 women are killed by the men who batter them.1,23,24 The most deadly time for a woman is when the batterer believes their relationship is over. Batterers often threaten to kill rather than to let their partner go.
1. Bureau of Justice Statistics Selected Findings. Violence Between Intimates (NCJ-149259). Washington, DC: US Department of Justice; November 1994.
2. Brown LS. Subversive Dialogues: Theory in Feminist Therapy. New York: Basic Books; 1994.
3. Walker LE. The Battered Woman. New York: Harper & Row; 1979.
4. American Psychological Association Presidential Task Force on Violence and the Family. Violence and the Family. Washington, DC: American Psychological Association; 1996.
5. Goodman LA, Koss MP, Fitzgerald LF, et al. Male violence against women. Current research and future directions. Am Psychol. 1993;48:1054-1058.
6. Centers for Disease Control and Prevention. Costs of intimate partner violence against women in the US.Washington, DC: US Department of Health and Human Services; 2003. http://www.cdc.gov/ncipc/pub-res/ipv_cost/ipv.htm. Accessed May 19, 2009.
7. American Psychological Association. Final Report of APA Working Group on Investigation of Memories of Childhood Abuse. Washington, DC: American Psychological Association; 1996.
8. Walker LE. The Battered Woman Syndrome.3rd ed. New York: Springer Publishing Company; 2009.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
10. Briere JN, Scott C. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage Publications, Inc; 2007.
11.Centers for Disease Control and Prevention. Behavioral risk factor surveillance system 2005 report; 2006. http://ftp.cdc.gov/pub/data/brfss/2005summarydataqualityreport.pdf. Accessed May 19, 2009.
12.Campbell JC, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93:1089-1097.
13. Centers for Disease Control and Prevention. Adverse health conditions and health risk behaviors associated with intimate partner violence—United States, 2005 [published correction appears in MMWR. 2008;57:237]. MMWR. 2008;57:113-117.
14. Charney DS, Deutch AY, Krystal JH, et al. Psychobiologic mechanisms of posttraumatic stress disorder. Arch Gen Psychiatry. 1993;50:295-305.
15. Babcock JC, Green CE, Robie C. Does batterers’ treatment work? A meta-analytic review of domestic violence treatment. Clin Psychol Rev.2004;23:1023-1053.
16. Walker LE. Abused Women and Survivor Therapy: A Practical Guide for the Psychotherapist. Washington, DC: American Psychological Association; 1994.
17. Browne A. Violence against women by male partners. Prevalence, outcomes, and policy implications. Am Psychol. 1993;48:1077-1087.
18. Walker LE. Feminist Therapy: Psychotherapy With the Experts Series.Needham Heights, MA: Allyn &Bacon; 1998.
19. Walker LE. The Abused Woman: A Survivor Therapy Approach. Assessment and Treatment of Psychological Disorders Video Series. http://www.psychotherapy.net/video/Abused_Woman. Accessed July 1, 2009.
20. Bancroft L, Silverman JG. The Batterer as a Parent: Addressing the Impact of Domestic Violence on Family Dynamics. Thousand Oaks, CA: Sage Publications, Inc; 2002.
21. Edleson JL. The overlap between child maltreatment and woman battering. Violence Against Women. 1999;5:134-154.
22. Clements CM, Sabourin CM, Spiby L. Dysphoria and hopelessness following battering: the role of perceived control, coping, and self-esteem. J Family Violence. 2004;19:25-36.
23. Bureau of Justice Statistics Special Report. Murder in Families (NCJ-143498). Washington, DC: US Department of Justice; 1994.
24. Bureau of Justice Statistics. Family Violence Statistics: Including Statistics on Strangers and Acquaintances. US Department of Justice. http://www.ojp.usdoj.gov/bjs/abstract/fvs.htm. Accessed May 19, 2009.
For More Information
• American Psychological Association Ad Hoc Committee on Legal and Ethical Issues in the Treatment of Interpersonal Violence. Potential Problems for Psychologists Working With the Area of Interpersonal Violence. Washington, DC: American Psychological Association; 1997.
• US Department of Justice. Violence Against Women Act (VAWA). 2005. http://www.ovw.usdoj.gov/regulations.htm.