Research Topic and Paper on Efficacy of Cognitive Behaviour Therapy and Client Centred Therapy on Treatment of Depressive Symptoms Among Female Domestic Violence Survivors
This chapter focuses attempts a conceptualization of the definition of domestic violence and an understanding of its prevalence. The chapter progresses to evaluate the various forms of domestic violence experienced by survivors as well as factors contributing to occurrence of domestic violence. In addition, the chapter explains the psychological effects of domestic violence and how they affect women.
Domestic violence, is also known as domestic abuse, wife beating, dating abuse, spousal abuse, family violence, and intimate partner violence (IPV). It is a pattern of behavior which involves the abuse by one partner against another in an intimate relationship such as cohabitation, marriage, dating or within the family sub-systems. Domestic violence includes physical hostility or assault which may involve one partner throwing objects, hitting, slapping, biting, shoving, restraining, battering or threating the other. Domestic violence also takes the forms of sexual abuse, controlling or domineering, stalking, intimidation, neglecting and economic deprivation (Dutton, 1994). It involves incidents of frightening behavior, violence or abuse be it sexual, psychological, physical, financial or emotional between adults who are or have been intimate partners or family members regardless of gender or sexuality. Studies have acknowledged violence as a result of interpersonal interactions of individual relationships and environmental factors (Heru, 2007). According to Heru (2007), many community and clinical studies have found that intimate partner violence is often two-sided or bidirectional, where each partner is both an aggressor (perpetrator) and a victim.
According to Ogbuji (2015), domestic abuse is any hurtful word or behavior from a spouse against his/her partner or children that is intentionally threatening and or inflicting pain. Domestic violence involves various aspects of human living such as physical, emotional, psychological, social, economic/financial, verbal, or spiritual. Feminist understandings shaped by the lived experiences of abused women and supported by research evidence have aided to develop conceptualization of domestic violence as physical force, physically injurious assault, coercive and controlling behaviors that cause psychological, interrelated range of abusive treatment, sexual or physical harm to the victim (Barnish, 2004). This definition concentrates largely on both genders, consistent with the evidence concerning main abuse trends.
The main research findings are to the extent dynamic in relation to domestic violence. They expound the theories, factors associated with vulnerability to victimization, perpetrator types, risk markers for perpetration, the harm done to women, and women’s reactions to domestic violence. However, some issues of terminology remain disputed if domestic violence should be a gender-specific or neutral referent encompassing all forms and incidents of abuse in all types of intimate relationships. The fact remains that abuse and violence have affected an individual in a trusting environment and relationship.
According to the United Kingdom criminal justice system, domestic violence is any assult between current and former partners in an intimate relationship. This kind of violence includes sexual, physical, emotional and financial abuse, and use of children (Barnish, 2004). Some organizations, including some police services and national probation services, incorporate abuse in other close relationships into their definitions. Police definitions generally limit their additional scope to violence towards adult family members, whereas definitions by probation and child protection services (CPS) includes child abuse, though the CPS limits its sphere of activity to criminal offences (Criminal Justice Trials Commission, 2015; Population Council, 2008).
The United States government has defined domestic violence as abusive behavioral patterns in a given relationship, deemed by one partner as a mileage to acquire or maintain power (social or political) and control over another intimate partner (Dutton, 1996). Anyone can experience domestic violence regardless of age, race, religion, sexual orientation, or gender and can take many forms, including
physical abuse, sexual abuse, emotional abuse, economic, and psychological abuse (Violence Against Women, 2011).
According to Adams and Bybee (2008), there is also economic abuse, which happens when one intimate partner has control over the other partner’s right to use economic resources. This diminishes the victims’ capacity to support oneself and forces him or her to depend on the perpetrator financially. Domestic violence cannot be narrowed to the obvious physical violence but also it involves all forms of endangerment, kidnapping, criminal coercion, harassment, unlawful imprisonment, trespassing, or stalking (National Network to End Violence, 2008/DC 2011).
2.2Prevalence of Domestic Violence
Prevalence is about some of the occurrences and frequencies of domestic violence. Domestic violence happens all over the world in various cultures and it affects people from all societies irrespective of economic status. According to the Bureau of Justice Statistics of United States in 1995, women reported a six times greater rate of IPV than men. Nevertheless, studies have found that men are much less likely to report assault when it occurs (Flury & Riecher-Rossler, 2010). According to Demographic Briefs on Domestic Violence (DBDV), reports show that minor force such as a slap is 49% among women compared to 36% men who sustain physical injury. Severe force such as choke, strangling, use of weapons has 77% women and 56% men who sustain physical injury (Flisher, Myer, Merais, Lombard, & Reddy, 2007).
A summary of Archer’s meta-analysis of domestic violence prevalence demonstrates that women experience 65% of domestic violence injuries (Langhinrichsen-Rohling, 2005). The World Conference on Human Rights held in Vienna the year 1993, as well as the Declaration on the Elimination of Violence against Women concluded that civil society and governments agreed that violence against women is a public health and human rights alarm. According to police records, 95% of child abuse victims in Nicaragua were girls, while according to anonymous population-based surveys, 70% of child abuse victims were girls and 30% boys (Flury & Riecher-Rossler, 2010). One can only be interested in following up and observing the future lives of such children to see how they progress in their lives. They may be living in fear, anxiety or depression, having been exposed to domestic violence at a vulnerable age. Some of them could be “skilled” perpetrators, repeating on others what was done to them. The thinking would be so distorted that they see no harm in abusing their relationship partners (Black, 2011).
Cases of domestic violence are under-reported. Therefore, the degree of seriousness and nature of offence are compromised due to stigma especially as regards sexual violence. Usually, these incidents go unreported but are treated in health facilities (Henrica & Jansen, 2009; Kantor, Jasinski, Williams, 2007). This means a lot of violence takes place in families but is kept secret for reasons best known to the victims. Over the centuries, many women have often been treated with cruelty in patriarchal societies (Ogbuji, 2015). Patriarchal society is a social setting where men are the heads of the families and thus women and children are under the authority of men. This kind of social setting is practiced
but it is sometimes abused and becomes oppressive when the power invested in men is misused. In patriarchal society settings, many women suffer exploitation in forms of denial of inheritance, economic marginalization, lack of formal education, wife battering, wife inheritance, sexual abuse including incest and rape (Ellsberg, 2006).
2.3 Forms of Domestic Violence Experienced by Survivors
Domestic violence is characterized by all sorts of maltreatment. Maltreatment is a behavior towards another person which is outside the norms of conduct, and entails a substantial risk of causing physical, psychological and emotional harm. These maltreatment patterns are also referred to as assaults. The commonly known assaults globally include sexual assault, physical assault, financial coercion, psychological and emotional abuse, verbal assault and neglect. These are briefly discussed below.
Physical abuse: Physical acts by a partner, spouse, parent, guardian or caretaker that cause physical injury to the victim. The perpetrator slaps, hits with a fist, kicks, hits against the wall, shoves, strangles, burns, stabs or uses other crude objects to inflict pain on the victim’s body.
Sexual abuse: This occurs when one of the partners is forced into sexual activity when they are not ready or they are prevented from using birth control measures. Sexual abuse as well occurs when adults who are step-parents, older siblings or other relatives molest underage children by luring them to some favors or threatening to withdraw privileges for the exchange of sexual activities. Sexual assault also includes fondling and exposure to indecent acts to family members who are not of age or willing.
Psychological and emotional abuse: This type of abuse is experienced when a partner demeans the other, tries to isolate the other partner for example by taking sides, leaving the victim alone without informing him or her the whereabouts. It occurs also when the victim is followed, stalked and not allowed to be independent. Victims can be traumatized when the perpetrator involves children in their abuse, use children to spy on them or obstructs the victim from visiting their children in school.
Financial coercion: This especially involves decision making on financial expenditure. In this case, one of the partners decides, without involving the other partner, on how finances are to be managed in a household. In addition, financial coercion occurs when one partner mishandles family finances or leaves little amount of money for family expenditure. Lastly, financial coercion is experienced when one of the partners attempts to use money and other goodies to control the other partner.
Verbal assault: This occurs when one of the partners uses insults, put-downs and name calling among others, which are inappropriate and intimidating to the other partner. Sometimes verbal assault can include the tone, pitch, and other non-verbal gestures, and body language.
Neglect: This is when the perpetrator does not play the expected roles of providing for the needs of the family such as food, clothing, medical care and education, among others. Furthermore, neglect can manifest itself when the vulnerable, especially a disabled or marginalized member of the family, is not attended to in the right manner. In addition, when the perpetrator abandons the family or tries to sabotage the parenting skills of the other partner, this harms the family wellbeing.
2.4 Factors Contributing to Domestic Violence
There are several factors related to likelihood of domestic violence occurrence, that is, victimization or perpetration between the partners. Risk factors for victimization and perpetration include childhood physical or sexual victimization, social and economic factors, alcohol and drug abuse, among others. These factors can be seen from a dimension of individual, relational, community and societal factors, that contribute to the risk of one becoming a victim or perpetrator of domestic violence. The awareness of these multilevel factors can aid in identifying various opportunities for prevention.
To start with, a number of studies have reported populations most at risk for domestic violence are those that have tendencies to have imbalance of power and control (Heise & Garcia-Moreno, 2002). Some people with very strong traditional beliefs, especially in patriarchal societies, believe that they are justified by their culture to control their partners. In addition, both men and women think that they are not equal. This brings about gender inequality and discrimination that cuts across public and private spheres of life, across cultural, political, social and economic rights (UN General Assembly, 2006). Coming from such a background, men are seen to be the most perpetrators of domestic violence while women and girls are victimized and marginalized in many aspects of life. Some cultural practices reinforce women and girls subordination while tolerating male violence, consequently encouraging male dominance. For example, some practices such as paying bride price are used by some men as a justification of dominating their spouses (Mbiti, 1999).
Secondly, Social economic factors contribute to occurrences of domestic violence. Studies show that domestic violence cuts across household income brackets. However, domestic violence is most frequent among the poor people who earn little household income or are completely unemployed. Limited economic opportunities aggravated by underemployment of men put their women at a higher risk of domestic violence. In addition, women and girls facing financial constraints are forced into child marriages, sexual exploitation by perpetrators and in some instances trafficking to other countries as slaves and for labor (Jenna, 2003).
Inter-ethnic relationships, religion and race (mixed marriages) are other factors which contribute to domestic violence. For example, in some African communities inter-ethnic relationships are discouraged. When some females get married in other ethnic communities, they experience
victimization from the local communities partly because they are seen as outsiders and different. Furthermore, marriages between inter-denominations are seen to experience higher rates of domestic violence. Lastly, in Western countries, black females experience higher rates of victimization when they get married to white males as compared to white females getting married to white males (Tjaden and Thoennes, 2000).
According to Heru (2007), domestic violence can be repeated from person to person or generation to generation if the correct interventions are not put in place in good time. This is because an abused individual can be an abuser in due time. Reccurrence of abuse is also attributed to children growing up and witnessing violence in their families or to children who experience bullying while growing up in their families or in school. Furthermore, when perpetrators convicted of domestic violence offences are released from prison, a good number of them often take revenge against their partners who had sent them to jail (Capaldi, et al, 2012).
Some studies have shown that women experience domestic violence from their partners when they are pregnant (Kamweya et al., 2013). This is because these women are in vulnerable conditions where they are not able to support themselves or meet the gendered roles. The perpetrators abuse them which consequently can affect the unborn baby in various ways such as miscarriage, low birth weight, premature births, fetal death and birth defects, (Heise & Garcia-Moreno, 2002).
People who abuse alcohol and other drugs are at a higher risk of causing domestic violence. This is because these people have little control of their behaviour due to the fact that they have no inhibitions. In addition, these people have difficulties in regulating their emotions such as anger and other strong emotions when they are intoxicated. Furthermore, they misuse household income, especially in sub- Saharan Africa where some perpetrators spend a lot of time in alcohol dens and ignore their responsibilities in family life (Khasakhala, 2013).
Some psychologists believe that biological or genetic factors predispose perpetrators to cause domestic violence. This is attributed partly to the hormone testosterone which is quite high in men making them to be over controlling and domineering against opposite gender. In addition, neuroanatomical variances and other biological factors in men and women lead to men’s tendency to be violent against women (Kantor & Jasinski, 1998).
Another factor which leads to domestic violence or put women and girls at a greater risk of violence is age. Females aged of 16 to 24 are at a higher risk of domestic violence. Mostly, these are females who are in high school, colleges, or are just settling down in relationships. The last factor is when some people have victim-blaming ideas which predispose them to become victims of domestic violence. For example, some victims believe that they are the ones to blame for the abuse. They see themselves as the cause of domestic violence because of their behaviour, mode of dressing, physical appearance, sexual orientation, among other irrational beliefs and personal judgements. In other cases, when the victim feels the need to terminate a relationship for practical reasons, there are some perpetrators who, out of anger, inflict pain onto the victims for lack of better ways to deal with the loss (Stith et al., 2004).
2.5 Psychological Effects of Domestic Violence
Negative effects of domestic violence are experienced differently by different individuals who have suffered or witnessed violence (Friedman, Loue & Goldman, 2011). Intimate Partner Violence (IPV) leads to youthful drugs and alcohol abuse, low income, low academic achievement, low self-esteem, as well as aggressive or delinquent behavior. Other symptoms of domestic violence are prior history of being physically abusive, antisocial personality traits, depression, borderline personality behaviors, anger, hostility, having few friends and being isolated from other people (Flury, Nyberg & Riecher- Rossler, 2010).
According to Lloyd, Taluc, Max, Rice, Finkelste and Bardwell (1999), there are several negative effects of domestic violence which include belief in strict gender roles (like male dominance and aggression in relationships), having a history of poor parenting experiences as a child, lack of employment, desire for power and control in a relationship, emotional dependence and insecurity, perpetrating psychological aggression, being a victim of physical or psychological assault, experiencing physical violent discipline as a child, among others, predisposes one to manifesting negative effects of domestic violence (Lloyd, et al., 1999; Leadbetter, 2004). According to Black et al., (2011), victims of frequent violence experience more severe consequences than victims of one- time incidents.
Besides deaths and injuries, physical assault by an intimate partner is also related to a number of adverse health outcomes (Black, 2011; Breiding, Black & Ryan, 2008). These conditions include
cardiovascular, gastrointestinal, endocrine and immune systems, which are due to chronic stress and other metabolic conditions (Black, 2011; Crofford, 2007; Leserman & Drossman, 2007). Other health disorders associated with IPV include bladder and kidney infections, fibromyalgia, asthma, gastrointestinal disorders, circulatory ailment, cardiovascular disease, joints disease, irritable bowel syndrome, chronic pain syndromes, central nervous system disorders, migraines and headaches, among others (Black, 2011).
Tjaden and Thoennes (2000) posit that domestic violence, whether physical, sexual, or psychological, can cause various psychological consequences to victims. These include antisocial behavior, anxiety, depression, and PTSD, suicidal behavior in females, low self-esteem and failure to trust others, especially in intimate relationships. More negative consequences are emotional detachment, fear of intimacy, flashbacks, sleep disturbances, and replaying assault in the mind. Such conditions are very common and sometimes not easily noticed. Victims of IPV sometimes face certain social consequences such as limited access to services, stressed relationships with health service providers and employers, seclusion from social networks, as well as homelessness, among others (Black, 2011; Coker et al. 2002; Heise & Garcia-Moreno 2002; Roberts, Klein, & Fisher 2003; Plichta 2004; Warshaw et al., 2009).
Women with a history of domestic violence are likely to show behaviors that present further health risks such as alcoholism, substance abuse, and suicide attempts, among others, as compared to women without a history of domestic violence (Heise & Garcia-Moreno, 2002; Plichta, 2004; Roberts, Auinger, & Klein 2005; Silverman et al., 2001). The relationship between domestic violence and psychological disorders is described in a systematic review and meta analysis study by Kylee and Trevillion (2012). The study shows that there is a higher risk of experiencing adult lifetime partner violence among women with depressive and anxiety disorders compared to women without mental health challenges (Kylee & Trevillion, et al., 2012). The reports show that the more severe the violence, the stronger its relationship to negative health behaviors by victims, (Khasakhala-Mwenesi, Buluma, Konǵani & Nyarunda, 2004).
2.6 Theoretical Framework
According to Craighead (1994), learning experiences or failure to receive or profit from various learning experiences accounts for the behavioral patterns of an individual. Therefore, a good behavioral modification model is one that provides learning experiences that promote adaptive and pro-social behavioral patterns of an individual. Following this trend of thought, cognitive behavioral
therapy involves training clients to engage in certain behaviors in order to demonstrate a learning experience in their new modes of behavior. This helped the researcher as the basis of choosing CBT as the key therapeutic approach for domestic violence intervention.
The theoretical framework of the study is based on the psychological theories of self-appraisal, learned helplessness, and identified behavioral patterns, which form the pillars supporting this research work as they explain the existence of the problem under study: domestic violence and the intervention using CBT. Self-appraisal refers to the way a people view themselves. This is also the continuous process of determining individual growth and progress, which can be raised or lowered by the treaments of a close significant other such as an abusive spouse or other family members. Individuals are more threatened by friends than strangers. Abraham Tesser, a social psychologist professor emeritus in the University of Georgia, developed the self-appraisal maintenance theory in 1988. The self-appraisal maintenance model has two assumptions: one, a person should try to maintain or increase their own self-appraisal, and two, self-appraisal is more often than not influenced by relationships with others (Tesser, 1988). This tells a lot about the women clients requiring CBT for them to start operating differently for better living.
Learned helplessness is a situation that occurs when a person is repeatedly subjected to an aversive impetus that he/she cannot escape. Ultimately, the person will stop trying to avoid the impetus and behave as if this is utterly difficult to change. Even when opportunities to escape are presented, learned helplessness prevents any thought for action to change the particular condition. When a person feels they have no control over their condition, they begin to behave in a stranded manner. This self procrastination leads someone to overlooking opportunities for self relief or change. Generally, women who have suffererd exposure to domestic violence have inclinations of helplessness, a manifestation that requires therapy, such as CBT, in order to change themselves. This concept of learned helplessness was discovered by two psychologists, Martin Seligman and Steven F. Maier, in 1967. Learned helplessness has also been linked with several different psychological disorders such as depression and anxiety, among others, which can be exacerbated by the same learned helplessness. On the other hand, CBT helps to overcome the thinking and behavioral patterns which cause learned helplessness leading to the indicators of psychological disorders, anxiety and depression in some cases.
For the purposes of this study, it is crucial to note that identifying behavioural patterns that cause the problems, is vital for psychological and emotional healing. For example, if a client decides to separate from their partner, she will miss the opportunity of learning what the particular experience was meant to imply from the other person. This kind of scenario exposes her to the danger of continuing to meet more of the same picture patterns in the next relationships that she tries to develop. This pattern of things keeps around until she resolves the emotional source of the previous experiences. A woman would therefore need to understand that change can happen if she focused honestly on what is going on in her live and her reactions as well as behavioural patterns, instead of projecting the blame onto her partner. Taking personal responsibility would help the woman alter the direction of her life and erect it firmly at a better position, which means self-empowerment. Self-empowerment simply means she is confidently taking charge of all aspects of her life. Hence, self-empowered characters do not allow their power to others to abuse, rather they use it suitably. Something of great importance to note is that individuals have the inborn ability to empower themselves but others have to relearn it. The dissimilarity between those who possess and know their power and those who do not, is simply an inside belief system, a self-defeatist talk, meaning one is incapable of self-empowerment, something that may have been instilled or conditioned since childhood. Cognitive behavioral therapy is known to be the best approach to these theoretical frameworks of the human mind.
The origin of cognitive behavior therapy is known from the stoic philosophy of Epictetus, who was in the first century known to report that people are more troubled by the interpretations they take of happenings than the events themselves. In principle, people are capable of choosing their orientation, and a person’s psychological standing is influenced by his or her views about the self in relation to the world (Woolfe, & Dryden, 1996) as observed above. Cognitions, verbalizations and feelings are recognized as inner events which function as stimuli in controlling the behavior of an individual (Weiss, 1978; Jacobson, 1981), and cognitive events play major roles in the theory of personality and behavior.
Cognitive Tehavioral Therapy is one of the various applicable approaches for creating new beliefs and behavioral variations (Craighead, 1994). This approach, being a psychological treatment, is intended alter maladaptive behaviors of thinking, leading to improvement on reduction of psychological disorders among people (Colledge, 2002). It is therefore highly diverse and concerned with the development, maintenance and alterations of behavior. Craighead (1994) posits that CBT’s
main purpose is to help people bring out the intended behaviors, without influencing intentions. In addition, CBT is more useful in face-to-face interactions than in group or community-level interventions. The CBT intervention is a amalgamation of many methods, strategies and techniques that can work in helping people overcome their particular emotional problems successfully without negative side effects (Briere & Scott, 2006 & 1996).
The cognitive part of the therapy refers to a thinking style or learning which is part of the therapy which can be imparted to the person (Kendal & Kriss, 1983). The individual then needs to put what has been taught into practice at home and on daily basis. Through repetition, the client feeds the new knowledge into her brain such that it becomes an automatic behavior or a habit. This is basically the same procedure as that of school teaching or learning. The client is taught new information and skills, absorbs them and uses them in her daily life. Of importance is that, when the client learns them well enough through repetition, it affects the retention processes and allows her brain to think, act, and feel differently. This exercise needs insistence, repetition, and endurance. When a client sticks with this therapy, without giving up, visible progress begins to happen (Beck, 1967). The cognitive approach claims that abnormality stems from defective cognitions about others, the world and oneself. This damaged thinking may come about due to cognitive shortages or cognitive distortions, resulting to processing things inaccurately. These thoughts cause distortions in the way the person sees things and the behavioural patterns that follow.
Albert Ellis (1957; 1962) suggested that distortions are through irrational thinking. He proposed that each individual has a sole set of assumptions about themselves and the world that serves as a guide through life. In addition, this also helps to determine the persons reactions to the various situations encountered. Regrettably, some individuals assumptions are profoundly irrational, which leads them to acting and reacting into inappropriate ways. This prejudices the person’s chances of happiness and success in life. In addition, Albert Ellis stated that these are some of the basic irrational assumptions in which some people assume irrationally that they are failures. They endlessly seek approval and persistently feel rejected. All their relations are affected by the elementary irrational assumptions when they do not get enough compliments. Beck (1967) proposes this to be a form of cognitive triad.
Albert Ellis (1957) developed an approach known as the ABC Technique of Irrational Beliefs. According to him, there are three steps of the process by which a person can develop irrational beliefs.
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