Abuse

Abuse refers to physical, sexual, or emotional harm to a person perpetrated by a relative, caregiver, or spouse, or others in a social relationship with the abused person. Common forms of abuse include intimate partner abuse, partner or marital rape, and elder abuse. All of these forms of abuse are typically contained within the broad term domestic violence.

In many cases, survivors of sexual abuse, physical abuse, intimate partner violence (IPV), or elder abuse may be referred to counseling and therapy by law enforcement or other professionals, such as medical doctors and nurses, social workers, police officers, and the court. Counselors should be aware that a client may live in the same household with the abuser at the time of referral; therefore, the client may be afraid or ashamed to disclose the abuse because of economic dependency or fear of further physical or psychological harm from the abuser. It is important for therapists working with abused clients to first ensure their physical safety. It is critical to acknowledge that the cause of the abuse resides in the person who abuses rather than in the survivor. Therapists may effectively use techniques from many therapeutic orientations when working with abused clients, as long as they possess sufficient knowledge of the nature of the abuse, consequences of abuse, available services and resources for treatment, and legal issues.

Intimate Partner Abuse

Intimate partner abuse is interpersonal violence that occurs between current and former marital partners, cohabiting partners, separated marital partners, or same-sex partners. Several terms are used to describe violence or abuse between intimate partners. These include marital abuse, spouse abuse, and domestic violence. However, the terms intimate partner abuse and intimate partner violence are more commonly used today. Intimate partner violence occurs among heterosexual and same-sex partners as well as across different racial and ethnic groups. It is estimated that IPV occurs in 10% to 20% of intimate couples in the United States. Some research suggests that the prevalence rate may be higher among some marginalized groups, including couples that cohabitate without marriage, rural populations, disabled individuals, and recent immigrants.

Violence against intimate partners includes physical violence, sexual violence, threats of violence, stalking, and psychological abuse. Each act can be placed on a continuum ranging from mild verbal abuse to severe physical violence and even partner homicide. Men and women are equally likely to be initiators of IPV; however, women are more often survivors of severe violence resulting in injury and death.

In addition to physical injury, negative consequences of IPV include psychological stress and financial costs in lost wages and medical fees for treatment. Survivors of IPV often experience strong psychological stress such as helplessness, fear, anger, and anxiety. Some survivors may develop nightmares, intrusive thoughts, intense anxiety, and fears associated with violence. These are common symptoms of posttraumatic stress disorder. Survivors of repeated violence may develop learned helplessness, a psychological condition in which survivors no longer attempt to escape from a painful situation because of previous failed attempts. These strong emotional stressors may further impair survivors’ cognitive and coping skills and even diminish survivors’ abilities to leave abusers.

IPV increases the cost of mental and medical health care and shelter services. Violence occurring between intimate partners is the number one cause of injury for women in the United States. Those injured in severe physical or sexual violence often need immediate medical attention. Multiple medical care visits may occur as a result of each violent incidence. Furthermore, female survivors of intimate partner violence suffer more reproductive health problems, sexually transmitted diseases, and unwanted pregnancies than other females. For some survivors, psychological stress due to living in a violent home environment can develop into physical illnesses such as headaches and back pain. In addition to medical costs, intimate partner violence also increases the need for mental health services. Nearly one third of female intimate partner survivors report using mental health counseling, often with multiple visits. For physically injured survivors, violence may mean a loss of productivity from both paid work and household chores. In some cases, survivors may lose their employment or become home-less due to the victimization or attempts of escape from abusers. In fact, family violence is one of the major causes of female homelessness in the United States, and shelter services are required as a result.

Explanations for Intimate Partner Violence

Risk factors are factors that have been shown to increase the likelihood of involvement in IPV victimization or perpetration. A combination of individual, relational, cultural, and social factors contribute to the risk of involvement in IPV. Identifying risk factors can be useful in prevention and intervention. However, it is important to remember that risk factors are not causes of violence and they do not predict who will become involved in IPV.

IPV occurs in every racial and socioeconomic group, although it is more prevalent among families with low socioeconomic status. In addition, younger partners (age 16 to 24) appear to be the most violent. Exposure to parental violence and childhood abuse increases the likelihood of becoming a perpetrator and a survivor of intimate partner violence. Children who are exposed to parental violence may learn to use violent acts as a means of conflict resolution with intimate partners.

Drug and alcohol abuse are frequently associated with IPV. Men with alcohol problems are more likely to perpetrate intimate partner abuse than those who do not abuse alcohol or other substances. However, not all perpetrators have histories of alcohol or drug problems. Therefore, some research suggests that the relationship between alcohol consumption and partner abuse may be accounted for by antisocial personality traits rather than drinking behavior alone. In fact, a significant proportion of IPV perpetrators report more depression, lower self-esteem, and more aggression than do nonviolent intimate partners. Evidence indicates that violent intimate partners may be more likely than others to have personality disorders or attachment problems.

Cultural acceptance of violence has been associated with IPV, especially patriarchal attitudes that assume men’s power over women and their right to control their female partners. Higher IPV rates occur among women who have little work experience and are dependent on their male partners for financial resources. However, the cultural value of patriarchy is not the sole cause of IPV.

Reasons for Leaving or Remaining in an Abusive Relationship

Even though “just leaving” seems a simple solution for terminating an abusive relationship, the decision survivors make to leave or remain in an abusive relationship is complex. Some internal barriers and external considerations may slow the process. In fact, it often takes several attempts before survivors permanently terminate their abusive relationships. Even though most women eventually terminate abusive relationships, research has found it is a difficult, stressful, and often dangerous process. In addition, counselors should not assume that leaving is the preferred intervention; for many survivors, this is not a desirable option, and their therapists should work from a harm reduction model.

Internal factors, such as low self-esteem and self-blame, denial of the abusive nature of the relationship, and emotional dependence may play a significant role in abused partners remaining in an abusive relationship. Many IPV survivors want to remain in the relationship, but have the battering stop. Research suggests that changes in beliefs regarding the likelihood of this wish are needed in order for IPV survivors to leave an abusive relationship. Survivors may experience events that act as a catalyst, leading them to the realization that the relationship will not improve. Following this realization, survivors may give up the dream of an idealized committed relationship and search for ways to safely leave the abuser.

In many cases, violent relationships are maintained through power and control. The abused partner may depend on the abuser for basic economic needs. Some IPV survivors remain in the abusive relationship simply because they have nowhere to go. They may not have economic resources, social support, or shelter information. Furthermore, leaving an abusive partner can be a dangerous process. When survivors try to leave their violent partners, perpetrators frequently threaten to harm the survivor or survivor’s children and family. Since laws often fail to protect survivors attempting to leave an abusive relationship, many survivors experience an increase in victimization when they attempt to leave. Therefore, it is important for counselors not to guarantee the safety of a client who is leaving a relationship; rather, they should assist in helping the client establish as many safeguards as possible during the transition.

Male IPV survivors may have additional barriers because traditional male gender roles emphasizing strength and independence may hinder them from reporting violent acts and seeking help. In addition, there are indeed fewer shelter resources and treatment groups available for male survivors of interpersonal violence. Similarly, sexual minorities may find a lack of services for treatment, given that many interventions and shelters were created from a male heterosexual perpetrator model.

Counseling Concerns

The primary counseling concern for survivors of IPV is their physical safety. Safety plans are strategies counselors can use to help survivors develop means of protecting themselves and their children during an abusive incident or when preparing to leave an abusive relationship.

A safety plan for survivors to use during an abusive incident includes staying out of rooms with no exit and staying away from rooms in which potential weapons may be accessible, such as the kitchen. Survivors can invent code words that alert friends, children, neighbors, or family to call the police. A safety plan for survivors preparing to leave an abusive relationship involves such strategies as the client’s opening a checking account in her or his own name and involving people or agencies that may be helpful. Survivors should prepare an extra set of keys and a bag packed with necessities, and should have important documents stored in an undisclosed location such as a friend’s home. Because many IPV survivors have limited financial resources, it is important to help them achieve economic independence by means such as obtaining temporary welfare benefits and improving their job-finding skills. Shelter treatments provide survivors with a temporary separation from abusers and assist them in developing safe leaving plans. Survivors may receive help from domestic violence programs or shelter workers to obtain restraining orders or other legal procedures and counseling and educational services. It is important to help clients establish a record of physical abuse by their partners, such as filing restraining orders, phoning 911 when incidents occur, and keeping photographs and other evidence (e.g., threatening or controlling letters).

If the abuser has left the shared residence, safety plans include changing locks on doors and windows, changing telephone numbers, screening calls and blocking caller ID, obtaining an order of protection, and inserting a peephole in the door. In addition, it is important to make sure that schools and day care centers know who is allowed to pick up the children. In terms of safety on the job and in public, survivors should be advised to keep orders of protection with them at all times. They should call police immediately if the abuser violates the order of protection. It is desirable to change regular travel routes and try to get rides with different people. Clients should let supervisors, human resource personnel, and/or security guards know about the situation and how to respond should the abuser show up at the workplace.

IPV survivors may recover from victimization through empowerment. Some IPV survivors may not be able to distinguish the differences between normal and abusive relationships; they may perceive their abusive situations as normative. Counselors help survivors realize that they are not the cause of the violence or the ones responsible for stopping the abuse. It is also essential for counselors to help survivors identify their strengths and help them develop coping skills so that survivors become more assertive and make self-directed decisions. In addition to individual therapy, survivors can be empowered by learning and supporting one another in a group setting. Group members may gain the awareness that their situation is not unique and they are not alone; they may be inspired by senior members who have made substantial progress; they may benefit by the chance to help and support other group members; and they may learn interpersonal and social skills during the course of therapy. Another important counseling concern is to help IPV survivors establish support systems. Social support networks are one of the most essential elements in helping survivors leave their abusive relationships. Survivors with diminished or nonexistent support networks are more likely to return to their abusers. Counseling should help survivors establish support systems from family members, friends, and religious groups.

Counselors need to possess knowledge about community resources, including social, psychological, healthcare, legal, and political services. The healthcare community should regularly screen clients for IPV. Once IPV survivors have been identified, they should be provided information and referred to appropriate agencies. If IPV survivors have drug or alcohol abuse problems, therapy addressing substance abuse should be considered. If survivors have prior victimizations, such as childhood sexual or physical abuse, therapists may help survivors process their early abuse experiences in relationship to their current abusive relationship.

Counselors need to possess additional knowledge when working with survivors with diverse backgrounds. For example, physically disabled survivors may need transportation assistance in order to access community services or go to court buildings. Lesbian IPV survivors may have limited support from family and peers who may not want to shed negative light on the lesbian community. Immigrant women may have difficulty understanding English and need interpreters.

Sexual Assault and Intimate Partner Rape

Sexual assault is any type of sexual act that is not consensual. These acts can be physical, verbal, or psychological and include inappropriate touching, attempted rape, and rape (e.g., vaginal, anal, or oral penetration). Often, sexual assaults are perpetrated by someone the survivor knows, such as a spouse, family member, date, coworker, friend, or acquaintance. If sexual violence occurs between intimate partners, it is often referred to as a form of intimate partner violence. Individuals may be forced into unwanted sexual activities because of threats or intimidation from the perpetrator, or they may be under the influence of drugs or alcohol and unable to give consent. Some individuals are unable to give consent because of age, physical disability, or mental illness. Although anyone can be a potential victim of sexual assault, females are the most common victims of sexual violence. Young women, women with physical and mental disabilities, and women living with limited economic resources are at higher risk.

Sexual assaults by intimate partners are often more violent, cause more injuries, and have a longer-lasting negative impact on survivors than sexual assaults by acquaintances. Aftermath effects may include emotional shock, panic, guilt, anger, denial, and/or feelings of powerlessness. Some survivors of sexual assault experience intense fear and nightmares associated with their victimization. Other short-term and long-term effects of sexual violence include gynecological problems, gastrointestinal disorders, substance abuse, somatic conditions, depression, eating disorders, high-risk behaviors, and suicidal thoughts and attempts.

Counseling Concerns

Psychological first aid immediately after a sexual assault is essential to help survivors recover from the victimization. Counselors need to be sensitive and provide support to survivors. Survivors of sexual assault should be advised to receive medical attention and report the assault. Preventive treatment for sexually transmitted diseases and administration of emergency contraception may be considered. Hospital emergency rooms have standard procedures for assisting survivors of sexual assault, such as collecting medical evidence or DNA samples for criminal prosecution. Additional information about legal services should be offered.

Counselors should make clear to sexual assault survivors that they are not to blame for the incident, even if they were attacked by an acquaintance, date, friend, or spouse; had sexual relations with the person before; were under the influence of alcohol or drugs; or were wearing clothes that society may consider seductive. No matter what the previous situations or circumstances were, they were assaulted if they were unable to say “no” or to physically fight back.

Counseling can help survivors understand the course of recovery from sexual assault, help them process and express their feelings, and encourage them to seek support from friends and family who can validate their feelings and affirm their strengths. Survivors can benefit from techniques that help them reduce anxiety, such as relaxation exercises, walking, yoga, music, reading, and hot baths. Journaling may also be a means for survivors to release feelings. Group therapy may provide an opportunity for survivors of sexual assault to normalize their feelings of guilt and shame and support one another.

Male survivors of sexual assault may experience additional emotional stress, as there are myths that only women are sexually assaulted, only gay men are assaulted, and men cannot be assaulted by women. These myths can further increase the emotional pain and shame that male sexual assault survivors may experience and increase their feelings of isolation. For these reasons, male survivors are less likely to seek help and report their crimes. Heterosexual, gay, and bisexual men are all potential victims of sexual assault. Being a victim is a difficult concept for most men to accept. Therefore, male survivors may define their assault as a loss of masculinity and blame themselves. In response to feelings of guilt, shame, and anger, some male survivors may engage in self-destructive behavior such as exhibiting more aggression, increasing drug and alcohol use, or withdrawing from social relationships. Some male survivors experience sexual difficulties after being assaulted, because negative feelings associated with sexual assault may be triggered by intimate sexual contact. They may have difficulty resuming sexual relationships or starting new ones after the assault.

For both heterosexual and gay men, sexual assault can lead to questions about their sexuality. Heterosexual men may feel confused about their sexual orientation after a male-perpetrated assault if they believe that only gay men will be sexually assaulted. Therefore, clients should be made aware that sexual orientation is unrelated to the experience of being sexually assaulted. For gay men, sexual assault may lead to feelings of self-blame attached to their sexuality. Some gay men with internalized homophobia may believe that somehow they deserved the assault. It is important to reassure survivors that sexual assault is an act of violence, power, and control and that no one engages in any behavior to provoke it. Gay men may also be less likely to report the assault due to fears of blame by police or medical personnel, resulting in insufficient treatment for the incident.

Elder Abuse

Elder abuse refers to intentional or unintentional acts by caregivers or other persons that cause harm or a serious risk of harm to a vulnerable adult. This abuse can happen to men and women, people of all ethnic backgrounds and social status, and gay, lesbian, bisexual, and transgender elders. The 1987 Amendments to the Older Americans Act was the first time the federal government defined elder abuse, neglect, and exploitation. These definitions, however, served only as guidelines for identifying elder abuse. Currently, elder abuse is defined by state laws, and these definitions vary by state in terms of what constitutes elder abuse. The broad definition of elder abuse includes physical abuse, emotional or psychological abuse, sexual abuse, financial or material exploitation, neglect, self-neglect, and abandonment.

Physical abuse consists of using enough force to cause unnecessary pain or injury to an elderly person. Physical abuse can range from slapping, shoving, and restraining to severe beatings. Emotional or psychological abuse occurs when a family member or a care-giver acts in a way that causes an elder person emotional distress or fear. The abuse can range from verbal assaults and threats of physical harm to isolating elders from other family members or regular social activities. Material or financial exploitation includes the misuse or exploitation of older adults’ material or monetary assets. Sexual abuse consists of any sexual activity for which an elder does not con-sent or is incapable of giving consent. The sexual activity can range from exhibitionism to fondling to oral, anal, or vaginal intercourse. Self-neglect is when elder persons fail to meet their own physical, psychological, and social needs due to illness, dementia, substance abuse, depression, and/or poverty.

Elder abuse falls into three basic categories: domestic, institutional, and self-neglect or self-abuse. Domestic abuse constitutes maltreatment by caregivers in the elder’s or caregiver’s home. Institutional abuse occurs in elderly care facilities, such as nursing homes, group homes, and board and care facilities. Sometimes elders neglect their own care, which can lead to illness or injury. Self-neglect can include behaviors such as not eating or drinking, leading to dehydration; poor hygiene; and failure to take medications. For some elders, the problem is coupled with Alzheimer’s disease or dementia, isolation, depression, and declining health. It is debated whether self-neglect is abuse, because the elder person chooses to neglect his or her own needs. Therefore, there is controversy over whether involuntary intervention should be implemented for elder people who engage in self-neglect.

Elder abuse is a complex issue. There is no single explanation for elder abuse, and many factors may contribute to its occurrence. The unique ways in which these factors interact with each other depends on the home environment of the perpetrator and victim of elder abuse. These factors may include family characteristics, caregiver issues, and the levels of dependency and impairment of the elderly people involved.

Elder abuse may be an extension of the family’s violent interaction behavior. Intergenerational violence may perpetuate elder abuse. Family stress and caregiver stress are often associated with elder abuse. Caring for a mentally-impaired or physically-ailing older adult is highly stressful. Caregivers who do not have sufficient information, skills, or financial and psychological resources may find caring extremely challenging and stressful, which may lead to abusive acts.

Some caregivers who are at risk for abusing elders have their own psychological maladjustment or difficulties. Caring for an elderly person demands psychological and physical energy, and caregivers who have emotional or substance abuse problems may have limited ability to cope with stressful life situations. Caring for an elderly person may exacerbate their psychological vulnerability and lead to abuse. Caring for an elderly person also requires financial resources. When a family is financially struggling, the family may fail to provide adequate care for an elderly family member. For some families, financial exploitation may occur when the family is financially in need or economically dependent on the elderly person. Social isolation is another risk factor for elder abuse because without social support and outside help, the care of an elderly person can increase the stress level of caregivers. If abuse does occur, social isolation may prolong the occurrence of the abuse since no one outside the family is aware of the abuse.

Certain societal attitudes toward elders may hinder the prevention and termination of elder abuse. Some members of society may devalue or lack respect for elderly people. The problem of elder abuse is not widely publicized or understood. In addition, given the strong emphasis on personal and familial privacy, elder abuse is often hidden within the family. Furthermore, abused elders commonly feel too humiliated or fearful to talk about the abuse; this lessens the possibility of intervention to stop the abuse.

The most important step in elder abuse prevention is acknowledging human dignity, which exists regardless of a person’s age and level of physical and psychological functioning. The media should offer positive images of elder lives and increase public awareness of elder abuse. Social resources and support groups need to be available to elderly individuals and their family members. Counseling and treatment resources should be available for families caring for elderly people. Mental and medical healthcare workers play a vital role in assisting elder abuse survivors, and regular medical screening of possible elder abuse is vital for detecting potential abuse. If suspicion of abuse arises, a call to local or state agencies may help stop future abuse.

References:

1. American Psychological Association. (2006). Elder abuse and neglect: In search of solutions. Retrieved February 7, 2016, from http://www.apa.org/pi/aging/resources/guides/elder-abuse.aspx
2. Barnett, O., Miller-Perrin, C., & Perrin, P. (2005). Family violence across the lifespan (2nd ed.). Thousand Oaks, CA: Sage.

See also:

• Counseling Process