A Stress and Coping Approach to Intervention with Abused Women

Author(s): Bonnie E. Carlson

Source: Family Relations, Vol. 46, No. 3 (Jul., 1997), pp. 291-298
Published by: National Council on Family Relations
Stable URL: http://www.jstor.org/stable/585127
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 A Stress and Coping Approachto Intervention
with Abused Women
Bonnie E. Carlson*

Physical abuse, especially severe, chronic abuse, is a significant source of stressfor womenwho experience it. A combinationof
external and internalfactors can inhibit womenfrom ending abuse in an intimaterelationship.Counselingcan be useful in ad-
dressing internalbarriers.An ecological model of interventionis presented based on the Lazarusand Folkman(1984) conceptu-
alization of stress and coping. The model also recognizes the stages abused women may experience in their appraisal of the
abuse experience. The proposed model includes attention to an orientation to practice with this client group, engagement in
treatment,assessment, interventionstrategies, and evaluationof effectiveness.

A lthough an increasing amount of attentionhas been de-
voted to the problemof woman batteringin recentyears,
there has been a rather limited focus on therapeutic
work with abused women. This, in part, derives from the reser-
vations of many in the batteredwomen's movement regarding
therapywith women who have been abused. This ambivalence
appearsto be groundedin four factors. The first is a concernthat
providing counseling for battered women implies preexisting
deficits that contributedto their being abused, which in turncan
lead to victim blaming (Dutton, 1992). Anotherconcern is relat-
ed to negative experiences with mentalhealth providersreported
by many batteredwomen who have sought counseling, only to
be held responsiblefor their own abuse or simply not be helped
(Hamilton & Coates, 1993; McShane, 1979; Ross & Glisson,
1991; Saunders & Size, 1986). The third issue concerns the
power imbalanceinherentin most therapeuticrelationships,risk-
ing the perpetuationof powerlessness in abused women (New
York State CoalitionAgainst Domestic Violence, N.D.). Finally,
and perhaps most important, is the belief that what battered
women need most of all is not therapybut ratherotherresources
that will permit them to terminateabusive relationshipsif they
wish to (Sullivan, 1991).
An alternativeview of counseling for abused women main-
tains that the process of being abused,especially if the abuse has
been chronicor severe, often resultsin a varietyof consequences
that compromise a woman's ability to effectively addressabuse
while still in a relationshipor to recoverfrom the effects of abuse
and move on with her life. Some of these adverse consequences
may serve as barriersto women being able to terminateabusive
relationships.
Assumptionsand Definition
A recentconceptualizationby Johnson(1995), based on data
from the 1985 Second National Family Violence Survey and
other qualitative data, has identified two different types of do-
mestic violence or abuse: common couple violence and patriar-
chal terrorism.The two are said to differ in terms of the nature,
severity, and chronicityof abuse, as well as the gender of perpe-
tratorand victim. Common couple violence tends to be used by
both men and women, occurs with relatively low frequencyin a
relationship,tends not to be physically injurious, and does not
show a pattern of escalation. In contrast, patriarchalterrorism
tends to be perpetratedby men toward women, shows a pattern
of escalation in frequency and severity over time, includes not
only physical violence but also "economicsubordination,threats,
isolation, and other control tactics," (p. 284) and "is rooted
deeply in the patriarchaltraditionsof the Westernfamily" (John-
son, 1995, p. 286). Woman abuse as discussed in this paper is
1997, Vol. 46, No.
3291
synonymouswith patriarchalterrorismand is defined as a pattern
of behaviors that can be physical (e.g., punching),emotional or
psychological (e.g., ignoring), verbal (e.g., ridiculing),or sexual
(e.g., coerced intercourse)that are intendedto control or demean
a womanby her partner.
It is assumed that each woman who experiences domestic
abuse is the unique productof many factors including her age,
cultural background,experiences in her family of origin, eco-
nomic circumstances, sexual orientation, intelligence, and so
forth. However, because of the stressfulnessof woman abuse as
defined here, there are numerouscommon effects on its victims
thatdifferentiateit from common couple violence:
Specific emotional, cognitive, and behavioralresponses that
are characteristicproducts of batteringinclude anger, fear
and anxiety, depression, low self-esteem, suicide or a high
risk of it, confusion, feelings of being overwhelmed,memo-
ry loss, poor concentration,physical problems, suspicious-
ness and paranoia,and recurrentexperiencingof the trauma
of abuse and an avoidance of the emotions associated with
it... (Dutton-Douglas& Dionne, 1991, p. 114).
Barriers to EndingAbuse
Barriersto ending an abusive relationshipcan be viewed as
consisting of factors both external and internal to the woman
(Strube& Barbour,1983). Externalfactors identified as impedi-
ments include lack of supportor criticism from extended family
members regardingterminationof the relationship,especially if
childrenare involved (Strube& Barbour,1983); low educational
attainmentand limited employmentskills, complicatingthe pro-
cess of becoming self-supporting in the absence of economic
contributionsfrom the abusive partner(Davis & Hagen, 1992;
Nurius,Furrey,& Berliner,1992); lack of supportiveinstitutional
responses (Mitchell & Hodson, 1983); and lack of affordable
housing and child care (Davis & Hagen, 1992). From a social
policy standpoint,what is needed to addressexternalbarriersis
not counseling but rathera spectrumof services that permit an
abused woman to decide whether to continue or terminate an
abusive relationship and facilitate leaving if that is her choice
(Davis & Hagen, 1992). Related policy changes and broad soci-
*Addresscorrespondenceto: Bonnie E. Carlson,School of Social Welfare, 135 West-
ern Avenue, The University at Albany, State University of New York, Albany, New York
12222.
Key Words: abused women, battered women, cognitive appraisal, coping, domestic vio-
lence, stress, womanabuse.
(FamilyRelations, 1997, 46, 291-298.)

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etal interventions would increase sanctions for using violence
against women, enhance the educationaland economic status of
women, and improvethe numberand qualityof concreteservices
available to women seeking to leave an abusive relationship.
Such interventionscan empower women to make more informed
decisions about whether to continue or terminatea relationship
without being hindered by factors outside of themselves that
serve as barriersto leaving.
However, even when women wish to leave and such services
are available, in many instances they are not sufficient to enable
such victims to initiate actions that lead to terminatinga violent
relationship(Davis, 1987). In such cases, forces internalto the
woman may also be operating that interfere with her ability to
take advantageof supportsthat exist in the community.Internal
barriersinclude psychological, emotional, and cognitive aspects
of functioningthat entrapwomen or complicate leaving or post-
abuse adjustment.Some of these factors may have existed prior
to the abuse occurring,such as low self-esteem, passivity, or de-
pression. For example, Johnson (1992) found that negative self-
perceptionswere associatedwith returningto an abusiverelation-
ship after staying in a shelter,but only when family income was
low and the woman was not employed. However, both these and
other factors, such as a sense of helplessness (e.g., Follingstad,
Neckerman, & Vormbrock, 1988; Walker, 1979), depression
(Andrews & Brewin, 1990; Follingstadet al., 1988; Rounsaville,
1978), and self-blaming causal attributionsfor the abuse (An-
drews & Brewin, 1990; Follingstadet al., 1988; Miller & Porter,
1983; Nuriuset al, 1992; Strube& Barbour,1983), may have de-
veloped as a consequenceof the abuse. Regardlessof when such
orientationsdeveloped, if they hinder leaving or post-abuse ad-
justment, they may be amenable to change via the therapeutic
process.
This paper discusses four internalbarriers(low self-esteem;
shame and self-blame for the abuse; poor coping skills; and pas-
sivity, depressionand learnedhelplessness) and presentsa stress
and coping approachto addressingthem in a therapeuticcontext
as a way of supplementing,but not replacing, interventionsde-
signed to address external barriers.The proposed intervention
model is broadlygroundedin an ecological perspectivethat rec-
ognizes that people's actions are determinedby a variety of fac-
tors located within themselves, in theirfamilies of origin and pro-
creation,in the social structure,and in the largersocioculturalen-
vironment (Carlson, 1984). The proposed interventionmodel is
based on the stress and coping paradigmof Lazarusand Folkman
(1984).
Rationalefor a Stress and Coping InterventionModel
A number of intervention models for use with abused
women have been described, most commonly grounded in the
trauma (e.g., Dutton, 1992; Walker, 1994) and feminist
paradigms(e.g., Pressman, 1989; Register, 1993; Walker, 1991;
1994). Others are not located in any specific theoretical
paradigm, for example that of Petretic-Jackson and Jackson
(1996). Although models based on the trauma paradigm ac-
knowledge the stress inherentin being abused,not all abuse vic-
tims meet the diagnostic criteria for PTSD. Nor does this
paradigmaddressthe subjectiveaspectsof abuse as a stressor,fo-
cusing insteadon the universalityof the traumavictim's response
to the traumaticcircumstances.In addition,none of the existing
models fully addressdysfunctionalcoping and its modificationas
the primaryfocus of intervention.For example, although both
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Petretic-Jacksonand Jackson(1996) and Dutton (1992) mention
coping, neither systematically analyzes coping skills of the
abused woman nor considers coping resources or constraintsto
effective futurecoping. Althoughthe proposedmodel has several
features in common with existing models, for example focusing
first on safety and providing information about domestic vio-
lence, it has threeuniquefeaturesas a model of treatment:(1) its
conceptualizationof woman abuse as a stressor(thoughnot nec-
essarily a trauma) that can surpass a woman's resources and
threatenher well-being, (2) its perceptionof a woman's dysfunc-
tional responsesto abuse as maladaptivecoping, and (3) framing
interventionas a process of restructuringand enhancingcoping.
The Stress and CopingPerspective
The Lazarusand Folkman (1984) conceptualizationdefines
stress as a property of the person-environmentrelationship in
which the person perceives something as "taxing or exceeding
his or her resources and endangeringhis or her well-being" (p.
21). Centralto this view is the role of cognitive appraisal,a con-
stantlyoccurringprocess that evaluates an encounterin terms of
its implicationsfor well-being (Lazarus& Folkman, 1984). Phe-
nomenological in its approachto stress, this perspective recog-
nizes the importance of the subjective meaning attached to an
event in termsof an individual'sresponseto it.
Cognitiveappraisal is said to take three differentforms, pri-
mary, secondary, and reappraisal,each having different func-
tions. The purposeof primaryappraisalis to determinewhether
an event is stressfulor not, and it can resultin threedifferentcon-
clusions: that the event is irrelevant,that it is benign-positive,or
thatit is stressful.Lazarusand Folkman(1984) note that
Stress appraisals include harm/loss, threat, and challenge.
In harm/loss, some damage to the person has alreadybeen
sustained, as in an incapacitatinginjury or illness, recogni-
tion of some change to self- or social esteem, or loss of a
loved or valued person. The most damaging life events are
those in which central and extensive commitmentsare lost.
Threat concerns harms or losses that have not yet taken
place but are anticipated(pp. 32-33, emphasisin original).
When primaryappraisalleads to the conclusionthatan event
is stressful, secondary appraisal comes into play to determine
what can be done to respondor how to cope. Secondaryappraisal
is a complex evaluativeprocess that takes into accountthreefac-
tors: coping alternatives,the likelihood that a particularchoice
will accomplishits intendedoutcome, and the likelihood that the
personcan actuallycarryit out. Whereasprimaryappraisalslook
at what is at stake, secondary appraisalsfocus on what can be
done (Lazarus& Folkman, 1984). The mannerin which individu-
als appraisean encounterhas direct implicationsfor their emo-
tional reactionsas well as how they will cope with the situation.
Although appraisalcan be viewed as a rationalprocess, in reality
it is influenced by a variety of factors such as personality,that
can lead to distortedor biased conclusions.
Coping is conceived as a dynamic process of "constantly
changing cognitive and behavioralefforts to manage specific ex-
ternaland/orinternaldemandsthat are appraisedas taxing or ex-
ceeding [one's] resources"(Lazarus& Folkman, 1984, p. 141).
Coping efforts have been differentiatedbased on whether their
function is to modify the circumstancecreatingthe harm,threat,
or challenge (problem-focusedor active coping), or to regulate
one's responseto those demands(emotion-focusedor avoidance-
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oriented coping). Problem-focusedcoping tends to occur when
the circumstances giving rise to the distress are perceived as
amenableto change, whereasemotion-focusedcoping comes into
play when it is concluded that the conditions creating harm,
threat,or challenge cannotbe modified. In actuality,most coping
efforts include aspects of both types of strategies (Lazarus &
Folkman, 1984).
Duringthe secondaryappraisalprocess that initiatescoping,
the individualasks herself what she can do to addressthe stress-
ful situation.Responses will be influencedby both the resources
she can bring to bear on the situationand the constraintsthat in-
hibit her from using these resources. Coping resources include
health and energy, positive beliefs (for example, high self-esteem
and hope), problem-solvingskills, social skills that enable one to
use others as resources, social support, and material resources
(Lazarus& Folkman,1984).
Three types of constraintsmight hindera person's ability to
use coping resources.Personal constraintsare "internalizedcul-
tural values and beliefs that proscribecertain types of action or
feeling, and psychological deficits that are a product of a per-
son's unique development"(Lazarus& Folkman, 1984, p. 165).
An example would be a woman having difficulty behaving inde-
pendently due to traditionalfemale sex-role socialization.Envi-
ronmentalconstraintsinterferewith optimal use of resourcesby
thwartinga person's coping efforts, for example, when a police
officer or court official refuses to take a complaint that might
lead to a restrainingorder. Finally, extreme level of threat can
play a constrainingrole if it creates intense emotional reactions
such as fear or rage that interferewith the ability to enact effec-
tive problem-focusedcoping or leads to "primitive,desperate,or
regressive"emotion-focusedcoping strategies(Lazarus& Folk-
man, 1984, p. 168).
A Stress and CopingAnalysis of WomanAbuse
Based on the Lazarusand Folkmanparadigm(1984), being
abused by an intimate partneris very likely to be perceived as
stressfulbecause of its strongpotentialto surpassa woman's re-
sources and endangerher well-being and may lead to the loss of
a valued relationship(Finn, 1985). Stressfulappraisalsare likely
to be made because a chronically abusive situation is likely to
have aspects of harm or loss, threat, and/or challenge. Abused
women experience stress when violence actually occurs as well
as from its anticipation(Mitchell & Hodson, 1983). When vio-
lence is perceived as stressful, abused women must use sec-
ondary appraisal and cope with their situations (Finn, 1985;
Follingstadet al., 1988; Mills, 1985; Nuriuset al., 1992).
Abused women commonly have limited coping resources
and experience numerousconstraintsagainstusing the resources
they have (Mitchell & Hodson, 1983; Nurius et al., 1992). Re-
searchindicatesthat women with historiesof partnerabuse often
have compromisedhealth,limited problem-solvingskills and so-
cial supports,and limited materialresources (Davis, 1995; Dut-
ton, 1992; Gelles & Harrop, 1989; Mitchell & Hodson, 1983;
Sullivan, 1991; Webb, 1992). In addition,powerful environmen-
tal constraintsmay be operatingin the criminaljustice, social ser-
vice, and mental health systems, preventingwomen from taking
positive action on their own behalf (Mitchell & Hodson, 1983).
Once abuse has become chronic or severe, the extreme level of
threatposed by the batterer's violence can create immobilizing
fear that may prevent almost any constructive action (Davis &
1997, Vol. 46, No. 3
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Srinivasan,1995). For example, Finn (1985) found thatincreased
stress from marital violence seemed to interferewith ability to
use effective problem solving. Similarly, Mitchell & Hodson
(1983) found that at the highest levels of abuse, avoidance-
orientedcoping such as ignoringthe problemwere more likely to
be used by battered women. Finally, personal constraints may
exist when abusedwomen possess belief systems thatdirectlyin-
terferewith their ability to take advantageof coping resourcesor
employ effective coping strategies.For example, a woman's be-
lief that childrenmust have a fatherin the home or that women
cannot effectively function without a man can interferewith ac-
ceptancethather abusivepartnerwill not change and thatleaving
the relationshipis the only alternativefor eliminating violence
from her life (Strube& Barbour,1983).
It is in this context that abusedwomen must considercoping
alternativesand evaluate their likely success and feasibility. Ex-
amplesof problem-focusedcoping might be talkingto an abusive
partnerthe day aftera violent incidentin the hopes of preventing
such abuse in the future or calling the police. Examples of
emotion-focusedcoping might be engaging in physical exercise
when worried about the possibility of an assault or talking to a
friendabouthow frightenedone is.
Stages of CognitiveAppraisaland Coping
How do batteredwomen actually cope? Research indicates
that abusedwomen typically engage in a varietyof coping strate-
gies designed to eliminatethe violence in theirlives. Coping may
be relatedto stages that some batteredwomen experiencein their
perceptionsof the abuse. The stages describedbelow are based
on published literatureon abused women's coping (Ferraro&
Johnson, 1983; Follingstad et al., 1988; Mills, 1985; Strube &
Barbour,1983), the author'sclinical experiences, and discussion
with domestic violence services providers,shelter staff in partic-
ular.
The first stage, which might be called, "It's My Fault," is
characterizedby guilt and characterologicalor behavioral self-
blame, with many women believing that the abuse is caused by
their own failings or shortcomings (Follingstad et al., 1988;
Miller & Porter, 1983; Strube & Barbour,1983). Such feelings
are often fueled by the abuser's criticisms of the kind of person
she is or her role performance.Problem-focusedcoping at this
stage might be directed at improved performance of wife and
motherroles. Some women at this stage cope by evaluatingthe
positive parts of the relationshipmore highly than the negative
parts or throughthe use of downwardcomparisons(e.g., "There
are a lot of other women who have it much worse than I do"), a
form of rationalization(Ferraro& Johnson, 1983; Herbert,Sil-
ver, & Ellard,1991; Mills, 1985).
If the abuse continues despite efforts at change, a woman
may come to realize that the abuse is not occurringas a result of
her own actions but ratheris related to the batterer'sbehavior.
Because the abuse at this stage is usually intermittentand the re-
lationshipis still more positive than negative, the abusive behav-
ior may be excused as an aberrationon the partof the abuser,not
the "realhim." Self-blame may shift from feeling responsiblefor
causing the abuse to feeling responsiblefor changing the abuser
(Miller & Porter, 1983). The focus of coping duringthis second
stage, which might be labeled, "It's Your Fault, But I'll Help
You," may focus on changing his behaviors, using problem-
focused strategies to control his drinking for example, or
293
emotion-focused coping designed to modulate her reactions to
the abuse, such as discussing her situationwith family or friends
(Horton& Johnson,1993; Strube& Barbour,1983).
If neitherof these kinds of coping is effective in eliminating
the stress, because the abuse is escalatingin frequencyor severi-
ty, the woman often comes to recognize that the abuseris solely
responsible for the abuse, but there is nothing she can do to
change him. During the thirdstage, "It's Your Fault, and I Hope
You'll Change," her coping options are primarily emotion-
focused because she appraises the source of the stress as not
being amenableto her change efforts. By this time, she may feel
entrappedin the relationship,depressed, anxious, overwhelmed,
or frightened, and may begin to think of herself as a victim
(Gelles & Harrop, 1989; Strube & Barbour, 1983). Avoidance
coping strategiessuch as withdrawingfrom friends may increase
(Mitchell & Hodson, 1983). She may be experiencinga number
of psychosomatic symptoms characteristicof stress and anxiety
such as headachesor extreme fatigue, with which she must also
cope. She may consider leaving the relationshiptemporarily,re-
sortingout of desperationto a domestic violence shelteror medi-
cating her symptoms with tranquilizers,antidepressants,or alco-
hol (Follingstadet al., 1988). Sometimes leaving temporarilyor
having the abuserarrestedcan serve as a problem-focusedcoping
strategyif it motivates the abuserto change or seek professional
help.
But if those strategiesdo not succeed, she may arriveat the
final stage in her understandingof the abuse, "Despair."She rec-
ognizes thather partneris solely responsiblefor the abuse, which
has become unbearable,and that he will not change. There is lit-
tle if anything positive left in the relationship,and she realizes
that her only alternativefor relieving her suffering is to perma-
nently end the relationship.Desperatecoping efforts such as sui-
cide or homicide may be consideredat this stage (Dutton, 1992;
Gelles & Harrop,1989).
Effects of Violenceand Abuse
Consistent with the stress and coping analysis of woman
abuse,both clinical descriptionsand empiricalresearchshow that
women victimized by violence in their intimaterelationshipsare
at increasedrisk for experiencingpsychologicalor emotionaldis-
tress. One review concluded that "the literatureto date reports
emotionaland psychologicaldeficits amongbatteredwomen who
have sought psychiatric help or refuge in a battered women's
shelter. Virtually every study mentions depression, anxiety, so-
matic problems, and suicide attempts" (Gelles & Harrop,1989,
p. 403). Findings from the 1985 Second National Family Vio-
lence Survey confirm reports from the shelter-based studies.
Comparedto women who had experiencedno violence or minor
violence, those who had experienced severe violence at least
once (e.g., kicked, bit, or hit with a fist, beaten up or choked)
were significantly more likely to report symptoms of moderate
(headaches, nervous or stressed, feelings of sadness or depres-
sion) or severe (felt overwhelmedby difficulties, felt very bad or
worthless, could not cope, wondered whether anything was
worthwhile,felt completely hopeless, contemplatedsuicide) psy-
chological distress (Gelles & Harrop, 1989). Even after marital
conflict, wife's health and age, and family income were con-
trolled, Gelles and Harrop (1989) concluded that "violence
makes a significant, independent,and nonspuriouscontribution
to the psychological distressexperiencedby women"(p. 415).
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The foregoing analysis suggests several conclusions with
implicationsfor intervention:(1) domestic violence is appraised
as stressfulby its victims; (2) abusedwomen have limited coping
alternativesas a result of internaland externalconstraintslimit-
ing the use of existing resources;(3) women's understandingof
abuse may go throughdifferentstages that guide and limit their
use of coping strategies;and (4) abuse can create emotionaldis-
tress for many victims, including anxiety, depression, lack of
self-esteem, and hopelessness that can serve as barriersthat keep
them entrappedin abusive relationshipsor complicate their re-
covery from abusiverelationships.
Intervention from a Stress and
Coping Framework
Three kinds of abused women can potentiallybenefit from
professionalcounseling or therapy:women who feel psychologi-
cally or emotionally entrappedin an abusive situation;women
who have other emotional distress related to their victimization,
such as posttraumaticeffects; or women who have terminatedan
abusive relationshipand need assistance to recover from its ef-
fects. Hortonand Johnson (1993) found that women who ended
abusive relationships,as well as those who remained,frequently
sought help from professionalcounselors,evaluatingsuch coun-
selors as helpful. The discussion that follows presents a stress
and coping frameworkfor individual interventionwith abused
women who are still at risk or who have permanentlyleft the
abusive relationship.Because of the seriousness and complexity
of problemspresentedby abusedwomen, the frameworkpresent-
ed is intendedto be used only by licensed professionalswho have
formal mental health training and who are also knowledgeable
aboutdomestic violence.
Orientationto Practice
It is importantfor cliniciansworkingwith batteredwomen to
subscribeto values that will promotethe well-being of this client
group.Such values include nonjudgmentalacceptance,a belief in
the importanceof self-determination(a client's rightto make her
own decisions and choices free from a counselor's pressure or
coercion;Hepworth,Rooney & Larsen,1997), strictadherenceto
confidentialitypolicies, and a willingness to view dysfunctional
behaviors as attemptsat coping, albeit maladaptive,ratherthan
psychopathology (Dutton, 1992). Other prerequisitesfor effec-
tive clinical work with abused women are a willingness to work
with other professionals, elicitation of client strengths, and be-
coming knowledgeableaboutrelevantlaws, procedures,policies,
eligibility requirements,and resources(Petretic-Jackson& Jack-
son, 1996). Finally, therapistsneed to be especially attunedto the
need for good supervisionand self-care because of the demands
inherentin working with traumatizedindividualsand the poten-
tial for vicariousvictimization.
Engagement
Regardless of the professional context in which battered
women are seen, engagementtechniquesare important.The goal
is to develop a collaborative relationshipthat actively engages
the client in the interventionprocess and to begin immediatelyto
counteractpassivity, learned helplessness, and low self-esteem.
Because many abused women have had negative experiences
with professionalhelpers (e.g., see Sullivan, 1991), and because
many seek professionalhelp only after other coping alternatives
Family Relations
have failed, it is importantto convey immediately that you be-
lieve what she tells you about her experiences and that you ac-
cept her unconditionally(Dutton, 1992; Webb, 1992). One way
to accomplish this is to communicatea desire to understandthe
abuse from her perspectiveby encouragingher to "tell her story"
(Davis & Srinivasan, 1995; Dutton, 1992; Petretic-Jackson&
Jackson, 1996). Both Dutton (1992) and Petretic-Jacksonand
Jackson (1996) recommend starting with an open-ended inter-
view that permits the client to relate her experiences, becoming
more structuredas the process unfolds. An alternativeis to elicit
informationaboutthe most recent violent incident,the first inci-
dent, and the worst incident (Saunders,1992). It is importantto
listen nonjudgmentallyand provide validationand supportwhen
the client is finished, which will help foster trust.Finally,it is im-
portantto offer the client a realisticbasis for optimism and hope
thather situationcan improve.
Assessment
The stress and coping model points to specific assessment
tasks. The clinician should be sensitive to the stress inherentin
the assessmentprocess, which requiresthat the client relate what
often have been brutal and demeaning experiences (Petretic-
Jackson & Jackson, 1996). First, it is important to determine
which stage the client is in with respect to her perceptionsand
understandingof the abuse and her ability, or lack thereof, to
control the violence. Dutton (1992) provides two brief instru-
ments that can be used to evaluate how the client perceives the
abuse, The AttributionQuestionnaireand Appraisal of Violent
Situation.Closely relatedto this is a determinationof the coping
efforts she has made in the past to escape, avoid, or survive the
abuse (Dutton, 1992; Petretic-Jackson & Jackson, 1996). Be-
cause most batteredwomen have made multipleefforts to stop or
control the abuse before seeking professional help (Sullivan,
1991), it is importantfor counselors to understandthese efforts
and to what extentthey have been effective.
Two potentiallyused instrumentsare availableto assist in as-
sessment of coping. The Ways of Coping Questionnaireis a 66-
item, self-reportinstrumentscored on a 4-point scale (0-3) that
yields seven scale scores such as distancing,seeking social sup-
port, and escape-avoidance(Folkman& Lazarus, 1988). Sample
items include, "I told myself things that helped me feel better"
(confrontivecoping scale) and "I made a plan of action and fol-
lowed it" (planfulproblem solving scale). This can be useful in
assessing currentcoping, providing ideas for enhanced coping,
and measuringtreatmenteffectiveness.The Responseto Violence
Inventory elicits information about abuse-related assistance
sought and other efforts made to addressdomestic violence and
their effectiveness, such as calling the police, going to a shelter,
and seeking a restrainingorder(Dutton,1992). It is especially im-
portantto determineif certainstrategiesseem to have contributed
to the abuse getting worse. The role played by social class and
culturalgroupin pastcoping effortsshouldbe considered.
Coping resources should also be carefullyevaluated,consis-
tent with a strengths perspective. Specifically, the clinician
should assess the client's physical and mental health and well-
being, attendingcarefully to anxiety and depression;belief sys-
tem, especially about the causes of the abuse; self-esteem;
problem-solvingskills; social skills and existing social supports;
and material resources. The results of an evaluation of the
client's stage of thinkingwith respect to the abuse as well as pre-
vious coping efforts will assist in assessmentof coping resources.
1997, Vol. 46, No. 3
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Consistentwith the ecological perspective,constraintsto ef-
fective coping should also be evaluated,including personal and
environmentalconstraintsand level of threat.Informationabout
environmentalconstraintsmay be elicited when assessing previ-
ous coping attempts.Personal constraintsmay be uncovered in
evaluating the client's understandingof the abuse and personal
beliefs as a coping resource. If not, her cognitions about the
abuse and why she chose to stay or continues to remain in the
abusive relationshipshould be explored (Dutton, 1992). This is
importantbecause many abusedwomen develop cognitive distor-
tions aboutthemselves and others that interferewith their ability
to function optimally (Webb, 1992). Webb suggests the use of a
journal as one techniqueto access these beliefs, which may be-
come a targetof laterintervention.With regardto level of threat,
at this stage of interventionit is appropriateto conducta lethality
or dangerousness assessment to determine the extent of risk a
woman faces while in treatmentif she still has contact with her
abusive partner(Petretic-Jackson& Jackson, 1996). The results
of such an assessmentare extremelyimportantin thatconcernfor
a client's physical safety must be paramountat all phases of the
interventionprocess.
Finally, the ecological perspective suggests that concurrent
stressors in the client's life be evaluated,in that they may affect
her ability to mobilize resources to address the abuse (Dutton,
1992; Petretic-Jackson & Jackson, 1996). For example, Finn
(1985) found that most abused women reportedmultiple stres-
sors, most commonly financialproblems,substanceabuse, fami-
ly conflicts, and strainedrelationshipswith childrenandrelatives.
Intervention
Clearly,interventionshould be linked to the outcomes of as-
sessment, in particularthe client's stage of understandingabout
the abuse. However, more generic interventiongoals can be pur-
sued that would be relevantto most abused woman. Such goals
include (1) the developmentof a safety plan, (2) increasinginfor-
mation about causes, dynamics, and effects associated with do-
mestic violence and community services available to address
abuse, (3) enhancementof coping strategiesand modificationof
cognitive distortions; (4) enhancementof problem solving and
decision making skills, and (5) reducingisolation and increasing
social support. These goals address coping resources and con-
straintsas well as internalbarriersthat keep women in abusive
relationships.
Developmentof a safetyplan. Safety is a paramountconcern
when working with batteredwomen. When clients are at risk for
ongoing abuse, safety planningis necessary. A safety or protec-
tion plan is a concreteplan of action that can be employed when
the threatof violence is imminent.The goal is to keep a woman
and her children safe. As a coping strategyit has both problem-
focused and emotion-focusedelements. Althoughhaving a safety
plan will not modify the violence, puttingit into effect may moti-
vate the abuserto addressthe problem.
The client must be actively involved in developing the plan,
despite the reluctanceof some clients to acknowledge that they
are at continued risk for future abuse due to their own denial
(Dutton, 1992). Workingon the plan presents an opportunityto
begin to challenge this distortedbelief, remindingthe client that
her partnerhas promisedto refrainfrom furtherabuse in the past,
only to renege on this promise.Developing a plan can help pene-
295
trate the denial, by reminding the client who remains with an
abusivepartnerthatthe abuse may occur again.
The content of the plan should be specific to the needs and
situation of the individual woman. Minimally, it should include
attention to a means of escape if violence seems imminent, a
place to stay if escape is necessary,and otherresourcesnecessary
to put the plan into effect. The plan may involve others, such as
childrentrainedto run to a neighbor'shome duringan argument
or trusted friends or family members who agree to provide a
place to stay in an emergencyor call the police when signaled. It
might entail hiding a set of car keys or cab fare in a secret place
or keeping a hidden suitcase packed with necessities. If the plan
includes a possible shelter stay, informationnecessary to be ad-
mitted to the shelter should be acquiredahead of time, such as
the phone numberand location, eligibility requirements,and so
forth. An example of a form that can be used to develop a safety
plan is availablefrom the author.
A good way to begin to develop the plan is by discussingthe
circumstancesthat have led to violent incidents in the past, with
the goal of developing insight about cues that signal violence
may occur. If the client has left home or attemptedto do so in the
past, her experiences should be discussed in light of the current
plan.
Increasing information.Three kinds of informationshould
be conveyed in the course of treatment.First, psychoeducational
approachescan be useful in informingabused women about the
natureof domestic violence and its effects. Feminist approaches
can also be valuable in conveying that batteringis not a problem
unique to a particularwoman but ratheris a manifestationof a
larger social problemthat occurs in the context of women's his-
torical oppression (Dutton, 1992; Petretric-Jackson& Jackson,
1996). It is importantto convey that no one deserves abuse or is
responsible for their own abuse as a means of addressing self-
blame.
Second, if the client is not alreadyso informed,it is impor-
tant to educate her regardingrelevant services available in her
local community, such as emergency shelter, social services,
child care, legal services, and police protection.Additionally,the
clinician should inform clients about the most effective ways of
accessing these services and what to expect from service
providers(Petretic-Jackson& Jackson, 1996). For example, what
can she expect if she calls the police in her jurisdiction?What
does she need to qualify for social services? Is there child care
available?
Finally, it is importantto educate abused women about the
common physical, cognitive, emotional, and behavioral afteref-
fects of victimizationto assist in "normalizing"theirexperiences.
Many of the maladaptive behaviors or emotional states about
which she feels badly, such as excessive alcohol or drug abuse,
violence toward others, immobilizingfear, or depression,can be
framed as common consequencesof violence or attemptsat cop-
ing with abuse.
Enhancementof coping. Coping is most effective when it
entails a variety of different strategies (Pearlin & Schooler,
1978). Thus, an importantfocus of interventionshouldbe evalua-
tion of the effectiveness of previous coping strategiesuncovered
duringassessment,encouragementof efforts thathave provedef-
fective, and development of a new repertoireof coping efforts.
Discussing the differences between problem-focused and
emotion-focusedcoping (Lazarus& Folkman, 1984) would be a
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startingplace. In general,problem-focusedcoping efforts are su-
periorto emotion-focusedefforts because they are directedat the
source of stress rather than its consequences. But in the real
world, the distinctionbetween problem- and emotional-focused
coping is blurredbecause most coping efforts involve aspects of
both. Because victims' behaviors and charactersdo not cause
abuse, options for problem-focusedcoping directedat the abuse
itself are limited, although enhanced problem-focused coping
might be directedat the victim's responsesto the abuse. Thus, in
addition to problem-focusedefforts, assistance in the develop-
ment of new emotion-focusedcoping efforts is useful. In consid-
ing new coping strategiesit is importantto discuss with the client
what kinds of efforts arefeasible based on her social class as well
as which are culturallycongruent.
Cognitive-behavioraltechniquescan be especially useful in
developing new ways of coping with the effects of abuse (Dut-
ton, 1992; Webb, 1992). These techniquescan be used to address
distortedand maladaptivebeliefs such as "I can controlmy part-
ner's violence" and "It's my own fault I was abused,"as well as
to modify dysfunctionalbehaviorssuch as excessive dependency
on the abusive partner. A variety of cognitive-behavior tech-
niques for use with battered women are described in Dutton
(1992) and Webb (1992). These include cognitive reframingto
alter the meaning of a behavior or think about it in a different
way; cognitive restructuringto modify erroneousor illogical be-
liefs; thought stopping as a means of interruptingintrusive or
dysfunctionalthoughtssuch as "I must be a bad wife"; stress in-
oculation; and modeling, coaching and providing feedback re-
gardingnew behaviorssuch as assertiveness.
Enhancementof problem solving and decision making. Be-
cause effective problem solving is a coping resource, enhance-
ment of problem-solvingand decision-makingskills is an impor-
tant interventiongoal. Essentialto effective problemsolving and
decision making is a woman's belief that she has the right to
make choices for herself and awarenessof existing options or al-
ternatives(Dutton, 1992). Therapeuticwork may be necessaryto
help her see that making choices is her right and to expand her
awarenessof availableoptions.
Problemsolving models are widely availableand can be eas-
ily taught and modeled in session. A modified problem solving
model includes attentionto six steps: defining the problem,gen-
eratinga rangeof possible solutions,criticallyevaluatingthe pros
and cons of the various solutions, choosing among the alterna-
tives, puttingthe solution into effect, and evaluatingthe solution
(Meichenbaum, 1977). A common problem for many battered
women that could be approachedusing this model is the decision
about whetherto stay in the abusive relationshipor terminateit.
A complex decision with many ramificationsand otherdecisions
nested within it, this is an ideal problem to approachusing the
problem-solvingmodel. One or more sessions could be used to
go throughthe steps of the process and assist the client in consid-
ering this decision.
Reducingisolation and increasingsocial support.Many bat-
tered women are socially isolated (Neilsen, Endo, & Ellington,
1992). Regardlessof whetherthey had limited social contactsbe-
fore the abuse began or exhaustedtheir social networksin their
attemptsto cope with the abuse (Mitchell & Hodson, 1983), they
are often isolated from needed social supportat the point when
they seek treatment.Researchhas indicatedthat abused women
who have improvedtheir lives have benefited greatly from the
Family Relations
support of family members (Davis & Srinivasan, 1995) and
friends (Horton& Johnson, 1993). Because social skills and so-
cial supportare criticallyimportantcoping resources,they should
be an early focus of intervention.Treatmentitself should provide
valuable social support,but because therapywill not last indefi-
nitely, an importanttreatmentgoal is to assist the client to ac-
quire social supportoutside of the therapeuticrelationship.If the
client lacks the necessary social skills to forge meaningfulrela-
tionshipswith others,developmentof those skills shouldbecome
an early goal of intervention.In other cases, it is the opportunity
for social contactsthat have been limited. Interventionstrategies
for increasing social support include encouraging the client to
mobilize family membersand friends and participatingin a bat-
teredwomen's supportgroup (Davis & Srinivasan,1995; Dutton,
1992). Acquiringthe supportof other women who have experi-
enced violence and abuse, especially if they have achieved a
violence-free lifestyle, is uniquely valuable for women who are
struggling to improve their situations (Brown & Dickey, 1992;
Hartman, 1987; Tutty, Bidgood, & Rothery, 1993; Wood &
Middleman, 1992). Goodman and Fallon (1995) describe a
15-week educationalgroupcurriculumto assist women who wish
to change and gain controlover theirlives thatcan be a useful ac-
companimentto individualtreatment.Several aspects of the pro-
gram are compatiblewith the interventionmodel proposedhere,
including goal setting, development of assertiveness skills, and
decision making.
Evaluation of Effectiveness
Determinationof which outcomes to measure is an impor-
tant first step in evaluation,an essential partof effective clinical
practice.One aspect of evaluationis client satisfactionwith treat-
ment. This is especially importantwith batteredwomen due to
researchindicatingwidespreaddissatisfactionwith mentalhealth
interventions(Hamilton & Coates, 1993; McShane, 1979). Be-
cause abused women often leave several times before ultimately
terminatingthe abusive relationship,anotherissue to consider is
whetherterminationof the abusiverelationshipshould be seen as
an indicator of treatment effectiveness. How the therapist re-
sponds to a client's reconciliationwith the abuseris important.It
is advisable that clinicians respond nonjudgmentallyto such ac-
tions, communicatingthatcounselingcan continuewhile reiterat-
ing concerns about safety planning and facilitatingdiscussion of
the reasons for returning.Rather than seeing reconciliation as
client weakness or failure of treatment,the therapistshould help
the client understandthe reasons that underlieher returnand en-
couragecognitive reappraisal,a process akin to primaryappraisal
of potentiallystressful situations,but based on new information.
For example, a client's partnermay have agreedto seek counsel-
ing to addresshis violence, so the resumptionof the relationship
would be viewed as benign-positiveratherthan stressful.In con-
trast,if a child's illness led to a decision to resume the relation-
ship, cognitive reappraisalmight lead to the conclusion that re-
turning to the abuser would be stressful. In addition, the time
away from the relationship,even if brief, may have some positive
effects, as Davis (1995) notes:
... many women who repeatedlyleave and returnto their
abusive male partnersmay be learninghow to use resources
and may be gaining strengthto enable them to make major
life changes later even if there is no immediate observable
change in theirbehavior.(p. 787)
1997, Vol. 46, No. 3
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Evaluationof effectiveness should also be linked to attain-
ment of mutually established goals. One area to consider is the
recurrenceof violence during the course of treatment,but this
should be evaluatedwith care because the abuse is not underthe
control of the clinician or the client. Otherperhapsmore appro-
priate areas for evaluation would be (1) perceptions of abuse
(more realistic appraisal,fewer cognitive distortions, less self-
blame, betterunderstandingof causes and consequences),(2) de-
velopmentof a safety plan, (3) improvedoverall functioningand
well-being (reduced distress, fewer psychological or physical
symptoms), (4) increaseduse of relevant services, (5) enhanced
coping (wider range of effective strategies, more coping re-
sources, improvedproblem-solvingand decision-makingskills),
and (6) improvedsocial support.
Summary
Being abusedby an intimatepartneris a stressfulexperience
for women because of its potential to threaten well-being and
overwhelm existing resources.As a result, abused women must
cope with theirvictimization.Oftentimes,a combinationof exter-
nal and internalbarriersinterferewith a woman's ability to cope
effectively with, end, or recover from violence and abuse in her
life. Counselingcan be useful in addressinginternalbarrierssuch
as low self-esteem, learned helplessness, self-blame, and poor
coping thatcan entrapwomen in abusiverelationships.
An interventionmodel was presentedbased on the Lazarus
and Folkman (1984) coping conceptualization. The proposed
model includes explicit attentionto the subjective and cognitive
aspects of stress (cognitive appraisal)and the stages a woman
may traverse as she attempts to understandand cope with the
abuse experience, as well as problem- and emotion-focused
forms of coping, coping resources,and personaland environmen-
tal constraintsto effective coping. Interventionwas presentedin
terms of the appropriate orientation to practice with abused
women, engagement in treatment, assessment, intervention
strategies,and evaluationof outcomes.
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The Updated Roster of 1996 Conference
Attendees is now Available.
On-site registrants included. Names, addresses, phone, e-mail, employer, and NCFR Section
membership of attendees.
Cost: $4.00 (includes postage and handling). Credit card orders available by phone or fax.
0
National Council on Family Relations
3989 Central Ave. NE, Suite 550, Minneapolis, MN 55421.
Toll Free: 888-781-9331; Phone: 612-781-9331; Fax: 612-781-9348
NCF
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Bonnie E. Carlsonis a social workerand developmentalpsychol-
ogist who has written about domestic violence, dating violence,
and the effects of domestic violence on childrenfor more than20
years.
Received 8-16-96
Revised & Resubmitted2-21-97
Accepted4-8-97
FR797
Family Relations