Intimate partner violence

Intimate partner violence (IPV) is domestic violence by a current or former spouse or partner in an
intimate relationship against the other spouse or partner.[1][2] IPV can take a number of forms,
including physical, verbal, emotional, economic and sexual abuse. The World Health Organization
(WHO) defines IPV as "any behavior within an intimate relationship that causes physical,
psychological or sexual harm to those in the relationship, including acts of physical aggression, sexual
coercion, psychological abuse and controlling behaviors."[3]: page 89 IPV is sometimes referred to
simply as battery, or as spouse or partner abuse.[4]

The most extreme form of IPV is termed intimate terrorism, coercive controlling violence, or simply
coercive control. In such situations, one partner is systematically violent and controlling. This is
generally perpetrated by men against women, and is the most likely of the types to require medical
services and the use of a women's shelter.[5][6][4] Resistance to intimate terrorism, which is a form
of self-defense, and is termed violent resistance, is usually conducted by women.[7][8]

Studies on domestic violence against men suggest that men are less likely to report domestic
violence perpetrated by their female intimate partners.[9][10] Conversely, men are more likely to
commit acts of severe domestic battery,[11][12][13] and women are more likely to suffer serious
injury as a result.[14]

The most common but less injurious form of intimate partner violence is situational couple violence
(also known as situational violence), which is conducted by men and women nearly equally,[6][4][7]
and is more likely to occur among younger couples, including adolescents (see teen dating violence)
and those of college age.[7][15]

Types of intimate partner violence

Domestic violence and abuse means physical injury, serious physical injury, stalking, sexual abuse,
assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual abuse, or
assault between family members or members of an unmarried couple.

Family member means a spouse, including a former spouse, a grandparent, a parent, a child, a
stepchild, or any other person living in the same household as the child if the child is the alleged
victim.

Member of an unmarried couple means each member of an unmarried couple which allegedly has a
child in common, any children of that couple, or a member of an unmarried couple who are living
together or have formerly lived together.

The Centers for Disease Control and Prevention (CDC) identifies four types of intimate partner
violence—physical violence, sexual violence, stalking, and psychological aggression. Information
about the important revisions in definition can be found in the CDC’s Intimate Partner Violence
Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0, which was
published in 2015. The CDC strongly advocates for coherent and uniform definitions to improve the
collection and analysis of data and help to identify trends and make comparisons (CDC, 2015).

 Physical Violence
Physical violence is the intentional use of physical force with the potential for causing death,
disability, injury, or harm. Physical violence includes, but is not limited to:

 Scratching, pushing, or shoving

 Throwing, grabbing, or biting

 Choking, shaking, aggressive hair pulling, slapping, punching, hitting or burning

 Use of a weapon

 Use of restraints or one’s body, size, or strength against another person

 Physical violence also includes coercing other people to commit any of the above acts. (CDC,
2016)

Research has shown that physical violence is often accompanied by psychological abuse and, in one-
third to one-half of cases, by sexual abuse (Heise & Garcia-Moreno, 2002). The violence is usually not
limited to one instance. The National Violence Against Women Survey (NVAWS) found that women
who were physically assaulted by an intimate partner averaged 6.9 physical assaults by the same
partner, while men who were assaulted averaged 4.4 assaults.

Women experience more chronic and injurious physical assaults at the hands of intimate partners
than do men. The NVAWS found that more than 40% of women who were physically assaulted by an
intimate partner were injured during their most recent assault, compared with about 20% of the
men. Most injuries, such as scratches, bruises, and welts, were minor. More severe physical injuries
may occur depending on severity and frequency of abuse. Physical violence can lead to death
(Tjaden & Thoennes, 2000).

 Sexual Violence

Sexual violence is divided into five categories, any of which constitute sexual violence, whether
attempted or completed. Additionally, all of these acts occur without the victim’s consent, including
cases in which the victim is unable to consent due to being too intoxicated (eg, incapacitation, lack of
consciousness, or lack of awareness) through their voluntary or involuntary use of alcohol or drugs
(CDC, 2016).

 Rape or penetration of victim. This includes completed or attempted, forced or

alcohol/drug-facilitated unwanted vaginal, oral, or anal insertion. Forced penetration occurs
through the perpetrator’s use of physical force against the victim or threats to physically
harm the victim.

 Victim was made to penetrate someone else. This includes completed or attempted, forced
or alcohol/drug-facilitated incidents when the victim was made to sexually penetrate a
perpetrator or someone else without the victim’s consent.

 Non-physically pressured unwanted penetration. This includes incidents in which the victim
was pressured verbally or through intimidation or misuse of authority to consent or
acquiesce to being penetrated.

 Unwanted sexual contact. This includes intentional touching of the victim or making the
victim touch the perpetrator, either directly or through the clothing, on the genitalia, anus,
groin, breast, inner thigh, or buttocks without the victim’s consent
  Non-contact unwanted sexual experiences. This includes unwanted sexual events that are
not of a physical nature that occur without the victim’s consent. Examples include unwanted
exposure to sexual situations (eg, pornography); verbal or behavioral sexual harassment;
threats of sexual violence to accomplish some other end; and /or unwanted filming, taking or
disseminating photographs of a sexual nature of another person (CDC, 2016).

Sexual and physical abuse is often accompanied by controlling behaviors. In a World Health
Organization survey of more than 24,000 women in ten countries, the percentage of those who had
experienced one or more of the following controlling behaviors ranged from 20% in Japan to 90% in
urban United Republic of Tanzania:

 Keeping her from seeing friends

 Restricting contact with her family of birth

 Insisting on knowing where she is at all times

 Ignoring or treating her indifferently

 Getting angry if she speaks with other men

 Often accusing her of being unfaithful

 Controlling her access to healthcare (WHO, 2005)

 Stalking and Cyberstalking

Stalking is a pattern of repeated, unwanted, attention and contact that causes fear or concern for
one’s own safety or the safety of someone else (eg, family member or friend). Some examples
include repeated, unwanted phone calls, emails, or texts; leaving cards, letters, flowers, or other
items when the victim does not want them; watching or following from a distance; spying;
approaching or showing up in places when the victim does not want to see them; sneaking into the
victim’s home or car; damaging the victim’s personal property; harming or threatening the victim’s
pet; and making threats to physically harm the victim (CDC, 2016).

In the United States 7.5 million people are stalked in one year, with 85% of the victims being stalked
by someone they know. Sixty-one percent of female victims and 44% of male victims are stalked by
an intimate partner. Among women who have been murdered, 76% were stalked by their intimate
partner and 67% had been abused by them. Stalking victims may become fearful and anxious, and
their physical and mental health can suffer as a result (National Center for Victims of Crimes, 2012).

Today, stalkers have at their fingertips a wide array of computers and equipment including the
Internet, global positioning systems, cell phones, and tiny digital cameras. In many states, general
stalking statues have not kept up with these new technologies. However, changes in the law in 2009
made cyberstalking a crime in Kentucky (KRS 508.130–150). Additional information for identifying
and dealing with cyberstalking is available from the Kentucky Attorney General’s office and at this
link.

 Psychological Aggression
Psychological aggression is the use of verbal and nonverbal communication with the intent to harm
another person mentally or emotionally, and/or to exert control over another person. Psychological
aggression can include:

 Expressive aggression (eg, name-calling, humiliating)

 Coercive control (eg, limiting access to transportation, money, friends, and family; excessive
monitoring of whereabouts)

 Threats of physical or sexual violence; control of reproductive or sexual health (eg, refusal to
use birth control; coerced pregnancy termination)

 Exploitation of victim’s vulnerability (eg, immigration status, disability)

 Exploitation of perpetrator’s vulnerability

 Presenting false information to the victim with the intent of making them doubt their own
memory or perception (eg, mind games) (CDC, 2016).

Coercive control and intimidation by the abusive partner is considered an underlying component of
all of these types of violence. The abusive partner’s ability to control relies on the abused person’s
belief that if she or he does not comply with the abusive partner’s demands, the victim, the victim’s
children, or other persons or things the victim cares about will be harmed. Often, threats are
alternated with acts of kindness from the perpetrator, making it difficult for the victim to break free
of the cycle of violence.

The ten-country World Health Organization survey and other research has consistently shown that
emotional abuse can have a more profound and negative effect than physical violence. Between 20%
and 75% of women across all the countries surveyed reported being the recipient of emotional abuse
within the previous 12 months (WHO, 2005).

Causes of intimate partner violence

(a) Cultural: religious and historical traditions in the past have sanctioned the chastising and beating
of wives particularly under the notion of entitlement and ownership of women. This, in turn,
legitimizes control over women's sexuality. In many societies, a women's sexuality is linked to family
honor. Traditional norms in these societies allow the killing of women who have been deemed to
have brought dishonor to the family. Furthermore, acts of sexual violence against women are seen as
a way of defiling enemies honor. Adverse childhood experiences, particularly witnessing domestic
violence and experiencing physical and sexual abuse, have been identified as factors that put
children at risk. Excessive consumption of alcohol and other drugs has also been noted as a
consistent factor incident of IPV.

(b) Economic: the link between violence and lack of economic resources and dependence is very
evident. Risk and threat of violence prevent women from seeking jobs, and because of lack of
financial independence, they are stuck in an abusive relationship.

(c) Legal: law enforcement agencies frequently reinforce the batterers’ attempts to control and
demean their victims. In many cases, despite the legislation in place, the perpetrators of IPV are
dealt with more leniently compared to perpetrators of similar violence with strangers.
(d) Political: there is a false notion of family being private and beyond control of the state. The
problem is compounded by the underrepresentation of women in power, politics, the media, and in
the legal system.[19,20]

(e) Role of alcohol as follows: (i) Cultural factors: there is strongly prevalent belief in society that
alcohol can encourage violent behavior after drinking and there is increasing the use of alcohol as an
excuse for violent behavior. Discriminatory upbringing with poor self-esteem also condone abuse of
females.[21] Furthermore, it may be that the association of IPV and alcohol is more concurrent and a
manifestation of expression of masculinity on part of men. (ii) Personal factors: Heavy drinking, by
itself can be a source of marital conflict and dissatisfaction which may lead to IPV. Alcohol per se may
increase the distortions of power and control motives.[22] (iii) Pharmaco-Cognitive factors: Alcohol
can by itself directly increase aggressiveness or can lead to various cognitive changes in the
individual that make him prone to aggressiveness. Alcohol impairs one's ability to exert self-control,
learning, and impair the ability to delay gratification which can lead to aggression.[22,23] It also leads
to severe difficulties in attention, concentration, cognitive flexibility, and executive cognitive
functioning.[24,25] (iv) Proximal and distal factors: proximal factors, such as pharmaco-cognitive
effects of alcohol, social, and environmental cues, state anger can trigger IPV. Distal factors are those
may themselves may not cause violence but under influence of proximal factors may lead to
violence. Examples are personality, relationship characteristics, and traits such as anger and hostility.
[22,26,27]

(v) Contextual Factors: excessive alcohol drinking by one partner may precipitate or exacerbate
marital disharmony, thereby increasing the risk of IPV.[22,28] Alcohol may just be like adding fodder
to a fire, that it be contributing rather than causing IPV.[29]

(vi) Early parenthood is a risk factor. Women who had children by age 21 were twice as likely to be
victims of intimate partner violence as women who were not mothers at that age. Men who had
fathered children by age 21 were more than three times as likely to be people who abuse as men
who were not fathers at that age. (Moffitt and Caspi, 1999).

(vii) Severe poverty and its associated stressors increase the risk for intimate partner violence—the
lower the household income, the higher the reported intimate partner violence rates (Carlson et al.,
2000). Moreover, researchers found that reductions in benefits from Aid to Families with Dependent
Children (AFDC) were associated with an increase in intimate partner homicides (Dugan, Nagin, and
Rosenfeld, 2003).

(viii) Intimate partner violence is linked with unemployment; one study found that intimate partner
violence impairs a woman's capacity to find employment (Goodwin, Chandler, and Meisel, 2003).
Another study of women who received AFDC benefits found that domestic violence was associated
with a general pattern of reduced stability of employment (Meisel, Chandler, and Rienzi, 2003).

Interventions

1. Individual treatment
Due to the high prevalence and devastating consequences of IPV, approaches to decrease
and prevent violence from re-occurring is of utmost importance. Initial police response and
arrest is not always enough to protect victims from recurrence of abuse; thus, many states
have mandated participation in batterer intervention programs (BIPs) for men who have
been charged with assault against an intimate partner.[89] Most of these BIPs are based on
the Duluth model and incorporate some cognitive behavioral techniques.

The Duluth model is one of the most common current interventions for IPV. It represents a
psycho-educational approach that was developed by paraprofessionals from information
gathered from interviewing battered women in shelters and using principles from feminist
and sociological frameworks.[90] One of the main components used in the Duluth model is
the 'power and control wheel', which conceptualizes IPV as one form of abuse to maintain
male privilege. Using the 'power and control wheel', the goal of treatment is to achieve
behaviors that fall on the 'equality wheel' by re-educate men and by replacing maladaptive
attitudes held by men.[90]

Cognitive behavioral therapy (CBT) techniques focus on modifying faulty or problematic

cognitions, beliefs, and emotions to prevent future violent behavior and include skills
training such as anger management, assertiveness, and relaxation techniques. [81]

Overall, the addition of Duluth and CBT approaches results in a 5% reduction in IPV. [91]
[92]
This low reduction rate might be explained, at least in part, by the high prevalence of
bidirectional violence[60] as well as client-treatment matching versus "one-size-fits-all"
approaches.[93]

Achieving change through values-based behavior (ACTV) is a newly developed Acceptance

and Commitment Therapy (ACT)-based program. Developed by domestic violence
researcher Amie Zarling and colleagues at Iowa State University, the aim of ACTV is teach
abusers "situational awareness"—to recognize and tolerate uncomfortable feelings – so that
they can stop themselves from exploding into rage.[94]

Initial evidence of the ACTV program has shown high promise: Using a sample 3,474 men
who were arrested for domestic assault and court-mandated to a BIP (either ACTV or
Duluth/CBT), Zarling and colleagues showed that compared with Duluth/CBT participants,
significantly fewer ACTV participants acquired any new charges, domestic assault charges, or
violent charges. ACTV participants also acquired significantly fewer charges on average in
the one year after treatment than Duluth/CBT participants.[94]

Psychological therapies for women probably reduce the resulting depression and anxiety,
however it is unclear if these approaches properly address recovery from complex trauma
and the need for safety planning.[95]

2. Conjoint treatment
Some estimates show that as many as 50% of couples who experience IPV engage in some
form of reciprocal violence.[60] Nevertheless, most services address offenders and survivors
separately. In addition, many couples who have experienced IPV decide to stay together.
These couples may present to couples or family therapy. In fact, 37-58% of couples who
seek regular outpatient treatment have experienced physical assault in the past year. [96] In
these cases, clinicians are faced with the decision as to whether they should accept or
refuse to treat these couples. Although the use of conjoint treatment for IPV is controversial
as it may present a danger to victims and potentially escalate abuse, it may be useful to
others, such as couples experiencing situational couple violence.[97] Scholars and
practitioners in the field call for tailoring of interventions to various sub-types of violence
and individuals served.[98]

Behavioral couple's therapy (BCT) is a cognitive-behavioral approach, typically delivered to

outpatients in 15-20 sessions over several months. Research suggests that BCT can be
effective in reducing IPV when used to treat co-occurring addictions, which is important
work because IPV and substance abuse and misuse frequently co-occur. [98]

Domestic conflict containment program (DCCP) is a highly structured skills-based program

whose goal is to teach couples conflict containment skills.

Physical aggression couples treatment (PACT) is a modification of DCCP, which includes

additional psychoeducational components designed to improve relationship quality,
including such things as communication skills, fair fighting tactics, and dealing with gender
differences, sex, and jealousy.[98]

The primary goal of domestic violence focused couples treatment (DVFCT) is to end violence
with the additional goal of helping couples improve the quality of their relationships. It is
designed to be conducted over 18 weeks and can be delivered in either individual or multi-
couple group format.[98][99]
Psychosocial counseling for IPV perpetrators is widely available, with well over 1000 programs in the
US. Most of these programs predominantly serve court-mandated populations and are focused on
men who have assaulted women. Although a range of program philosophies and practices exist
(Table 2), programs for perpetrators of IPV, often labeled batterer intervention programs (BIPs), tend
to advocate an open admissions group modality and can last from 8 to 52 weeks.

There are 2 common types of BIPs. The first assumes a gender-themed root cause of IPV, such that
the patriarchal nature of societal and institutional structures reward male domination and justify any
means (including physical aggression) that reinforce male power, control, and privilege.28 For
example, the widely adopted Duluth Abuse Intervention Project model aims to prevent IPV via
largely didactic psychoeducational reprogramming of (male) offenders. This model focuses on
exposing patriarchal/misogynistic attitudes, encourages accountability and personal responsibility,
and promotes gender-egalitarian behaviors. Although this approach has been criticized because of
theoretical inconsistencies and lack of empirical support, most existing intervention programs use
some variation of this model.8,29-31

A second BIP model uses cognitive-behavioral therapy (CBT).32,33 This model aims to change behavior
through a collaborative therapeutic relationship, exposure and disputation of distorted cognitions,
and various problem-solving and mood-regulating techniques.34-38 Couples-based CBT that focuses on
enhancing communication and problem-solving skills between partners remains controversial
because of concerns about a heightened risk of injury to partners who remain with an abusive
individual while simultaneously receiving treatment for potentially volatile relationship conflicts.

Despite the widespread adoption of BIPs, evidence for their effectiveness is limited and inconclusive.
Most studies of BIP effectiveness have substantial methodological limitations, including very high
rates of sample attrition, inadequate treatment standardization, little or no documentation of
treatment fidelity, and systematic biases in random assignment.37,39 For men assigned to BIPs,
average violence recidivism rates are about 5% lower than those for men assigned to control
conditions (eg, probation monitoring), with no differences in effectiveness between the Duluth
model and therapeutic CBT programs.38 Couples-based approaches have not been found to be more
effective, or more dangerous, than gender-specific IPV treatments.40 Thus, the empirical status of
BIPs is decidedly uncertain, despite the enormous public health and safety concerns about IPV and
the promise that such interventions have in rehabilitating offenders.

Alternative strategies

Interventions designed to enhance motivation and readiness to change have added value, beyond
traditional BIP services.39 In recent years, the focus has been on developing and evaluating
alternative interventions, including medication therapy, comprehensive mental health case
management, integrated treatment for substance use problems and IPV, culturally specific
interventions, trauma-informed therapies, and interventions targeting motivation to change.
Whereas all of these approaches can be well justified conceptually, empirical support remains
limited.

An integrated CBT program for substance use problems and IPV produced significant short-term
benefits in violence reduction during treatment; however, these differences were not maintained at
a 6-month follow-up.41 Kraanen and colleagues18 evaluated the effectiveness of a CBT program that
primarily targeted substance use disorders with a single session dedicated to IPV. At the 8-week
follow-up, significant reductions in IPV and substance abuse were seen. The researchers concluded
that a CBT program that targets substance abuse with some content regarding IPV may be a more
economical solution in terms of financial and labor costs.

One study of a culturally focused program compared a group of African American men with mixed-
race and same-race groups receiving a conventional BIP program. The results did not support same-
race or culturally specific programs-the re-arrest rate for participants in the same-race groups was
higher than for men in the conventional mixed-race groups.42

A trauma-informed treatment for veterans who have perpetrated IPV was recently developed.43 The
treatment was designed to help veterans understand the effect of military and combat experiences
on intimate relationships while emphasizing strength and coping resources and the development of
new relationship skills. Initial pilot findings suggest that this approach was favorably received by
veterans; however, no controlled trial data have been presented.

The focus of several interventions is on motivation and readiness to change, areas of considerable
challenge in working with IPV perpetrators (who are often forced by courts or partners to seek
treatment). Brief motivational interviewing-a supportive and highly empathic counseling style
designed to resolve ambivalence about change-has been shown to enhance positive treat-ment
engagement and compliance with behavior change recommendations.44,45 Group approaches
designed to help clients move through the stages of intentional behavior change have increased
treatment adherence for highly resistant IPV offenders in one study and produced lower
posttreatment violence relative to standard BIP services in another.46,47

28. Dobash RE, Dobash R. Violence Against Wives: A Case Against the Patriarchy. New York: Free
Press; 1979.

42. Gondolf EW, Williams OJ. Culturally focused batterer counseling for African American
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43. Taft CT, Macdonald A, Monson CM, et al. “Strength at home” group intervention for military
populations engaging in intimate partner violence: pilot findings. J Fam Violence. 2013;28:225-231.

44. Crane CA, Eckhardt CI. Evaluation of a single-session brief motivational enhancement
intervention for partner abusive men. J Couns Psychol. 2013;60:180-187.

45. Musser PH, Semiatin JN, Taft CT, Murphy CM. Motivational interviewing as a pregroup interven-
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46. Scott K, King C, McGinn H, Hosseini N. Effects of motivational enhancement on immediate

outcomes of batterer intervention. J Fam Violence. 2011;26:139-149.

47. Alexander PC, Morris E, Tracy A, Frye A. Stages of change and the group treatment of batterers: a
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33. Wexler DB. Stop Domestic Violence: Innovative Skills, Techniques, Options, and Plans for Better
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35. Murphy CM, Eckhardt CI. Treating the Abusive Partner: An Individualized Cognitive-Behavioral
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36. Stosny S. Treating Attachment Abuse: A Compassionate Approach. New York: Springer Publishing;
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