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How Do You Define Abuse?
Arch Fam Med. 1998;7:31-32.
abuse (n): 1. Physical maltreatment. 2. abuse (vt): To use so as to injure or damage: MALTREAT. 3. To attack in words: REVILE.—Merriam-Webster, 1993
PREVALENCE FIGURES describing wife abuse are often met with skepticism. In a nationwide community survey examining aggressive behaviors among couples in the United States, Straus and Gelles1 found an 11% annual incidence of husband-to-wife physical violence, and a 22% prevalence over a woman's lifetime. Using similar methods in primary care practices, others have found far higher rates; for example, a 22% prevalence of abuse in the past year.2-3 Some readers believed these estimates are exaggerated. Were the researchers really assessing "abuse"? Indeed, many repeated, severe, and harmful acts were represented in these studies; however, the data also included low-frequency, low-severity behaviors. Thus, using their data, one slap in a lifetime could be labeled as "abuse."
The extremes of the definition of abuse are easy to identify. The stereotyped view of wife abuse depicts frequent, severe, intentional, unidirectional, aggressive behavior in the husband-perpetrator, and serious psychological and physical consequences in the wife-victim. This definition is juxtaposed against the definition of a nonabusive relationship, marked by a complete absence of aggressive behaviors, both verbal and physical. However, this creates an enormous gray area. What type of marital argument could be labeled emotional abuse? Consider the couple who trade insults when they are angry with each other, or the husband who publicly berates his wife. What frequency or severity of aggressive acts could be defined as physical abuse? Consider the husband who slaps his wife once per year, or one who slaps his wife once per month, or one who stabs his wife once, or the couples who hit each other. Is an aggressive behavior considered abusive if it has no ill effects? Consider the small woman who regularly punches her large husband, or the husband who controls his wife's behavior through shame and guilt.
Language limits our ability to label these gray areas. When aggression does not fall into the stereotypical view of abuse, a patient may have no language to describe it and no well-defined way to ask for help.4 For example, an acquaintance once telephoned me to clarify a personal event regarding a man she had been dating for about 8 weeks. After an evening out, they returned to his apartment where he scolded and berated her for dancing with another man. Then he used a wrestling move to sweep her feet out from under her, and she fell. For hours, whenever she tried to rise from the floor, he would cause her to fall again. He never hit her or used his hands on her or threatened her with harm—he treated it as a joke—but he would not allow her to stand up or leave, and she fell again and again. The next day she had bruises all over her body. After relating the event to me, she asked "Is this abuse?" We had no word to describe what had happened to her, and she was hesitant to end the relationship based on one undefined event.
To a person on the inside of a violent relationship, defining abuse is extremely difficult. The relationship itself creates a context that blurs the distinctions between harmful and harmless. The first hit—a singular, unique and surprising act—is rarely considered abuse. Aggressive acts that follow are judged against time together that also includes loving acts. Violence is minimized, justified, or reframed to protect the positive aspects of the relationship. In addition, the perpetrator can reinforce "no harm done" explanations by limiting the victim's contact with people who might challenge this definition of the aggression. However, over time, as abuse repeats (which it generally does5 ), or as it begins to affect other aspects of life (such as the children), the victim will redefine these events as abusive. Kelly4 found that frequency was the most important factor influencing how soon a woman defined a man's behavior as abusive. Mills6 described a model of progression through a violent relationship that reflected the evolution of the victim's definitions of abuse and of herself over time. Stages included: (1) entering the relationship; (2) managing the violence, including self-protection and justifying the relationship; (3) experiencing a loss of self, referring to self-identity and perspective; (4) reevaluating the relationship; and (5) restructuring the self, as either a survivor or a victim. Not until stage 4 did victims view their relationship as abusive.
To a person on the outside of a violent relationship, defining abuse—especially in those gray areas—is controversial, with varying professionals declaring abuse as under-reported or overreported. The examination by Wagner and Mongan7 of how women view abuse was a response to critics of violence research who wonder, "Do researchers really assess ‘abuse'?" She used researchers' language— threatening, throwing, pushing, slapping, kicking, hitting, beating up, and using weapons—and asked women if they considered these actions "abusive." Nearly every subject did. In addition, compared with others, women who identified themselves as abused were more likely to believe that using insults and spiteful words were abusive acts. Their perspective on the entire pattern of violence in relationships may be unknown to women who have not been abused, or to women who are in earlier stages of abusive relationships but who have not yet self-identified as victims.
Of all forms of abuse, emotional abuse is an especially gray area. How does one identify it? Pence and Paymar8 describe the key element in abusive relationships as a pattern of one partner's power over the other. To maintain control, the more powerful partner must suppress the other's attempts to act or think independently or to detach from the partner. In abusive relationships, several strategies maintain power and control: verbal insults or humiliation, intimidation, threats, economic control, isolation, male privilege (in male-against-female abuse), minimization, and using children.8 These strategies are almost always found in physically abusive relationships; however, even when no hitting occurs, these behaviors can control the other partner. For example, the more powerful partner, A, can suppress B's contrary opinions with insults, criticism, or public humiliation. A can counter B's criticisms with threats or intimidation. To prevent B from making independent financial decisions, A can control family finances and discourage employment by B. If B's friends disapprove of A, A can undermine those relationships and socially isolate B. B's attempts at self-improvement through further education or advanced employment can be met with ridicule or accusations of bad parenting, family neglect, or sexual infidelity. Emotional abuse gets less attention from health professionals, perhaps because the damage is less obvious or the aggression is more subtle. The article by Wagner and Mongan7 is the first to demonstrate that emotional abuse is associated with poorer health status and functioning and thus deserves intervention by health care personnel.
Given the limitations of language, the variation in insider and outsider perspectives, and the enormous gray areas in the definition, how should physicians identify and intervene with abuse? To begin, routinely talk to patients about their relationships, and ask them how they handle stress, conflict, or disagreement. Follow this with specific questions about violent and controlling behaviors using behavioral terms such as "hit," "hurt," or "threaten." Do not use abstract words like "abuse," "assault," or "violence" unless the patient uses them first. Help patients clarify the personal impact of their experiences and offer a sympathetic perspective.
For all levels of partner violence, including emotional abuse, physicians' interventions should address both medical and psychological recovery9 with a focus on maintaining safety. Treat the medical problems and educate patients about the psychological effects of emotional or physical aggression. Connect them with community resources that specialize in helping victims of violence, such as counseling centers, shelters, and legal services. If a victim of physical violence is not ready to change the living situation today (and most will not be), help develop a "safe plan"—an emergency plan for escape if the partner becomes violent. The safe plan should include an escape route, a mode of transportation, a destination, and a package with money, important papers, and a change of clothing. Urgent persuasion for change is warranted for the more physically dangerous relationships; however, avoid "taking charge," because this behavior replicates the perpetrator's power and control strategies. Dangerousness is indicated by ready access to weapons; alcohol or drug abuse or suicidality in the violent partner; a pattern of repeated, escalating violence; and recent life stressors such as job loss, pregnancy, or marital separation. Finally, follow up with the patient on a regular basis to assess levels of safety and psychological recovery. The key to intervention is to find a common language to describe the abusive experiences, identify helpful resources in the community, and work in a collaborative fashion to promote the patient's safety and recovery from victimization.
Sandra K. Burge, PhD
Department of Family Medicine
University of Texas Health Science Center
San Antonio
REFERENCES
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1. Straus MA, Gelles RJ. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. J Marriage Fam. 1986;48:465-479.
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2. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust. 1996;164:14-17.
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3. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med. 1992;24:283-287.
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4. Kelly L. How women define their experiences of violence. In: Yllo K, Bograd M, eds. Feminist Perspectives on Wife Abuse. Newbury Park, Calif: Sage Publications; 1988:114-132.
5. Feld SL, Straus MA. Escalation and desistance of wife assault in marriage. Criminology. 1989;27:141-161.
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6. Mills T. The assault on the self: stages in coping with battering husbands. Qual Sociol. 1985;8:103-123.
7. Wagner PJ, Mongan PF. Validating the concept of abuse: women's perceptions of defining behaviors and the effects of emotional abuse on health indicators. Arch Fam Med. 1998;7:25-29.
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8. Pence E, Paymar M. Education Groups for Men Who Batter: The Duluth Model. New York, NY: Springer Publishing Co Inc; 1993.
9. American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, Ill: American Medical Association; 1992.
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