Stages of Change & Domestic Abuse Survivors

In this post, I’m reviewing literature that discusses the stages of change as it applies to providing care to victims of intimate partner violence. As an intern working at a homeless shelter for women, I find the work highly relevant to what I see from day to day.  This post includes segments of old assignments…

“Why does’t she just leave him?!?!?!?”

“Queries like, “Why does she put up with that?” and “Why does she stay?” continue to haunt battered women…The implication is that the battered women’s behavior is problematic…This ego-deflating and incriminating element can serve to keep a woman trapped in a situation she may view as incapable of ending herself” (Burman, 2003, p. 83).

During my internship class last quarter, a fellow classmate began discussing a client she was seeing who was just left an abusive relationship.  At one point my professor made an interesting statement that made me stop and think:

“The key is to understand the unresolved issues they have yet to work through”

This statement made me stop and think a bit about my own history, and the “it years”.  Mind you, the abusive behavior was psychological and emotional.  However, there is certainly a parallel.   Throughout the relationship, I can’t tell you how many times I heard someone say: “Why don’t you just leave him?”  I recall thinking silently, “it’s just so complicated, you don’t understand.”  My response was, often to remain silent, and simply ignore the question.  There was no point in explaining to those who ask, what they are blind to and unable to conceive…

It is for this reason, that my professor’s comments really struck me.  In response to questions such as these I might say iterate what my own professor said, “what unresolved issues lay in their life history that I hadn’t worked out yet as an explanation for why they would be in a relationship like this?”

To put it another way, let’s look at this issue from a behavioral perspective.  Mind you, this theory isn’t necessarily my favorite since I feel we are much more than pavlovian dogs.  However, what’s clear about human behavior is that we do what works.  Even, if at first, behaviors appear self-destructive, we must ask ourselves what they “payoff” is.  In my own case, there was an emotional “hot potato” was the unresolved trauma of bullying and ostracism in my childhood.    I was so incredibly desperate to avoid the rejection and loneliness of my childhood, this relationship was the “lesser of two evils” as an alternative to re-experiencing the traumas of my childhood.

Admittedly, this personal perspective in my own life history, might not apply to many other cases of domestic violence.  However, the point is, rather than asking “why don’t they leave?”  We must ask ourselves, how this relationship reflects the the summative emotional impact of life experiences?  I love John Malkovich’s assertion that to a create character successfully we must see them without judgment.  Maybe this is also true with clients:  to see their life experiences without judgment.

“Attempting to understand the nature of the battering and how women cope, we can glean some insights into…the strengths that are utilized to make the decision to leave, act upon and sustain this goal” (Burman, 2003, p. 84).

Two articles are useful in providing information in understanding a domestic violence situation as a guide throughout the counseling process.  These articles describe a woman’s adaptations to spousal abuse in terms of the following stages: pre-contemplation, contemplation, preparation, action, maintenance, and termination (Burman, 2003; Fraser, et al, 2001).  According to this theory, change is not a singular event but a process that occurs in an observable sequence of stages.   For example, during pre-contemplation, a woman tends to minimize and deny the issues and their consequences. Traumatic bonds are quite pronounced at this point and a sense of isolation and dependence grows along with a growing feeling of responsibility and self-blame (Burman, 2003, p85). The contemplation phase marks a period of ambivalence during which an increasing level of cognitive dissonance develops and a woman vacillates on whether to leave (Burman, 2003, p85). Determination and Action involve the process of preparing to leave and enacting one’s plan. Finally, brief descriptions are provided of the maintenance and termination stages.  What follows is an overview of the stages of change as it applies to victims of intimate partner violence.

Overview of The Stages of Change

Pre-Contemplation

The pre-contemplation stage is characterized by either denial and minimization of the problem.  For example, during this stage a client may resist any attempts to discuss and acknowledge that abuse is occurring. This might can present as a defensiveness towards anyone who suggests and/or suspects that there is a problem (Burman, 2003).  Alternatively, the client might also present with a desire to accommodate “herself to the situation, constantly hoping that by pleasing her partner he will change his ways” (Burman, 2003, p. 84).  Sometimes expressions of hopelessness regarding the possibility of change can also be seen (Frasier, et al, 2001).  Alternatively, the client may describe the hopelessness of the situation while blaming herself and/or others:

“There is no need to talk about it; it won’t change a thing,”

“If the supper had been ready on time…”

“But, he is a good provider…”

“If the children weren’t so noisy…”

During this early stage, the traumatic bond begins to develop.  I prefer to call it a “boot camp” period, where you’re slowly broken in like a pair of new boots.  Momentary expressions of love and/or positive reinforcement are intermingled with various forms of abusive behavior.  You’re slowly isolated from others and dependency upon your partner grows slowly over time.  An extremely low self-esteem exists that one cannot see beyond, as an all-encompassing perspective of oneself.  This is the hardest to explain, for those who don’t understand.  However, I would simply like to note that people can’t see what they haven’t experienced, like explaining the color purple to a blind man.

Contemplation

This stage is characterized by feelings of ambivalence as the client vacillates between “concern and..unconcern, motivation to change and to continue unchanged” (Burman, 2003, p. 85).  The therapist’s primary goal is to addrress feelings of ambivalence.  As the situation continues in an unremitting manner, the client’s coping mechanisms wear down. Consequently, denial is no longer possible and they begin to recognize that a problem exists.  The client struggles to make sense of their partner’s behavior and process their feelings of ambivalence by weighing various options as “what if’s”.

“I wish that I could figure out what to do differently so he won’t get so angry with me,.”

“What would happen if I did leave, can I ‘go it alone’?”

Preparation

“Patients in this stage are consciously aware of their problems. They are `committed’ to taking action usually within the next month” (Frasier, et al, 2001, p. 214).  During this stage the primary goal is to “determine the best course of action and prepare to carry it out” (Burman, 2003, p. 86).  Planning is underway as the client seeks counseling, legal assistance, saving money, and a safe place to stay.  Both resources for this post mention that change is sometimes a fluctuating process and clients can occasionally be seen moving back and forth between preparation and contemplation (Burman, 2003; Fraser, et al, 2001).

Action

During this stage, the client begins putting her plans into action and makes efforts to change.  “The prospect of leaving, is often dangerous and scary, provoking feelings of fear and anxiety (Burman, 20030.  Therefore, great energy is now directed toward ensuring your personal safety and rebuilding your life.   Victims of abuse may seek counseling, participate in a local support group for victims of domestic violence, and/or request that their partner seek treatment as part of a court-ordered protective or restraining order. Some victims may also train for or seek work outside the home in order to establish economic independence.” (Fraser, et al, 2001 p. 214).

Maintenance

During the maintenance stage, clients are struggling to avoid problematic behaviors.  The goal during this stage is to prevent relapses into old destructive habits.  Burman, (2003) states that 5-7 attempts are commonly made to leave an abusive relationship before success is achieved. “Various reasons have been given for this action, including ‘fear, continuing emotional involvement, desire to keep the family together, and lack of viable alternatives'” (Burman, 2003, p.86).   “Maintenance depends not only on the thoroughness of the action plan but also on a continuing support system” (Fraser, 2001, p. 2014).

Assessment Client Needs

Nature of Abuse

It is also important to obtain more detail on the nature and severity of the past abuse history in order to begin working through the effects of these experiences (Burman, 2003).   This should also entail an assessment for symptoms of PTSD and dissociation.

Self-Esteem & Coping Style

Issues for women recovering from a history of spousal abuse include a diminished self esteem, as well as dysfunctional cognitive and affective adaptations (Holiman & Schlilit, 1991). This diminished self-esteem can be thought of as a sense of powerlessness and low self-worth. It causes individual’s develop maladaptive belief systems about themselves in relation to others (Holiman & Schlilit, 1991). Emotionally, long-term spousal abuse also causes a paradoxical attachment, in which victims come to rely on a hope for something they never receive (Holiman & Schlilit, 1991).

Readiness for Change

Interventions should be geared towards a client’s level of readiness for change and aimed addressing resistance. For example, for women who have not yet left relationships, you would note they are either one of two things. They may be in the pre-contemplative change and unwilling to acknowledge the problem. Or they may be in the contemplative change and considering leaving, but unsure of how they may do so.

Depression & self-care (Kakurt, 2014)

Participants in this article described feeling depressive symptoms and difficulty engaging in adequate self-care (Karkurt, et al, 2014). Additionally they felt a mixture of emotions including being overwhelmed and stressed about the big life decision they just made. These overwhelmed feelings would arise when they began discussing the tasks before them as they attempted to rebuild their lives. Others were angry for themselves for not having left sooner.

Shame & Self-Blame (Karakurt, 2014)

A subgroup of participants in this research suffered with several more severe co-morbid diagnoses that required additional interventions. Issues common in this group include bipolar disorder, depression, suicide, dissociative PTSD, borderline personality disorder (Karakurt, et al, 2014). Finally, individuals who had suffered longer-term severe abuse, were most likely to deal with feelings of excessive guilt and self-blame (Karakurt, et al, 2014).   These feelings of guilt and self-blame made their decision to leave particularly difficult to cope with. For example, this article describes one participant stating they felt they had betrayed the trust of their partner (Karakurt, et al, 2014). This insight points at the importance of understanding an abusive situation from the perspective of someone who has lived it.   From an outsider’s point of view, these feelings make little sense. On the other hand, from the perspective of someone living the experience, the feelings are altogether different. It is our job to work at appreciating things in this vantage point, and helping from within this perspective.

Emotional Response to Violence

Holiman, (1991) “describes a paradox for women in violent situations: the woman is trapped because she feels even more afraid when she contemplates separation than when she imagines being intimate in a battering relationship…the fear of being without a partner was overriding, more important than whether or not the violence stopped” (p. 346).

When I read the above quote, I was again reminded of that relationship in college.  I would like to reiterate it wasn’t physically violent,  however emotionally, psychologically and sexually abusive.  I can recall a similar feeling of fear upon separation.  I recall breaking up with him during a family vacation to London.  My mother had arranged it with his parents.  He was going to visit them for a week, while I went to London.  It was my first time away from him.  I recall breaking up with him from this safe distance, and feeling a nagging fear & anxiety throughout the remainder of the trip.  This paradoxical feeling is admittedly difficult to explain however quite overwhelming.  Holiman (1991) suggests this is due to a process of traumatic bonding takes place between the woman and her partner, similar to the relationship between hostage and captor.” (p. 346).

Interventions

“Effective Interventions Matched with Stages of Change” for victims of abuse. (Fraser, et al, 2001, p. 215).

“Roberts’ Seven-Stage Crisis Intervention Model & Battering Severity Continuum” (Holiman, 2003, p. 88).

Burman, (2003) includes a description of a Crisis Intervention Model based on research that focuses on domestic violence.  This Crisis Intervention Model is based on the idea that abuse can be observed to occur along a continuum of severity.  “Divided into seven stages, the model details hierarchical assessment and intervention activities that aim to subdue a crisis so that strength-oriented empowering cognitive, and independent function can be achieved” (Burman, 2003, p. 88).

Crisis Defined:

“An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping mechanisms. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable or unbalanced state, a precipitating factor, an active crisis state based on the person’s perception, and the resolution of the crisis.” (Roberts, 2005, p. 778)

Seven Stages of Intervention (Roberts, 2005).

Continuum of Abuse (Burman, 2003).

A treatment plan

The following is a hypothetical treatment plan I created for my practicum course some time ago.  I utilized the resources below to create it…

References

Burman, S. (2003). Battered women: Stages of change and other treatment models that instigate and sustain leaving. Brief Treatment and Crisis Intervention, 3(1), 83.
Fraser, P. Y., Slatt, L, Kowlowitz, V., & Glowa, P. T. (2001). Using the stages of change model to counsel victims of intimate partner violence. Patient Education and Counseling. 44, 211-217.
Holiman, M. & Schlilit R. (1991). Aftercare for battered women: How to encourage maintenance of change. Psychotherapy. 28(2), 345-353.
Karakurt, G., Smith, D., & Whiting, J. (2014). Impact of Intimate Partner Violence on Women’s Mental Health. Journal of family violence29(7), 693-702.
Roberts, A. R., & Ottens, A. J. (2005). The seven-stage crisis intervention model: A road map to goal attainment, problem solving, and crisis resolution. Brief Treatment and Crisis Intervention, 5(4), 329-339

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