Hiding in Plain Sight: The Neglected Problem of Domestic Violence in Society

October is the month of fall, football, and domestic violence (DV). Although the first DV Awareness Month was established In October of 1987, unfortunately a disturbing video of a football star has provoked more public discourse on domestic violence than the longstanding efforts of government agencies and non-profits. If we are honest, it is not really that surprising that DV exists behind closed doors within the NFL; it is more difficult to accept that it is happening in the homes of our friends and neighbors, spanning socio-economic lines. Despite periodic appearances and ensuing public outrage, DV continues to persist out of sight.

Women and children are not the only victims of DV, but they carry the greatest physical and psychological burden. One in four women will be the victim of intimate partner violence in the course of her life, while three million children are exposed to it each year. Intimate partner violence accounts for 20 percent of non-fatal violent crimes against women while approximately 30 percent of all female homicides are committed by someone with whom the woman was intimately involved. Victims suffer from dramatic rates of depression, anxiety, PTSD as well as substance abuse and suicidality. A recent study based on a representative U.S. sample of over 25,000 adults indicated that new onsets of major mental health problems were more than twice as common amongst those exposed to DV in the past year.

These statistics are striking but cannot convey what is truly a shattering psychological paradox. Experiencing violence is always traumatic, but violence at the hands of the person with whom you live, on whom you may depend, and even, love -- often occurring repeatedly, arbitrarily, and accompanied by emotional abuse -- represents an even deeper trauma. It can cause a dramatic unraveling of one's self esteem, emotional stability, and capacity to think. Work and child-care abilities are profoundly affected. One's very sense of self is altered as distorted thoughts take over, including un-warranted self-blame, doubt, and disorientation about what is real and not. Family relationships and friendships become compromised as shame leads to secrecy, and isolation takes over.

Children who live in violent homes suffer whether or not they directly experience the violence themselves. They often have significant behavioral and emotional problems including depression and conduct disorders. Their cognitive development is also impaired. Studies show that exposure to DV is associated with inferior verbal skills, impaired memory, and diminished activity in "executive control" areas of the brain that manage complex functions such as planning, carrying out goals, and inhibiting impulses. Similar to adult victims, children exposed to DV experience chronic fear, helplessness, and anxiety. Most profoundly, their fundamental orientation toward relationships (i.e., what to expect from others and how to love) is disturbingly -- perhaps permanently -- altered. They internalize relationship models that are filled with humiliation and rage and that blend love and threat, intimacy and fear. Moving into adulthood, their capacity to form trusting relationships is significantly challenged and the possibility of abuse coexisting with love looms large. Research shows that men who witnessed domestic violence as children are twice as likely to be abusers in adulthood; and there is a 30-60 percent chance that men and women who witness domestic violence in their childhoods will enter into abusive relationships as adults. Not only does intimate partner violence cause traumatic psychological effects, it is clear that psychological factors contribute to and perpetuate patterns of violent relationships.

Compounding the tragedy of DV is the fact that it remains hidden and under-treated. That we all may have something in common with perpetrators and victims of DV diminishes our ability to acknowledge and attend to it. Underlying any violent interaction is the universal human struggle with aggression, and its myriad complex contributing factors -- family and developmental history, self-esteem, power dynamics, fear of abandonment and humiliation, emotional regulation, impulse control, and the capacity for empathy, guilt, and remorse. The possibility that DV exists at the far end of a continuum of aggression that includes our own is difficult to accept. We reassure ourselves by drawing a line in the sand between "our" behavior and "theirs." Moreover, with this black-and-white orientation comes moral judgment. We may pity but also disdain the victim, and vilify the abuser -- contributing to a stigma that discourages those affected from coming forward and getting the help they need. Finally, as neighbors and bystanders, we do not speak up. DV today is viewed as drunk driving was several decades ago -- we assume that intruding into others' private lives will be met with hostility, and in fact, often it is.

Full recognition of the scope of the problem is just one step. Our society has relegated DV to the socio-criminal-legal sphere; victims of violence receive social services and violent individuals are punished. Psychiatrists and psychologists are surprisingly absent from this landscape. While important, the existing framework does not adequately address victims' pharmacologic needs or deeper psychological dimensions that contribute to and perpetuate the patterns of violent relationships.

The issue of how to treat perpetrators is complicated. Just as it is the mandate of the criminal justice system to punish violent behavior, so is it the mandate of psychiatry-psychology to leave aside judgment and seek to understand all manner of human behavior, for the benefit of those suffering. There are vastly different profiles of violent individuals -- on the one end of the spectrum are untreatable sadists and sociopaths, and on the other, otherwise empathic and remorseful individuals who react violently to extreme stressors. Most perpetrators lie somewhere in between and violent behavior has many faces. Far from condoning DV, maintaining this psychological perspective, and utilizing the full array of our treatment tools, can contribute to the possibility of early prevention and identifying warning signs.

To effectively address this significant public health issue, two things are needed. First, to overcome our temerity and denial of the problem. Second, we must expand services to address the contributing and resulting psychological factors affecting those in DV situations. Psychiatrists and psychologists could and should engage more by integrating our clinical skills into treatment settings and focusing research on the neurobiological underpinnings these violent interactions. One example of this model is the newly formed partnership between the Psychiatry Department at Columbia University and the city-run Bronx Family Justice Center (BFJC), which is adding psychiatric and psychological care to the Center's services. Although just one program, this innovative model can be readily expanded and disseminated.

Beyond the greater involvement of these mental health fields, we must accept that DV is our collective problem.

Anna Chapman, M.D. is a psychiatrist on the faculty of the Columbia University Medical Center and the Columbia University Psychoanalytic Training and Research.

Catherine Monk, Ph.D. is an Associate Professor of Medical Psychology at Columbia University and Co-Director of the CU-BFJC DV Program.

Jeffrey Lieberman, M.D. is Professor and Chair of Psychiatry
Columbia University Medical Center New York Presbyterian Hospital