Community Mental Health Journal, Vol. 28, No. 6, December 1992
CLINICAL CARE UPDATE Family Violence: Contemporary Research Findings and Practice Issues Bonnie L. Yegidis, Ph.D.
A B S T R A C T : The purpose of t h i s p a p e r is to describe recent e m p i r i c a l r e s e a r c h findings about f a m i l y violence, and to explore selected social w o r k t r e a t m e n t issues in the light of these findings. The l a s t two decades has seen a proliferation of r e s e a r c h about f a m i l y violence. Most of t h e e a r l y r e s e a r c h used s m a l l clinical s a m p l e s a n d so generalizi n g findings to o t h e r groups h a s been difficult. However, t h e recent r e s e a r c h h a s e x a m i n e d a n u m b e r of i m p o r t a n t psychosocial correlates of f a m i l y violence u s i n g more methodologically sound methods. As a result, we now know quite a bit about how and w h y f a m i l y violence occurs. Also, w i t h i n the l a s t decade a n u m b e r of studies have explicated the k i n d s of t r e a t m e n t s a n d approaches t h a t are most effective in d e a l i n g w i t h abusive people. This p a p e r s u m m a r i z e s these t r e a t m e n t strategies.
I N T R O D UCTION During the past two decades the professional literature addressing family violence has increased markedly. Research studies have addressed all forms of family violence including child abuse, sexual abuse, marital violence and abuse of the elderly. This increase in professional attention to family violence is related to a number of factors. First, clinicians and researchers are becoming increasingly aware of the serious effects that a history of family violence has on individuals and families. Some of these effects include: alcoholism or drug addiction (Gayford, 1975; Hilbermann, 1980), eating disorders (Sloan & Leichner, Bonnie L. Yegidis, Ph.D., is Director, School of Social Work, University of South Florida, Tampa, Florida 33620. An earlier version of this paper was presented at the 13th Annual Conference on Professional Social Work Development, National Association of Social Workers, Florida Chapter, Tampa, Florida. March 31-April 2, 1989. 519
9 1992 Human Sciences Press, Inc.
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1986; Hall, Tice, Beresford, Wooley & Hall, 1989), depression (Hilbermann, 1980) and family dysfunction (Gayford, 1975; Renvoize, 1978). Also, public policy has become more responsive to the needs of violent families. Hence mandated reporting laws and treatment programs have been implemented and research addressing their effectiveness has been published. In addition, several theoretical frameworks have been developed that describe the dynamics of violent families. The purpose of this paper is to describe recent research findings about family violence, and to explore selected treatment issues in working with violent families. Historically, the research on family violence has been less than satisfactory; methodological flaws have abounded. For example, most of the early research was characterized by the use of small, nonrepresentative samples, by the lack of comparison groups, and by the use of nonstandardized measuring instruments. As a result, it has been difficult to compare findings and to build a cohesive knowledge base from which to inform practitioners. However, more recently comparative groups and nonclinical samples have been used as the basis for research inquiry in this area. R E C E N T R E S E A R C H FINDINGS Overview It has been said that violent families are easy to describe but difficult to explain. The research on family violence has consistently found intergenerational transmission, low socioeconomic status, social and structural stress, social isolation, and personality problems or psychopathology (Gelles & Maynard, 1987). Bolton & Bolton (1987) have summarized the major social, psychological and family process factors correlated with violent families. A summary of these follows. Social Factors. Abusive families tend to be socially isolated, experiencing multiple sources of environmental ~press," with poor capacities for survival and coping. Characteristically, they are likely to be overrepresented as racial or ethnic minorities with education limitations and occupational difficulties. For example, they are likely to be underemployed or unemployed. Psychological Factors. Most studies on abusive families have shown that the adult members feel powerless to effect changes in their environments. They tend to be immature, inadequate copers with low self-
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esteem and strong dependency needs. There is literature on the psychopathology of abusive people (Elmer, 1967, Kempe & Helfer, 1972, & Zalba, 1967). However, little agreement has been reached regarding a personality profile of the abuser, per se.
Family Process Factors. Finally, a set of family process variables characteristic of abusive families may be articulated. They include poor communication patterns, recurrent family or marital stress, inappropriate behavioral expectations of the victim, role confusion or reversal, step-family relationships, overreliance on physical punishment for disciplining, and inadequate knowledge on child rearing or caretaking. The Incidence of Family Violence The private nature of family violence and the lack of a standard definition of it conspire to make the development of reliable incidence data difficult. However, at least two large scale national surveys have been conducted to try to estimate the national incidence of family violence. A summary of the findings from these studies follows. In 1975, Straus, Gelles and Steinmetz used a national probability sample of 2143 people to conduct in-depth interviews for this purpose. In 1985 the study was repeated, using a probability sample of 6002 households interviewed by telephone. Measures of abuse were operationally defined by scores on the Conflict Tactics (CT) Scales (Straus, 1979). The Conflict Tactics Scales were developed by Gelles and Straus (1979) to measure intrafamily conflict. Three specific conflict resolution tactics are measured by the instruments: reasoning, verbal aggression and physical aggression. The Conflict Tactics Scales indicate the percentage of parents or spouses who have used any of the violent acts included in the instrument. The items measuring minor violent acts are: threw something, pushed, grabbed or spanked. The severe violence items of the CTS measure acts that have a high probability of causing an injury to a person. The severe violence items are: kicked, bit, hit with fist, tried to hit with something, beat up, threatened with gun or knife, used gun or knife. The scales have been used extensively by social science researchers; reliability and validity data may be found in Straus & Gelles (1980). The authors compared violence rates as measured by the CTS from 1975 to 1985. For parent to child violence, the rate of overall violence (minor and severe) showed a slight decline for the decade from ~630 per thousand children in 1975 to 620 per thousand children in 1985" (Straus & Gelles, 1986, p. 469). Of this amount, the rate of severe violence was shown to be 140 per thousand.
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For marital violence, there was also a slight decline in reported violence from ~121 per thousand couples in 1975 to 113 per thousand couples in 1985" (Straus & Gelles, 1986, p. 470). The comparison of severe family violence rates over the decade under consideration show that severe child assault was down approximately 17%, and severe wife assault was down about 7% (Straus & Gelles, 1986). With respect to spouse battery, the authors report that while husbands and wives tend to commit violence against their spouses at about the same rate, the damage that men do to women is greater and often requires medical attention. This is in part due to the difference in physical strength. In addition, they have shown that violence by wives tends to be retaliatory in nature; that is, that women become abusive for reasons of self-defense. The decline in reported severe child assault very likely is attributable to the national focus on child abuse reporting and treatment that has evolved since the early 1970s. Every state currently has a mandatory reporting law for child abuse. Thus, as of 1985, reported family violence is still relatively high. However, the trend is for a decrease in the two major forms of family violence, chi]d abuse and spouse battery.
Alcohol Abuse and Family Violence Nearly all of the published research on this topic has found that there is a strong positive association between alcohol abuse and family violence, except when alcohol abuse is extreme. This is so likely because extreme alcohol abuse has an anesthetizing influence rather than a disinhibiting one. Alcohol abuse has been shown to be more clearly associated with spousal violence than with child abuse. Other variables that influence the relationship between alcohol abuse and family violence include: gender of the abuser, social class standing and family structure variables (Gottheil, Druley, Skoloda & Waxner, 1985). Alcohol has been shown to be an immediate antecedent of wife abuse in 25% of reported instances (Kantor & Straus, 1987). However, most research on the relationship between alcohol and family violence has consistently concluded that alcohol is neither a necessary nor a sufficient explanation for family violence, but is one important factor often associated with it.
Intergenerational Transmission of Family Violence The data on child abuse and spouse abuse have historically supported the theory that violence begets violence. Investigators have shown that observing violence in the home may contribute to one's later use of
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violence. Through modeling, children learn that violence is an appropriate way to resolve conflict in intimate relationships (Straus, Gelles, & Steinmetz, 1980). In addition to modeling, the research has consistently shown that children who are victims of physical abuse are likely to develop abusive patterns of behavior as adults. Thus, clinicians and researchers have come to accept that violence is transmitted from generation to generation (Hughes & Hampton, 1984). In the last few years, some researchers have suggested that perhaps this theory is overstated. A couple of studies have reviewed the findings on this theory and have found that the designs used to validate it have been weak (Burgess & Youngblade, 1985; Kaufman & Zigler, 1987). In addition, few studies have examined how abused individuals feel about their lives and what kinds of accommodations they have been able to make. The recent research on the effects of learning on behavior has determined that learning to use violence is the result of a number of complex and interrelated factors. Moore, Pepler, Mae and Kates (1989) have suggested that children reared in violent homes are affected emotionally, cognitively and behaviorally by these experiences. These children are quick to perceive conflict and to tune in to anger as an emotion. And, they are slow at perceiving nonviolent alternatives. The work of researchers like Moore et al. (1989) perceives the intergenerational approach to family violence from a much broader perspective. This view may hold real promise for use by mental health practitioners.
Psychosocial Functioning of Abusive Families Recent research has shown that families with abused and neglected children are more depressed than non-abusive families (Sturkie & Flanzer, 1987). In addition, these children are more depressed and have lower self-esteem than their parents do. Hughes (1988) compared abused children with non-abused children on measures of self-esteem, anxiety, depression, and behavior problems. The abused children scored significantly more damaged on these measures than their non-abused cohorts did. Children who have been sexually abused have been shown to develop personality difficulties, severe behavior and eating disorders, and problems with interpersonal relationships. Male victims of sexual abuse have been found to display homophobic concerns, infantile behaviors, firesetting and other dysfunctions in behavior and affect (Sebold, 1987). Adult female victims of incest often demonstrate clinical pathology in
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the form of avoidant and submissive personality patterns as well as borderline and paranoid personality disorders (Wheeler & Walton, 1987). They may also engage in self-mutilating behavior (Shapiro, 1987). A literature is now emerging showing that sexually abused women tend to develop anorexia or bulimia more often than women without histories of sexual abuse and that the sexual abuse they experienced was severe. (Jones, 1985; Friedrichs, 1988; Pyle, Perse, Mitchell, Saunders & Skoog, 1989; Powers, Coovert & Brightwell, 1988). The research on family violence of the 1960's primarily explored the relationship between personality factors and abusive behavior. This type of research became passe in the 1970's and 80's in favor of research that examined the relationships among sociocultural factors and family violence. Possibly, violent families may be best described and understood as being characterized by a specific set of psychosocial factors against the backdrop of impoverished social conditions.
A MODEL FO R P R A C T I C E
One can enumerate perhaps as many as sixteen theories that have been used to explain family violence. However, one theory emerges as perhaps the most useful for providing a model to practitioners; that of social learning theory. According to Bandura (1977) social learning is conceptualized by both a modeling component and the concept of ~'reciprocal influence." Reciprocal influence suggests that we influence our environments and can therefore, in part, shape our futures. Social learning theory as applied to family violence and presented by O'Leary (1988) examines the effects of modeling on behavior, the role of stress, the use of alcohol, the presence of relationship dissatisfaction, and aggression as a personality style. Modeling, of course, is the observation of physical aggression by parents or the direct experience of having been physically abused. In a study of wife abuse and marital rape this author conducted a few years ago, it was found that viewing parental violence was just as important in establishing a later pattern of abuse as the direct experience of child abuse itself (Yegidis, 1988). Modeling increases the likelihood that one will use violence to resolve interpersonal difficulties. There is an extensive literature on the relationship between stress, frustration and aggression (Staub, 1971; Farrington, 1980). While stress does not alone cause violence, it may be understood as a stimulus that serves to arouse some individuals. Thus in the face of a stressor
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and perhaps influenced by having viewed parental aggression, one might choose a violent course of action. The relationship between alcohol and family violence has been previously discussed. Research has suggested that there may be two important aspects to this relationship, both the disinhibiting effect that alcohol has on behavior and the expectancy effect (Stuart & Leonard, 1983). The use of alcohol by abusers permits and excuses the violent behavior; alcohol use by victims anesthetizes them and contributes to their feelings of powerlessness. In addition, it is generally held that some degree of marital or family discord must be present for violence to occur. Certainly an analysis of a typical wife battering event would show a tension-building stage, an eruption usually verbal to start, and the violent encounter (Hilbermann, 1980). Finally, this theory postulates that abusers are individuals with aggressive-impulsive personality styles. These people are more likely to get angry than others and may actually get angrier more often than others do. Thus, the synthesis of these hypotheses provides a framework for understanding and intervening with violent families. In the following sections, these tenets will be explored as they relate to the treatment of violent families.
THE T R E A T M E N T C O N T E X T
Violent families present a facade of normality. They have a strong need to have others believe they are just like any other family, but are being persecuted by the system. ']:his manipulation of facts and unwillingness to submit to counseling makes them very difficult to work with. It's perhaps one reason why securing a court order for treatment is desirable. This is true particularly when the victim is a child. Abusive parents put a great deal of pressure on victims to maintain the facade of family harmony. In fact, child victims frequently display accommodating behaviors that go beyond even what their parents may wish (Bolton & Bolton, 1987). Abused women usually present as helpless, dependent, and ambivalent. This passiveness is consistent with their having learned to be victims. These characteristics of abusive families mean that helping professionals must move very slowly with them. In child abuse cases, one can expect to do a fair amount of collaboration with state protective services workers, legal professionals and guardians. These factors all make helping violent families very time
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consuming. These are not the kinds of families that realistically the worker can see one hour per week in the office. They frequently require crisis intervention, since they escalate their difficulties and have poor coping capacities. In addition, they may very well need assistance in securing concrete services, such as housing or economic aid. In treating sexually abusive families, it is unreasonable to expect the adult family members to protect the child victim or other children in the home. Given their histories, coping styles and stressors, they are usually unable to empathize with others or effectively care for their children. Clinical Work with Violent Families When working with families where child abuse is the primary problem, parents require help in learning child management skills. Additionally, they need to develop anger management and self-control skills. Helping them to use support services is also essential. The goal of these strategies is to lessen the likelihood that they will become frustrated with their attempts to influence their environments, and displace their frustration onto their children. Some abusive parents will be unable to engage in a process of exploration of feelings and attitudes and so it may be unrealistic for the therapist to attempt insight-orientation treatment. This is particularly true for personality disordered individuals. These types of clients are more likely to benefit from group and/or family therapy that is supportive in nature, that focuses on problems stated behaviorally, and that is designed to provide relief from the pain the family is experiencing. Once the therapist has gained the trust of the client, confrontation of the abusive behavior is crucial. When working with families where child sexual abuse is present, the above goals are applicable. In addition, a key focus of treatment is control; the perpetrator must be helped to develop internal controls of his/her behavior. This may be accomplished through the use of behavior modification strategies including aversive deconditioning. These strategies are consistent with social learning theory. Of course in some of these cases, the perpetrator must serve time in prison or in some community control program. This is probably a therapeutically useful experience for the perpetrator in that it communicates a number of important messages: first of all, that he/she cannot get away with continuing the abuse, and that societal controls will be brought to bear on him/her. Additionally, it communicates that sexual
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abuse is a serious crime. When the perpetrator is out of the home, counseling must focus first on the victim and then with the family that is available. Victims of sexual abuse often require long-term individual treatment (Kilgore, 1988; Stream 1988). The major focus of this work is to foster the client's ability to trust by providing a supportive professional relationship. Within this context, the client's grief and loss may be addressed, and feelings may be validated. The client is helped to understand his/her symptoms as an adaptation to the abuse. Healthy coping mechanisms are introduced, and the therapist helps the client to develop an identity beyond that of a victim. Family therapy with abusive families of all types must confront the abuse openly. The therapist will need to address issues related to parental boundaries, role, and enmeshment. Child management issues and communication difficulties should also be addressed. Possibly the establishment of a visitation plan will be required as well as the development of appropriate goals for individual family members and the family as a whole. The clinical work with the mother is often especially key, particularly in sexual abuse cases. She must be helped to address her disbelief and to develop her ability to protect her children. One must also keep in mind the possibility of continuing violence even when the family is in treatment. Thus methods to control for this must be anticipated and applied. Some examples of such methods include developing a contract for non-violence as a condition of providing treatment, or formally involving the state protective services agency if there is a concern of potential child abuse. Certainly to treat a family where there is active abuse is illegal and unethical. It also reinforces for the abuser that he/she can successfully "con" the professionals and manipulate the system with impunity. Usually family therapy is useful only when the violent behavior is already under control or when the abuser is receiving separate behavior management treatment. This also applies to the treatment of violent couples. Unless the perpetrator's violent behavior is in check, couple counseling is probably not going to be productive. In fact, Deschner (1984) believes that couples should be separated until the violence is brought under control as verified by the victim, rather t h a n by the abuser's self-report. The focus, then, of couple counseling is replacing mutual dependency with respect, teaching stress and anger management skills and improving the communication patterns. Cognitive restructuring techniques have also been used successfully with violent
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husbands, and helping abused women to become somewhat more selfsufficient is desirable. The use of support groups for victims is important. Groups lend additional support and friendship and break down somewhat the barriers that isolation imposes. Support groups for victims of sexual abuse are especially of importance. Frequently these groups are co-facilitated. They tend to be activity-focused rather than strictly feeling-oriented. This is so because the experience of having been victimized can be extremely intense. Therefore, opportunities to express strong feelings must be skillfully handled by therapists.
SUMMARY
The 1980's have provided clinical practitioners with empirical research data about violent families. Social workers and other helping professionals have the opportunity to work with these families in a wide variety of service settings. These families present themselves at hospitals, clinics, mental health settings, and family and children's agencies with a range of symptoms and presenting problems. Practitioners must be aware of the possibility of abuse among families and be willing to make an assessment of abuse. The published data on clinical treatment with violent families show that these families can be helped by applying the appropriate range of treatment strategies. The challenge for helping professionals in the 1990's is two-fold: 1. to use the research data about violent families to identify them as early as possible; and 2. to intervene quickly and appropriately with abusive families so that the physical and emotional damage may be minimized. REFERENCES Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bolton, F. C., & Bolton, S. R. (1987). Working with violent families. Newbury Park, Beverly Hills, London, New Delhi: Sage Publications. Burgess, R. L., & Youngblade, L. M. (1985). Social incompetence and the intergenerational transmission of abusive parental practices. Pennsylvania State University, Department of Individual and Family Studies. Deschner, J. P. (1984). The hitting habit: Anger control for battered couples. New York, NY: Free Press.
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Elmer, E. (1967). Children in Jeopardy: A study of abused minors and their families. Pittsburg: University of Pittsburg. Farrington, K. (1980). Stress and family violence. In M. Straus & G. Hotaling (Eds.). The social causes of husband-wife violence. Minneapolis, MN: The University of Minnesota Press. Friedrichs, M. (1988). The Dependent Solution: Anorexia and Bulimia as a Defense Against Danger. Women and Therapy, 7(4), 53-73. Gayford, J. J. (1975). Battered wives: Medicine, science, and the law, 15-(4), 237-245. Gelles, R. J., & Maynard, P. E. (1987). A structural family systems approach to intervention in cases of family violence. Family Relations, 36, 270-275. Gottheil, E., Druley, K. A., Skoloda, T. E., & Waxner, H. M. (1983). Alcohol, drug abuse, and aggression. C. C. Shannon. Hall, R. C., Tice, L., Bevesford, T. P., Wooley, B., & Hall, A. K. (1980). Sexual abuse in patients with anorexia nervosa and bulimia. Psychosematices, 30(1), 73-79. Hilberman, E. (1980). Overview: The wife beater's wife reconsidered. American Journal of Psychiatry, 137, 1336-1347. Hughes, H. M. (1988). Psychological and behavioral correlates of family violence in child witnesses and victims. American Journal of Orthopsychiatry, 58(1), 77-90. Hughes, H. M. & Hampton, K. L. (1984). Relationships between the affective functioning of physically abused and nonabused children and their mothers in shelters for battered women. Paper presented at the 92nd Annual Convention of the American Psychological Association, Toronto, Canada. Jones, D. M. (1985). Bulimia: A False Self Identity. Clinical Social Work Journal, 13(4), 205-216. Kantor, G., & Straus, M. (1987). The ~Drunken Bum" theory of wife beating. Social Problems, 34(3), 213-230. Kaufman, J., & Kigler, E. (1987). Do abused children become abusive parents? American Journal of Orthopsychiatry, 57(2), 186-191. Kempe, C. H. & Helfer, R. E. (Eds.) (1972). Helping the Battered Child and His Family. Philadelphia: J. B. Lippincott. Kilgore, L. (1988). Effect of early childhood sexual abuse on self and ego development. Social Casework, 227-230. Moore, T. Pepler, D., Mae, R., & Kates, M. (1989). Effects of Family Violence on Children: New Directions for Research and Intervention. In B. Pressman, G. Cameron and M. Rothery (Eds.) Intervening with Assaulted Women: Current theory, research, and practice. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Publishers. Powers, P., Coovert, D., & Brightwell, D. (1988). History of sexual abuse in three eating disorders: A descriptive analysis of three clinical samples. (unpublished manuscript). Pressman, B., Cameron, C., & Rothery, M. (Eds.) (1989). Intervening with Assaulted Women: Current theory, research, and practice. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Publishers. Pyle, R., L., Perse, T., Mitchell, J. E., Saunders, D., & Skoog, K. (1988). Abuse in Women with Bulimia Nervosa. Paper presented at the meeting Current Perspectives in Eating Disorders, Tampa, Florida. O'Leary, K. D. (1988). Physical aggression between spouses. In Van Hassett, V. B., Morrison, R. L., Bollack, H. S., & Hersen, M. (Eds.). Handbook of family violence. New York, NY: Plenum Press. Renvoize, J. (1978). Web of violence: A study of family violence. London: Routledge and Kegan Paul. Sebold, J. (1987). Indicators of child sexual abuse in males. Social Casework, 68(2), 75-80. Shapiro, S. (1987). Self-mutilation and self-blame in incest victims. American Journal of Psychotherapy, XLI(1), 46-54. Sloan, G., & Leichner, P. (1986). Is there a relationship between sexual abuse or incest and eating disorders? Canadian Journal of Psychiatry, 31(7), 656-660. Staub, E. (1971). The learning and unlearning of aggression. In J. Singer (Ed.). The control of aggression and violence, New York, NY: The Academic Press. Straus, A., & Gelles, R. (1986). Societal change and change in family violence from 1975-1985 as revealed by two national surveys. Journal of Marriage and the Family, 48, 465-479. Straus, M. (1979). Measuring intrafamily conflict and violence: the conflict tactics scales (CTS). Journal of Marriage and the Family, 41 (February): 75-88.
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Straus, M. A., Gelles, R. J. & Steinmetz, S. K. (1980). Behind Closed Doors: Violence in the American Family. Garden City, New York: Anchor Books. Stream, H. S. (1988). Effects of childhood sexual abuse on the psychosocial functioning of adults. Social Work, 33(5), 465-467. Sturkie, K., & Flanzer, J. P. (1987). Depression and self-esteem in the families of maltreated adolescents. Social Work, 32(6), 491-495. Wheeler, B., & Walton, E. (1987). Personality disturbances of adult incest victims. Social Casework, 68(10), 597-602. Yegidis, B. (1988). Wife abuse and marital rape among women who seek help. A fillip" Journal of Women and Social Work, 3(1), 62-68. Zalba, S. R. (1967). The abused child: II, typology for classification and treatment. Social Work, 12, 70-79.
CLINICAL CARE UPDATE Family Violence: Contemporary Research Findings and Practice Issues Bonnie L. Yegidis, Ph.D.
A B S T R A C T : The purpose of t h i s p a p e r is to describe recent e m p i r i c a l r e s e a r c h findings about f a m i l y violence, and to explore selected social w o r k t r e a t m e n t issues in the light of these findings. The l a s t two decades has seen a proliferation of r e s e a r c h about f a m i l y violence. Most of t h e e a r l y r e s e a r c h used s m a l l clinical s a m p l e s a n d so generalizi n g findings to o t h e r groups h a s been difficult. However, t h e recent r e s e a r c h h a s e x a m i n e d a n u m b e r of i m p o r t a n t psychosocial correlates of f a m i l y violence u s i n g more methodologically sound methods. As a result, we now know quite a bit about how and w h y f a m i l y violence occurs. Also, w i t h i n the l a s t decade a n u m b e r of studies have explicated the k i n d s of t r e a t m e n t s a n d approaches t h a t are most effective in d e a l i n g w i t h abusive people. This p a p e r s u m m a r i z e s these t r e a t m e n t strategies.
I N T R O D UCTION During the past two decades the professional literature addressing family violence has increased markedly. Research studies have addressed all forms of family violence including child abuse, sexual abuse, marital violence and abuse of the elderly. This increase in professional attention to family violence is related to a number of factors. First, clinicians and researchers are becoming increasingly aware of the serious effects that a history of family violence has on individuals and families. Some of these effects include: alcoholism or drug addiction (Gayford, 1975; Hilbermann, 1980), eating disorders (Sloan & Leichner, Bonnie L. Yegidis, Ph.D., is Director, School of Social Work, University of South Florida, Tampa, Florida 33620. An earlier version of this paper was presented at the 13th Annual Conference on Professional Social Work Development, National Association of Social Workers, Florida Chapter, Tampa, Florida. March 31-April 2, 1989. 519
9 1992 Human Sciences Press, Inc.
520
Community Mental Health Journal
1986; Hall, Tice, Beresford, Wooley & Hall, 1989), depression (Hilbermann, 1980) and family dysfunction (Gayford, 1975; Renvoize, 1978). Also, public policy has become more responsive to the needs of violent families. Hence mandated reporting laws and treatment programs have been implemented and research addressing their effectiveness has been published. In addition, several theoretical frameworks have been developed that describe the dynamics of violent families. The purpose of this paper is to describe recent research findings about family violence, and to explore selected treatment issues in working with violent families. Historically, the research on family violence has been less than satisfactory; methodological flaws have abounded. For example, most of the early research was characterized by the use of small, nonrepresentative samples, by the lack of comparison groups, and by the use of nonstandardized measuring instruments. As a result, it has been difficult to compare findings and to build a cohesive knowledge base from which to inform practitioners. However, more recently comparative groups and nonclinical samples have been used as the basis for research inquiry in this area. R E C E N T R E S E A R C H FINDINGS Overview It has been said that violent families are easy to describe but difficult to explain. The research on family violence has consistently found intergenerational transmission, low socioeconomic status, social and structural stress, social isolation, and personality problems or psychopathology (Gelles & Maynard, 1987). Bolton & Bolton (1987) have summarized the major social, psychological and family process factors correlated with violent families. A summary of these follows. Social Factors. Abusive families tend to be socially isolated, experiencing multiple sources of environmental ~press," with poor capacities for survival and coping. Characteristically, they are likely to be overrepresented as racial or ethnic minorities with education limitations and occupational difficulties. For example, they are likely to be underemployed or unemployed. Psychological Factors. Most studies on abusive families have shown that the adult members feel powerless to effect changes in their environments. They tend to be immature, inadequate copers with low self-
Bonnie L. Yegidis, Ph.D.
521
esteem and strong dependency needs. There is literature on the psychopathology of abusive people (Elmer, 1967, Kempe & Helfer, 1972, & Zalba, 1967). However, little agreement has been reached regarding a personality profile of the abuser, per se.
Family Process Factors. Finally, a set of family process variables characteristic of abusive families may be articulated. They include poor communication patterns, recurrent family or marital stress, inappropriate behavioral expectations of the victim, role confusion or reversal, step-family relationships, overreliance on physical punishment for disciplining, and inadequate knowledge on child rearing or caretaking. The Incidence of Family Violence The private nature of family violence and the lack of a standard definition of it conspire to make the development of reliable incidence data difficult. However, at least two large scale national surveys have been conducted to try to estimate the national incidence of family violence. A summary of the findings from these studies follows. In 1975, Straus, Gelles and Steinmetz used a national probability sample of 2143 people to conduct in-depth interviews for this purpose. In 1985 the study was repeated, using a probability sample of 6002 households interviewed by telephone. Measures of abuse were operationally defined by scores on the Conflict Tactics (CT) Scales (Straus, 1979). The Conflict Tactics Scales were developed by Gelles and Straus (1979) to measure intrafamily conflict. Three specific conflict resolution tactics are measured by the instruments: reasoning, verbal aggression and physical aggression. The Conflict Tactics Scales indicate the percentage of parents or spouses who have used any of the violent acts included in the instrument. The items measuring minor violent acts are: threw something, pushed, grabbed or spanked. The severe violence items of the CTS measure acts that have a high probability of causing an injury to a person. The severe violence items are: kicked, bit, hit with fist, tried to hit with something, beat up, threatened with gun or knife, used gun or knife. The scales have been used extensively by social science researchers; reliability and validity data may be found in Straus & Gelles (1980). The authors compared violence rates as measured by the CTS from 1975 to 1985. For parent to child violence, the rate of overall violence (minor and severe) showed a slight decline for the decade from ~630 per thousand children in 1975 to 620 per thousand children in 1985" (Straus & Gelles, 1986, p. 469). Of this amount, the rate of severe violence was shown to be 140 per thousand.
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For marital violence, there was also a slight decline in reported violence from ~121 per thousand couples in 1975 to 113 per thousand couples in 1985" (Straus & Gelles, 1986, p. 470). The comparison of severe family violence rates over the decade under consideration show that severe child assault was down approximately 17%, and severe wife assault was down about 7% (Straus & Gelles, 1986). With respect to spouse battery, the authors report that while husbands and wives tend to commit violence against their spouses at about the same rate, the damage that men do to women is greater and often requires medical attention. This is in part due to the difference in physical strength. In addition, they have shown that violence by wives tends to be retaliatory in nature; that is, that women become abusive for reasons of self-defense. The decline in reported severe child assault very likely is attributable to the national focus on child abuse reporting and treatment that has evolved since the early 1970s. Every state currently has a mandatory reporting law for child abuse. Thus, as of 1985, reported family violence is still relatively high. However, the trend is for a decrease in the two major forms of family violence, chi]d abuse and spouse battery.
Alcohol Abuse and Family Violence Nearly all of the published research on this topic has found that there is a strong positive association between alcohol abuse and family violence, except when alcohol abuse is extreme. This is so likely because extreme alcohol abuse has an anesthetizing influence rather than a disinhibiting one. Alcohol abuse has been shown to be more clearly associated with spousal violence than with child abuse. Other variables that influence the relationship between alcohol abuse and family violence include: gender of the abuser, social class standing and family structure variables (Gottheil, Druley, Skoloda & Waxner, 1985). Alcohol has been shown to be an immediate antecedent of wife abuse in 25% of reported instances (Kantor & Straus, 1987). However, most research on the relationship between alcohol and family violence has consistently concluded that alcohol is neither a necessary nor a sufficient explanation for family violence, but is one important factor often associated with it.
Intergenerational Transmission of Family Violence The data on child abuse and spouse abuse have historically supported the theory that violence begets violence. Investigators have shown that observing violence in the home may contribute to one's later use of
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violence. Through modeling, children learn that violence is an appropriate way to resolve conflict in intimate relationships (Straus, Gelles, & Steinmetz, 1980). In addition to modeling, the research has consistently shown that children who are victims of physical abuse are likely to develop abusive patterns of behavior as adults. Thus, clinicians and researchers have come to accept that violence is transmitted from generation to generation (Hughes & Hampton, 1984). In the last few years, some researchers have suggested that perhaps this theory is overstated. A couple of studies have reviewed the findings on this theory and have found that the designs used to validate it have been weak (Burgess & Youngblade, 1985; Kaufman & Zigler, 1987). In addition, few studies have examined how abused individuals feel about their lives and what kinds of accommodations they have been able to make. The recent research on the effects of learning on behavior has determined that learning to use violence is the result of a number of complex and interrelated factors. Moore, Pepler, Mae and Kates (1989) have suggested that children reared in violent homes are affected emotionally, cognitively and behaviorally by these experiences. These children are quick to perceive conflict and to tune in to anger as an emotion. And, they are slow at perceiving nonviolent alternatives. The work of researchers like Moore et al. (1989) perceives the intergenerational approach to family violence from a much broader perspective. This view may hold real promise for use by mental health practitioners.
Psychosocial Functioning of Abusive Families Recent research has shown that families with abused and neglected children are more depressed than non-abusive families (Sturkie & Flanzer, 1987). In addition, these children are more depressed and have lower self-esteem than their parents do. Hughes (1988) compared abused children with non-abused children on measures of self-esteem, anxiety, depression, and behavior problems. The abused children scored significantly more damaged on these measures than their non-abused cohorts did. Children who have been sexually abused have been shown to develop personality difficulties, severe behavior and eating disorders, and problems with interpersonal relationships. Male victims of sexual abuse have been found to display homophobic concerns, infantile behaviors, firesetting and other dysfunctions in behavior and affect (Sebold, 1987). Adult female victims of incest often demonstrate clinical pathology in
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the form of avoidant and submissive personality patterns as well as borderline and paranoid personality disorders (Wheeler & Walton, 1987). They may also engage in self-mutilating behavior (Shapiro, 1987). A literature is now emerging showing that sexually abused women tend to develop anorexia or bulimia more often than women without histories of sexual abuse and that the sexual abuse they experienced was severe. (Jones, 1985; Friedrichs, 1988; Pyle, Perse, Mitchell, Saunders & Skoog, 1989; Powers, Coovert & Brightwell, 1988). The research on family violence of the 1960's primarily explored the relationship between personality factors and abusive behavior. This type of research became passe in the 1970's and 80's in favor of research that examined the relationships among sociocultural factors and family violence. Possibly, violent families may be best described and understood as being characterized by a specific set of psychosocial factors against the backdrop of impoverished social conditions.
A MODEL FO R P R A C T I C E
One can enumerate perhaps as many as sixteen theories that have been used to explain family violence. However, one theory emerges as perhaps the most useful for providing a model to practitioners; that of social learning theory. According to Bandura (1977) social learning is conceptualized by both a modeling component and the concept of ~'reciprocal influence." Reciprocal influence suggests that we influence our environments and can therefore, in part, shape our futures. Social learning theory as applied to family violence and presented by O'Leary (1988) examines the effects of modeling on behavior, the role of stress, the use of alcohol, the presence of relationship dissatisfaction, and aggression as a personality style. Modeling, of course, is the observation of physical aggression by parents or the direct experience of having been physically abused. In a study of wife abuse and marital rape this author conducted a few years ago, it was found that viewing parental violence was just as important in establishing a later pattern of abuse as the direct experience of child abuse itself (Yegidis, 1988). Modeling increases the likelihood that one will use violence to resolve interpersonal difficulties. There is an extensive literature on the relationship between stress, frustration and aggression (Staub, 1971; Farrington, 1980). While stress does not alone cause violence, it may be understood as a stimulus that serves to arouse some individuals. Thus in the face of a stressor
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and perhaps influenced by having viewed parental aggression, one might choose a violent course of action. The relationship between alcohol and family violence has been previously discussed. Research has suggested that there may be two important aspects to this relationship, both the disinhibiting effect that alcohol has on behavior and the expectancy effect (Stuart & Leonard, 1983). The use of alcohol by abusers permits and excuses the violent behavior; alcohol use by victims anesthetizes them and contributes to their feelings of powerlessness. In addition, it is generally held that some degree of marital or family discord must be present for violence to occur. Certainly an analysis of a typical wife battering event would show a tension-building stage, an eruption usually verbal to start, and the violent encounter (Hilbermann, 1980). Finally, this theory postulates that abusers are individuals with aggressive-impulsive personality styles. These people are more likely to get angry than others and may actually get angrier more often than others do. Thus, the synthesis of these hypotheses provides a framework for understanding and intervening with violent families. In the following sections, these tenets will be explored as they relate to the treatment of violent families.
THE T R E A T M E N T C O N T E X T
Violent families present a facade of normality. They have a strong need to have others believe they are just like any other family, but are being persecuted by the system. ']:his manipulation of facts and unwillingness to submit to counseling makes them very difficult to work with. It's perhaps one reason why securing a court order for treatment is desirable. This is true particularly when the victim is a child. Abusive parents put a great deal of pressure on victims to maintain the facade of family harmony. In fact, child victims frequently display accommodating behaviors that go beyond even what their parents may wish (Bolton & Bolton, 1987). Abused women usually present as helpless, dependent, and ambivalent. This passiveness is consistent with their having learned to be victims. These characteristics of abusive families mean that helping professionals must move very slowly with them. In child abuse cases, one can expect to do a fair amount of collaboration with state protective services workers, legal professionals and guardians. These factors all make helping violent families very time
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consuming. These are not the kinds of families that realistically the worker can see one hour per week in the office. They frequently require crisis intervention, since they escalate their difficulties and have poor coping capacities. In addition, they may very well need assistance in securing concrete services, such as housing or economic aid. In treating sexually abusive families, it is unreasonable to expect the adult family members to protect the child victim or other children in the home. Given their histories, coping styles and stressors, they are usually unable to empathize with others or effectively care for their children. Clinical Work with Violent Families When working with families where child abuse is the primary problem, parents require help in learning child management skills. Additionally, they need to develop anger management and self-control skills. Helping them to use support services is also essential. The goal of these strategies is to lessen the likelihood that they will become frustrated with their attempts to influence their environments, and displace their frustration onto their children. Some abusive parents will be unable to engage in a process of exploration of feelings and attitudes and so it may be unrealistic for the therapist to attempt insight-orientation treatment. This is particularly true for personality disordered individuals. These types of clients are more likely to benefit from group and/or family therapy that is supportive in nature, that focuses on problems stated behaviorally, and that is designed to provide relief from the pain the family is experiencing. Once the therapist has gained the trust of the client, confrontation of the abusive behavior is crucial. When working with families where child sexual abuse is present, the above goals are applicable. In addition, a key focus of treatment is control; the perpetrator must be helped to develop internal controls of his/her behavior. This may be accomplished through the use of behavior modification strategies including aversive deconditioning. These strategies are consistent with social learning theory. Of course in some of these cases, the perpetrator must serve time in prison or in some community control program. This is probably a therapeutically useful experience for the perpetrator in that it communicates a number of important messages: first of all, that he/she cannot get away with continuing the abuse, and that societal controls will be brought to bear on him/her. Additionally, it communicates that sexual
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abuse is a serious crime. When the perpetrator is out of the home, counseling must focus first on the victim and then with the family that is available. Victims of sexual abuse often require long-term individual treatment (Kilgore, 1988; Stream 1988). The major focus of this work is to foster the client's ability to trust by providing a supportive professional relationship. Within this context, the client's grief and loss may be addressed, and feelings may be validated. The client is helped to understand his/her symptoms as an adaptation to the abuse. Healthy coping mechanisms are introduced, and the therapist helps the client to develop an identity beyond that of a victim. Family therapy with abusive families of all types must confront the abuse openly. The therapist will need to address issues related to parental boundaries, role, and enmeshment. Child management issues and communication difficulties should also be addressed. Possibly the establishment of a visitation plan will be required as well as the development of appropriate goals for individual family members and the family as a whole. The clinical work with the mother is often especially key, particularly in sexual abuse cases. She must be helped to address her disbelief and to develop her ability to protect her children. One must also keep in mind the possibility of continuing violence even when the family is in treatment. Thus methods to control for this must be anticipated and applied. Some examples of such methods include developing a contract for non-violence as a condition of providing treatment, or formally involving the state protective services agency if there is a concern of potential child abuse. Certainly to treat a family where there is active abuse is illegal and unethical. It also reinforces for the abuser that he/she can successfully "con" the professionals and manipulate the system with impunity. Usually family therapy is useful only when the violent behavior is already under control or when the abuser is receiving separate behavior management treatment. This also applies to the treatment of violent couples. Unless the perpetrator's violent behavior is in check, couple counseling is probably not going to be productive. In fact, Deschner (1984) believes that couples should be separated until the violence is brought under control as verified by the victim, rather t h a n by the abuser's self-report. The focus, then, of couple counseling is replacing mutual dependency with respect, teaching stress and anger management skills and improving the communication patterns. Cognitive restructuring techniques have also been used successfully with violent
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husbands, and helping abused women to become somewhat more selfsufficient is desirable. The use of support groups for victims is important. Groups lend additional support and friendship and break down somewhat the barriers that isolation imposes. Support groups for victims of sexual abuse are especially of importance. Frequently these groups are co-facilitated. They tend to be activity-focused rather than strictly feeling-oriented. This is so because the experience of having been victimized can be extremely intense. Therefore, opportunities to express strong feelings must be skillfully handled by therapists.
SUMMARY
The 1980's have provided clinical practitioners with empirical research data about violent families. Social workers and other helping professionals have the opportunity to work with these families in a wide variety of service settings. These families present themselves at hospitals, clinics, mental health settings, and family and children's agencies with a range of symptoms and presenting problems. Practitioners must be aware of the possibility of abuse among families and be willing to make an assessment of abuse. The published data on clinical treatment with violent families show that these families can be helped by applying the appropriate range of treatment strategies. The challenge for helping professionals in the 1990's is two-fold: 1. to use the research data about violent families to identify them as early as possible; and 2. to intervene quickly and appropriately with abusive families so that the physical and emotional damage may be minimized. REFERENCES Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bolton, F. C., & Bolton, S. R. (1987). Working with violent families. Newbury Park, Beverly Hills, London, New Delhi: Sage Publications. Burgess, R. L., & Youngblade, L. M. (1985). Social incompetence and the intergenerational transmission of abusive parental practices. Pennsylvania State University, Department of Individual and Family Studies. Deschner, J. P. (1984). The hitting habit: Anger control for battered couples. New York, NY: Free Press.
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Elmer, E. (1967). Children in Jeopardy: A study of abused minors and their families. Pittsburg: University of Pittsburg. Farrington, K. (1980). Stress and family violence. In M. Straus & G. Hotaling (Eds.). The social causes of husband-wife violence. Minneapolis, MN: The University of Minnesota Press. Friedrichs, M. (1988). The Dependent Solution: Anorexia and Bulimia as a Defense Against Danger. Women and Therapy, 7(4), 53-73. Gayford, J. J. (1975). Battered wives: Medicine, science, and the law, 15-(4), 237-245. Gelles, R. J., & Maynard, P. E. (1987). A structural family systems approach to intervention in cases of family violence. Family Relations, 36, 270-275. Gottheil, E., Druley, K. A., Skoloda, T. E., & Waxner, H. M. (1983). Alcohol, drug abuse, and aggression. C. C. Shannon. Hall, R. C., Tice, L., Bevesford, T. P., Wooley, B., & Hall, A. K. (1980). Sexual abuse in patients with anorexia nervosa and bulimia. Psychosematices, 30(1), 73-79. Hilberman, E. (1980). Overview: The wife beater's wife reconsidered. American Journal of Psychiatry, 137, 1336-1347. Hughes, H. M. (1988). Psychological and behavioral correlates of family violence in child witnesses and victims. American Journal of Orthopsychiatry, 58(1), 77-90. Hughes, H. M. & Hampton, K. L. (1984). Relationships between the affective functioning of physically abused and nonabused children and their mothers in shelters for battered women. Paper presented at the 92nd Annual Convention of the American Psychological Association, Toronto, Canada. Jones, D. M. (1985). Bulimia: A False Self Identity. Clinical Social Work Journal, 13(4), 205-216. Kantor, G., & Straus, M. (1987). The ~Drunken Bum" theory of wife beating. Social Problems, 34(3), 213-230. Kaufman, J., & Kigler, E. (1987). Do abused children become abusive parents? American Journal of Orthopsychiatry, 57(2), 186-191. Kempe, C. H. & Helfer, R. E. (Eds.) (1972). Helping the Battered Child and His Family. Philadelphia: J. B. Lippincott. Kilgore, L. (1988). Effect of early childhood sexual abuse on self and ego development. Social Casework, 227-230. Moore, T. Pepler, D., Mae, R., & Kates, M. (1989). Effects of Family Violence on Children: New Directions for Research and Intervention. In B. Pressman, G. Cameron and M. Rothery (Eds.) Intervening with Assaulted Women: Current theory, research, and practice. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Publishers. Powers, P., Coovert, D., & Brightwell, D. (1988). History of sexual abuse in three eating disorders: A descriptive analysis of three clinical samples. (unpublished manuscript). Pressman, B., Cameron, C., & Rothery, M. (Eds.) (1989). Intervening with Assaulted Women: Current theory, research, and practice. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Publishers. Pyle, R., L., Perse, T., Mitchell, J. E., Saunders, D., & Skoog, K. (1988). Abuse in Women with Bulimia Nervosa. Paper presented at the meeting Current Perspectives in Eating Disorders, Tampa, Florida. O'Leary, K. D. (1988). Physical aggression between spouses. In Van Hassett, V. B., Morrison, R. L., Bollack, H. S., & Hersen, M. (Eds.). Handbook of family violence. New York, NY: Plenum Press. Renvoize, J. (1978). Web of violence: A study of family violence. London: Routledge and Kegan Paul. Sebold, J. (1987). Indicators of child sexual abuse in males. Social Casework, 68(2), 75-80. Shapiro, S. (1987). Self-mutilation and self-blame in incest victims. American Journal of Psychotherapy, XLI(1), 46-54. Sloan, G., & Leichner, P. (1986). Is there a relationship between sexual abuse or incest and eating disorders? Canadian Journal of Psychiatry, 31(7), 656-660. Staub, E. (1971). The learning and unlearning of aggression. In J. Singer (Ed.). The control of aggression and violence, New York, NY: The Academic Press. Straus, A., & Gelles, R. (1986). Societal change and change in family violence from 1975-1985 as revealed by two national surveys. Journal of Marriage and the Family, 48, 465-479. Straus, M. (1979). Measuring intrafamily conflict and violence: the conflict tactics scales (CTS). Journal of Marriage and the Family, 41 (February): 75-88.
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Straus, M. A., Gelles, R. J. & Steinmetz, S. K. (1980). Behind Closed Doors: Violence in the American Family. Garden City, New York: Anchor Books. Stream, H. S. (1988). Effects of childhood sexual abuse on the psychosocial functioning of adults. Social Work, 33(5), 465-467. Sturkie, K., & Flanzer, J. P. (1987). Depression and self-esteem in the families of maltreated adolescents. Social Work, 32(6), 491-495. Wheeler, B., & Walton, E. (1987). Personality disturbances of adult incest victims. Social Casework, 68(10), 597-602. Yegidis, B. (1988). Wife abuse and marital rape among women who seek help. A fillip" Journal of Women and Social Work, 3(1), 62-68. Zalba, S. R. (1967). The abused child: II, typology for classification and treatment. Social Work, 12, 70-79.
