Depression is a significant mental illness with devastating relational and economic effects in terms of lost productivity and lost relationships. 16.2 million adults have at least one major depressive episode in a given year (Depression: Facts, n.d.). Depression is of great concern to clinicians who want to help alleviate their clients’ symptoms and increase their life satisfaction. But what is really behind that frown? If counselors are focused on increasing self-esteem, building resilience and coping strategies, they may miss the very real possibility that the root cause of a woman’s depression lies in her intimate partner relationship. Depression is strongly correlated with intimate partner violence (Spencer, Mallory, Cafferky, Kimmes, Beck, & Stith, 2019). IPV, or domestic violence, can lead to depression and might not be diagnosed without proper screening tools (Gibbs, Dunkle, & Jewkes, 2018). Abuse is extremely common with 20 people experiencing IPV every minute (Statistics, n.d.). 7/10 of psychologically abused women have PTSD or depression symptoms but nearly 1/3 are never treated (Statistics, n.d.). It’s my strong belief that women who present with depression should be screened for IPV. Otherwise clinicians may continue to treat the symptoms while the real problem continues to rage unfettered and unaddressed. One meta-analysis suggests that clinicians working with couples in an intimate partner violence situation should screen both partners for mental health (Spencer, et al., 2019). I suggest the opposite as well, that clinicians working with depressed women in particular should screen them for domestic or intimate partner violence.
Intimate partner violence includes a variety of behaviors used to create a sense of power over a victim and to control her in every way, including controlling her emotional self. It happens in all income levels. In fact, women who earn more than 65% of their household income are more likely to experience psychological abuse (Statistics, n.d.). Physical violence such as hitting, punching and strangling is easy to diagnose. Even overt verbal abuse can be readily recognized, such as when an abuser calls his partner names or criticizes her in public. More covert and difficult to identify without specific training are the covert forms of abuse. Treating a spouse well in public but poorly behind closed doors can make the public not believe her when she does speak up. Using subtle forms of intimidation such as raised eyebrows can send her a signal that she is out of line and will be dealt with at home. Even more covert are things like ignoring a partner, redirecting a conversation without addressing her concerns, subtly inferring that she has once again done something wrong. It’s at this level of abuse that victims don’t even know that they are being abused. They sense that something is not right, they start to feel bad about themselves and eventually they feel like nothing they can do is good enough. If there is no overt physical or verbal abuse, they may not identify as a victim and may not talk about these subtle things to their therapist, if they even have one. So IPV often remains undetected and untreated (Feltner, Wallace, Berkman, Kistler, Middleton, Barclay, Jonas, 2018). Women may describe their loss of zest for life and their feelings of hopelessness that can be easily identified as depression, but neither they nor a therapist might think to screen them for IPV.
Learned helplessness occurs when someone has tried and tried different approaches to changing their situation but nothing helps (Schneider, Gruman, & Coutts, 2012). Many previously positive minded women become depressed in abusive situations. Even those whose outlook on life generally is hopeful can in fact learn helplessness and hopelessness when every effort they try to change things is met with further abuse. While some depressed women do have a depressogenic attribution style, many do not. This type of bias describes a person who characteristically across situations believes that bad things in their life are based on underlying factors that will never change (Schneider, et al., 2012). Instead many victims’ situations have led them to correctly believe that more negative incidents will happen to them. Coping methods and survival skills leave them to adjust their behavior in ways that inhibit openness and zestful living, such as speaking up less about their own opinions in order to prevent abuse or avoiding certain places and people. And depression sets in.
Symptoms of depression include anxiety and restlessness, thoughts of death or suicide, anger management issues, loss of interest in activities, irritability over minor things, focus on negatives or on the past (Depression: Facts, n.d.), decreased energy, hopelessness, difficulty sleeping or concentrating, and anhedonia, (Depression in women, n.d.). Abuse can change a woman’s self perception, causing her to feel unworthy of better treatment or unable to change her situation. Psychological abuse causes long term mental health damage to a victim (Statistics, n.d.). Women in IPV may develop depression and many other health consequences including PTSD, suicidal thoughts, anxiety, substance abuse problems, chronic pain (Feltner, et al., 2018). Higher levels of abuse correlate to more severe levels of PTSD and depression (Wood, Voth Schrag, & Busch-Armendariz, 2018). One of the antidotes to depression is understanding and adjusting the person’s mindset (positive self talk, increase self worth and autonomy) but if she’s still in the abuse it can be like running on a treadmill where you never get off and get a break, you stay beaten down just as quickly as you try to build your internal self up.
Treatment for depression and for intimate partner violence is not the same. While a victim may need positive self talk and coping strategies to increase her mental health, she first needs safety. When she receives enough support and people believe her, and she gets to a safe place, some of the effects of the abuse will naturally start to diminish. Her joy will return simply from no longer having to live with abuse. Other mental cognitions may have to be adjusted through therapy. Even something like learned helplessness can be reversed. She will learn over time that she does have control over her life and that her efforts to heal will bring positive results. Because an abusive person continually undermines the victim’s sense of self, it leads to internal causal attributions in the victim. She starts to believe that she really is at fault for the crazy things that he does because he tells her this so often. This leads her to continually try to adjust her behavior to avoid his angry reactions. Eventually she learns helplessness when nothing that she tries solves the problem. Part of healing includes the recognition that he is 100% responsible for his behaviors and they aren’t because of anything she has done. Then she is able to move towards external causal attribution, realizing that he is causing his behavior, rather than internalizing and thinking it is about her.
Clinicians should regularly screen depressed women for IPV especially if they are in a relationship or have recently left one. Research shows that screening for IPV can successfully identify it (Feltner, et al., 2018). However some assessment tools only assess the level of physical violence or what is called the lethality assessment. In order to accurately assess whether a woman with depression has been in an emotionally abusive relationship, you need an assessment tool that also includes questions about self-esteem and emotional well being related to the partner. For example, “Do you feel that nothing you do is ever good enough for your partner?” (Grohol, 2018). This question refers to the tendency of abusers to put down their mates regularly, using everything from demeaning language to the silent treatment. “Do you feel anxious or nervous when you are around your partner?” is a question that signifies the walking on eggshells feelings many victims get with a partner who explodes for any little thing. Depression is devastating and so is violence in the home. Both need appropriate treatment. But without screening for domestic violence, we may be actually treating a symptom but not the cause.
References
Depression: Facts, statistics, and you. (n.d.). Healthline. Retrieved on Feb. 9, 2019 from: https://www.healthline.com/health/depression/facts-statistics-infographic#1.
Depression in women: Five things you should know. (n.d.) National Institute of Mental Health. Retrieved Feb. 9, 2019 from: https://www.nimh.nih.gov/health/publications/depression-in-women/index.shtml.
Feltner, C., Wallace, I., Berkman, N., Kistler, C., Middleton, J., Barclay, C., Jonas, D. (2018). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: Evidence report and systematic review for the US preventive services task force. JAMA: Journal of the American Medical Association, 320(16), 1688-1701.
Gibbs, A., Dunkle, K., & Jewkes, R. (2018). Emotional and economic intimate partner violence as key drivers of depression and suicidal ideation: A cross-sectional study among young women in informal settlements in South Africa. PLoS ONE, 13(4), 18.
Grohol, J. (2018). Domestic Violence Screening Quiz. Psych Central. Retrieved Feb. 9, 2019 from: https://psychcentral.com/quizzes/domestic-violence-quiz/.
Schneider, F., Gruman, J., & Coutts, L. (2012). Applied social psychology: Understanding and addressing social and practical problems. Thousand Oaks, CA: Sage Publications.
Spencer, C., Mallory, A., Cafferky, B., Kimmes, J., Beck, A., & Stith, S. (2019). Mental health factors and intimate partner violence perpetration and victimization: A meta-analysis. Psychology of Violence, 9(1), 1-17.
Statistics. (n.d.). NCADV. Retrieved on Feb. 9, 2019 from: https://ncadv.org/statistics.
Wood, L., Voth Schrag, R., & Busch-Armendariz, N. (2018). Mental health and academic impacts of intimate partner violence among IHE-attending women. Journal of American College Health.