Domestic abuse can have very negative consequences for a person’s mental health [1] so if you have been a victim of domestic abuse, you may experience symptoms of depression or anxiety, or even both. You need to understand that this is your body’s normal reaction to the overwhelming stress that being in an abusive relationship puts you through. It doesn’t mean that you are weak or flawed, it means you are human! Do not blame yourself for going through feelings of depression or anxiety, because it is not your fault you are suffering. No one chooses or deserves to suffer from a mental health problem. Indeed, some may struggle so much that they might feel as if they are losing control or going crazy. If that is the case for you, find peace in the fact that this is not true: you are neither losing control, nor going crazy. You are simply going through a rough time. Please, realise that you are not alone. Many people are going through and have gone through these unpleasant symptoms and many have been able to get over them because fortunately, mental health issues can be treated. The reason why you might be feeling as if you are losing control when you are suffering from a mental health problem such as depression or anxiety could be because you do not know why you are experiencing these negative symptoms. This is why visiting a mental health professional can be extremely helpful. A psychotherapist can educate and help you understand the nature of your condition and the process of your recovery [2]. They can teach you ways to deal with both your symptoms as well as with negative life events. Most importantly, they are someone you can talk to in a safe environment, who will show understanding and will listen to you without being critical or judgemental in any way. A list of some of the most popular and effective types of psychological treatments follows. Please read through them in order to find out which one you’d be more comfortable with. Keep in mind that in all psychological treatments, confidentiality between the therapist and the client is guaranteed.
COGNITIVE BEHAVIOURAL THERAPY (CBT)
When you think about ‘psychotherapy’, an image of a person lying on a couch and talking about their childhood might come to your mind. However, this image is completely different from the type of treatment CBT is. First of all, instead of focusing on childhood and past experiences, CBT tries to deal with present symptoms. For this reason, CBT is a brief type of psychotherapy which means that, depending on each individual case, treatment can last from 6 weeks to no longer than 6 months. Sessions typically take place once a week in the beginning, and then once every two or three weeks and last around one hour each. With CBT, clients are required to engage in specific ‘exercises’ in their daily life, such as keeping a diary of their negative thoughts and feelings. This happens because the therapist wants to monitor which thoughts and interpretations of life events that the client makes are negative, biased and false. The goal is to help the client find evidence that challenge these biased and negative thought patterns, as well as to help them learn strategies that encourage positive and realistic assumptions.
For instance, if a depressed individual sees a friend of hers on the street and her friend doesn’t greet her, she might think that her friend is avoiding her on purpose, that she could be angry at her or that she no longer wants to be friends with her. She could even start thinking that she isn’t worthy of anyone’s friendship and so on. In such a case, the therapist could look for evidence that contradict the client’s assumptions. For example, if the client and her friend didn’t have an argument and the last time they had met each other they had a good time, then there is no real evidence to support the assumption that the friend wanted to avoid her. Furthermore, by pointing out the fact that the client has friends in her life, the therapist can challenge the other false assumption that the client is not worthy of anyone’s friendship. The therapist would also offer alternative, more realistic and positive assumptions that the client should use from then onwards by indicating that her friend could have been lost in her own thoughts and that she simply wasn’t paying attention to the people around her so, as a result, she probably didn’t see her on the street, which is why she did not greet her.
Looking at the example given above, you may realise that CBT is about reprogramming the brain into thinking in a positive, realistic way rather than a negative, self-defeating manner. Just like bad habits, negative patterns of thinking and interpreting information in a negative way need breaking. A CBT therapist shows you the way to achieve this and by the end of treatment, you should become your own ‘therapist’ as you will be able to identify false assumptions and negative beliefs, ignore them and exchange them with positive ones. Apart from challenging a flawed way of thinking, CBT also encourages clients to engage in activities that are likely to help them have positive experiences, such as taking up a new hobby or going out with friends, in order to break the cycle of depression, withdrawal, and avoidance that many depressed individuals get caught in [3].
Furthermore, in cases where the client is also suffering from suicidal thoughts and thoughts of self-harm, the therapist can help them understand why they feel the way they do, challenge their negative thoughts, offer them new ways to deal with emotional distress, and most importantly help them problem solve the situations they are facing in their lives, as well as help them find ways to improve their social support so that they will no longer have feelings of hopelessness [4]. For example, the therapist can explain to the client that they may be feeling helpless because they (wrongly) think that there is no way to deal with their current situation, so they feel that the only option they have is to ‘escape’ the situation by committing suicide. The therapist will then challenge these negative thoughts, and provide alternative, positive and realistic ones. They can show the client ways to properly solve the problems they are facing in their lives and introduce them to a network of social support where they can connect with people who are going through or have successfully overcome similar situations.
In terms of panic disorder, CBT has been found to be one of the most effective treatments. In fact, it has been found to be more efficient than medication [5][6][7]. Typically, CBT therapists explain to the client that the symptoms of a panic attack are the body’s normal reaction to stress and, once more, evidence is used to challenge the client’s false belief that the panic attack will lead them to have a heart attack or a nervous breakdown. For example, when the client thinks that there is somethi ng wrong with their heart, the therapist can bring up evidence that go against this false belief such as, “You hear your heart thumping sometimes, even in your ears, but because of your fears you focus on your body and that makes you notice it. When you notice it you get anxious and that makes it louder because your heart beats are bigger”. Or, “You have chest and rib tightness throughout the day, but cardiac patients don’t. They get chest pain (often crushing and more localized) during heart attacks. It is muscle tension due to work stress. It is mild after a good night’s sleep and easier on weekends. It is worst after a stressful day at work” [8].
The therapist also helps the client to interpret their symptoms in a realistic, rather than a catastrophic manner. For instance, when the client has realised that their problem is their belief that there is something wrong with their heart, the therapist can substitute their previously catastrophic interpretations of their panic symptoms with realistic ones such as, “You think you are dying in a panic attack and that thought makes you anxious, producing many more sensations and setting up a vicious circle”. Or, “Distraction sometimes helps. That makes sense if the problem is your thoughts. It does not make sense if the problem is a heart attack. The same argument applies to leaving the situation. That would not stop a heart attack but it makes you feel more comfortable and undermines the negative thoughts” [8].
Indeed, many sufferers of panic disorder avoid engaging in certain activities in fear of experiencing a panic attack or, while experiencing one, they will try to slow down their breathing if they fear they’re having a heart attack, they will lean against a wall or an object if they’re afraid they’re going to faint, and they will try extremely hard to control their thinking if they’re scared they’re going crazy [9]. In reality, not only don’t these ‘safety behaviours’ help the person overcome their panic attack, they may actually maintain the disorder. Therefore, part of the CBT treatment for panic disorder is exposing the client to the sensations they find threatening by making them hyperventilate or feel dizzy. The purpose is to help the client realise that these sensations are not threatening to their lives. Additionally, clients are taught relaxation techniques such as breathing exercises so that they can stop hyperventilating and understand that they are experiencing bodily reactions that can be controlled [10].
Similarly, exposure therapy is used as an effective treatment for posttraumatic stress disorder (PTSD) since people who suffer from this disorder also engage in avoidance behaviour. Again, through exposure the therapist tries to break the association that the client has made between the traumatic event and, for example, the site of the event so that the pattern of avoidance which maintains the fear is interrupted. The aim is to help the client realise that the stimuli (for instance, the site) they have associated with the traumatic event are not threatening, that the memories of the event are different from the trauma itself, and that their PTSD symptoms are not signs that they are losing control or ‘going crazy’[11].
There are two types of exposure therapy: imaginal exposure and in vivo exposure. During in vivo exposure, the situations that are related to the traumatic event are confronted in real life, for example the client would visit the area where the event took place. On the other hand, in imaginal exposure, the client relives the traumatic memories by visualising the traumatic event and describing it using present tense in as much detail as possible, including the way they feel [12]. The idea is to help the client understand that they can face a situation which they view as stressful without any harm taking place so that anxiety will disappear. In order to achieve this, the client is taught relaxation techniques before facing repeated and brief confrontations (either imaginal or in vivo) with the stressful stimulus. The client is asked to use the relaxation techniques while confronting the stressful stimulus so that it will eventually no longer be associated with fear or stress. Anxiety management training includes relaxation training [13] and breathing retraining [14]. Relaxation training involves progressive muscle relaxation by systematically tensing and then relaxing each major muscle group in the body, while breathing retraining is about learning to take slower and deeper breaths (breathing from the belly rather than the chest) and pausing between inhales and exhales, as well as between each breath. Inhaling is typically performed through the nose while exhale through the mouth. Exposure therapy has been found to be an extremely effective treatment especially when combined with the replacement of negative thought patterns with realistic, positive ones that we mentioned above [15][16].
COUNSELLING (PERSON-CENTERED THERAPY)
Counselling is an effective type of treatment if you generally feel that you have no one to talk to, if you don’t understand why you feel the way that you do, or feel confused about your emotions. As with any type of psychological treatment, confidentiality in counselling is guaranteed so you can rest assured that no one will know what you tell your therapist.
There are six main principles involved in counselling [17]:
— Both the therapist and the client must be committed to the treatment.
— The client’s experience and awareness need to correspond. Furthermore, the client should feel psychologically vulnerable so that they will be motivated to remain in therapy.
— The therapist must genuinely want to help the client get better, and can even draw on his own experiences in order to achieve that.
— The therapist must accept the client unconditionally and without judgement, without approving or disapproving them.
— The therapist has to be empathetic towards the client.
— The client needs to recognise the therapist’s compassion and unconditional acceptance that they have for them.
Contrary to CBT where the therapist will teach you certain techniques or will give you instructions on how to deal with your problem, counselling does not involve doing ‘homework’ such as keeping a diary of your thoughts and feelings, as the therapist’s role is to help you understand your feelings and recognise your self-worth by interpreting the information you provide but without leading the therapeutic process: they leave the client take the lead. One technique that is sometimes used in counselling in order to help the client investigate the relationship they have with themselves, their feelings, or people in their lives is the ‘empty chair technique’ during which the client talks to an empty chair as though it was themselves, a particular feeling they are experiencing, or another person [18]. Sometimes the client may even change seats and answer back, having a discussion with themselves. This can be a helpful technique as it gives you the opportunity to explore aspects of yourself or of your emotions, and to confront people in your life that you cannot actually confront (because, for example, they have passed away, or you are scared of them). This can be an excellent technique for victims of abuse as they would be able to virtually confront their abuser without feeling afraid, and would ultimately regain their sense of self-worth.
INTERPERSONAL THERAPY
Interpersonal therapy is mainly focused on how problems in the client’s current relationships can negatively affect their psychological well-being. Therefore, it is the therapist’s job to help the client identify and express the feelings they have regarding their relationships, and then help the client solve any problems they may have in their relationships. The therapist explores enduring patterns in the client’s relationships that could lead to unpleasant feelings, and shows the client that improving their way of dealing with these patterns will decrease their negative emotions. Similarly to CBT, interpersonal therapy is a brief type of treatment in which the therapist will try to improve the client’s communication and problem solving skills, and will propose new and more positive behaviours to engage in.
However, contrary to CBT, this therapy does not involve doing ‘homework’, and focuses on four interpersonal issues, investigating which ones might be affecting the client negatively [19]:
—–> Unresolved grief – for instance, experiencing delayed grieving after losing a loved one.
—–> Role transitions – for example, transitioning from child to mother or from single woman to wife.
—–> Role disputes – for example, resolving different relationship expectations between husband and wife.
Interpersonal or social deficits – for example, being unable to start a conversation with a stranger. Interpersonal therapy is found to be very effective in treating depression and as it focuses on a person’s relationships with others and how these can affect our mental health, it could be a very good type of treatment for victims of domestic abuse who are suffering from psychological problems, since their issues would have been triggered by dealing with abusive relationships.
MEDICAL TREATMENT
For information on medical treatment, please consult your General Practitioner.
No matter what type of treatment you choose to follow, have faith in the fact that psychological therapy works and step by step you will be able to see and feel the difference. Even though you may not feel like it at the moment, you are strong so draw power from the fact that a lot of women who used to be in your shoes have managed to get help and get over their mental health issues once and for all through a professional psychological intervention. If others have made it, you can make it, too.
REFERENCES
[1] Fikree, F.F., & Bhatti, L.I. (1999). Domestic violence and health of Pakistani women. International Journal of Gynecology & Obstetrics, 65(2), 195-201.[2] Yehuda, R. (2002). Post-Traumatic Stress Disorder. The New England Journal of Medicine, 346(2), 108-114.
[3] Martell, C.R., Addis, M.E., & Jacobson, N.S. (Eds.) (2001). Ending depression one step at a time: The new behavioral activation approach to getting your life back. New York: Oxford University Press.
[4] Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.250). Asia: John Wiley & Sons, Inc.
[5] Gould, E., Otto, M.W., & Pollack, M.H. (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15, 819-844.
[6] DeRubeis, R.J., & Crits-Cristoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.
[7] Clark, D.M. (1994). Cognitive therapy for panic disorder. In J.D. Maser & B.E. Wolfe (Eds.), Treatment of panic disorder: A consensus development conference (pp.121-132). Washington, DC: American Psychiatric Association.
[8] Clark, D.M. (1996). Panic disorder: From theory to therapy. In P.M. Salkovskis (Ed.), Frontiers of cognitive therapy (p.330). New York: Guilford.
[9] Clark, D.M. (1996). Panic disorder: From theory to therapy. In P.M. Salkovskis (Ed.), Frontiers of cognitive therapy (p.327). New York: Guilford.
[10] Craske, M.G., & Barlow, D.H. (2001). Panic disorder and agoraphobia. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (pp.1-59). New York: Guilford.
[11] Foa & Jaycox (1999) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[12] Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[13] Jacobson (1938) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[14] Clark et al. (1985) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[15] Foa et al. (1997) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[16] Marks et al. (1998) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
[17] Rogers (1957; 1959) as cited in Prochaska, J.O., & Norcross, J.C. (2007). Systems of Psychotherapy: A Trans-theoretical Analysis (pp.142-143). New York: Thompson Books/Cole.
[18] Nichol, M. P., & Schwartz, R. C. (2008). Family Therapy: Concepts and Methods (8th ed.) (p.227). New York: Pearson Education.
[19] Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.43). Asia: John Wiley & Sons, Inc.