WELCOME TO CHAYN’S
MENTAL HEALTH TOOLKIT
This Toolkit offers a thorough guide of the various psychological issues that specifically affect victims of violence and abuse. The information in the Toolkit has been sourced from a variety of Psychology journals and studies in order to provide the most accurate, up-to-date data on mental illness, as well as to cover each subject as widely as possible. The Toolkit has also been written by psychologists in an easy-to-follow style that offers an overview of each topic, relates each disorder to a real-life application, and then suggests a variety of treatments that can be chosen as per the specific nature of each individual case.
In the Toolkit you will find information on anxiety, depression, self-harm and suicidal thoughts, Post-traumatic Stress Disorder, Stockholm Syndrome, and treatment options. Each topic is divided into a quick definition, followed by a detailed look at the topic including symptoms, causes, factors, and real-life examples of how the psychological condition may affect a victim of violence and abuse. We hope this Toolkit will enable you to effectively cope with the challenges people who have undergone abuse face in their lives, along with the issues domestic violence and abuse cause on psychological well-being.
Going through abuse and trauma, be it emotional, sexual, physical or psychological, is an extremely painful and stressful experience. Not surprisingly, people who have gone through abuse, violence, or other kinds of trauma often exhibit symptoms of psychological distress such as anxiety and depression; however, some may not be in a position to recognise that they are suffering from a mental health disorder and that the negative effects they are experiencing are a result of the abuse they have endured. We realise it is of vital importance as well as an essential part of the healing process that people who have been subjected to abuse become informed of the direct negative effect abuse has on mental health, while being able to identify any disorders they may be suffering from in order to treat and overcome them.
Abuse does not only cause wounds on the physical body; whether verbal, emotional, or physical, abuse hurts. The psychological scars it creates can take months, or even years, to heal. As organisations aiming to offer support to people who have gone through abuse, it is imperative that we fully understand the complexities of the psychological trauma they are dealing with, as well as inform them of available treatments and coping mechanisms.
How was it written ?
Please Note: This Toolkit was written specifically with women victims of domestic violence in heterosexual relationships (with male partner) in mind. However, you can use the content of the Toolkit to offer support to victims of any gender or sexual orientation, in any type of domestic situation (eg., parents as abusers), or victims of any kind of severe or minor trauma (domestic abuse, neglect, harassment, etc.).
The Toolkit is licensed under a Creative Commons Attribution Only License, which means that you can use the content from this Toolkit while attributing it to Chayn.
While there are many organisations that help victims of domestic violence escape the abusive situations and assist them in creating a new life for themselves, the psychological health of these victims is often not made a top priority. This is not due to negligence or lack of awareness of mental health issues demonstrated by victims. One of the many reasons this may happen is due to the lack of resources available to most NGOs and charity organisations . Resources that organisations lack may be in the form of expert support (on-team psychologists), training for support workers, or even time for research and training.
What is Chayn? [Hera]
A University of Glasgow Psychology graduate, Evangelia has received training on domestic violence while working with the Association of Social Exclusion and Mental Health (E.K.A.PS.Y.) in Greece and has been the Chief Psychologist and Manager of Chayn Pakistan since 2013. Currently based in Greece, you can contact her on LinkedIn at https://gr.linkedin.com/pub/evangelia-kampouri/78/a17/20a
Raised in Dubai and now living in Bangalore, Nida’s passions are film and women’s rights. Manager at Chayn India. You can contact her at @thenidasheriff on twitter.
Use this Table of Contents to navigate your way through the Mental Health Toolkit. You will be able to find each main topic, plus its contents divided into easily navigable sections for further, more detailed information.
Information on Psychological Interventions
At a Glance: In this section you will learn what depression is, the symptoms of depression, who is at risk, factors associated with developing depression, and how it is related to domestic violence. We’ve also included a link to a self-scored questionnaire which assesses whether one is experiencing normal highs and lows in their mood, or is going through depression.
Summary: Depression is a mood disorder that negatively affects the way one thinks, feels, and behaves. It is not merely a feeling of sadness and a decrease in interest and pleasure. It can involve a number of symptoms, ranging from a change in appetite and sleep patterns, to a loss of energy and feelings of worthlessness. People who have gone through an abusive relationship are at a higher risk of experiencing depression, with women being almost twice as likely to suffer from it as men. Many factors can cause a person to experience feelings of depression: biology and genetics, personality, childhood history, environment, lack of social support and low self-esteem, that could lead to feelings of hopelessness, sometimes shame or guilt, and negative ways of thinking about themselves, the world, and the future. Self-blame, which is seen in many survivors of domestic violence, can also play a significant role in causing the development of depressive symptoms.
Depression in Focus:
It is normal for all of us to go through a period of sadness at some point in our lives, especially after experiencing a negative event such as losing a loved one, enduring a serious illness, or losing a job. However, if you consistently feel sad or cannot find pleasure in everyday activities over a long period of time (at least two weeks), and these feelings of sadness are not caused by normal bereavement (for example, if someone you loved recently passed away), then you might be suffering from major depressive disorder, which people commonly refer to as depression.
You could be going through depression if along with experiencing sad mood and a loss of interest and pleasure for a period of at least two weeks, you are also experiencing at least four of the following symptoms:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). (4th ed.). Washington, DC: Author.
Depression has been found to occur almost twice as often in women as in men. There are several reasons as to why women/girls, particularly those in abusive relationships, are more vulnerable to depression :
Adult women are more likely than men to deal with situations that cause stress such as having to take care of others or living on very little money. Likewise, many abusers control their victims’ finances, either by forbidding them to work so that they will depend on them for an allowance (which they will withhold if the victim does not follow their ‘rules’), monitoring how much money they spend, or harassing them at work so that they will be fired. Being a victim of an abusive relationship is a very stressful experience so, not surprisingly, it can lead you to feel depressed.
Twice as many girls as boys are victims of sexual abuse during childhood. Indeed, women have been found to be more exposed to sexual violence, including childhood sexual abuse and rape, than men .
The roles and standards set by today’s society can lead girls to be more self-critical about their appearance than boys .
In order to follow what society dictates and expects of them, women may be prevented from engaging in activities that they might find rewarding because these activities are not viewed as “feminine” (for example, ‘I really want to study and become a doctor, but I should not because that is not a woman’s job’). It goes without saying that your life belongs to you and you should be the one to decide how you want to live it. Unfortunately, abusers want to control every aspect of their victims’ lives. As a result, your abuser may forbid you to pursue activities that interest you and that you find enjoyable. These restrictions can lead to depression.
Women are more likely to seek approval and closeness within their relationships with other people (including friends, family, and co-workers), which can lead them to be more sensitive when stressful situations occur within their relationships with others (for example, becoming more upset than normal when you have an argument with a friend) . While a healthy relationship between a husband and wife is based on love and respect for one another, abusive relationships are all about the power and control the abuser exerts over his victim. So, abusive relationships constantly create stressful situations for the victims. And since women can be more sensitive to stressful events within their interpersonal relationships, having an abusive husband can lead them to become depressed.
While men usually try to distract themselves when feeling sad by engaging in various activities such as playing sports, women tend to dwell on their sad mood, thinking over and over about the reasons why unhappy events have happened, which can lead these feelings of sadness to last for a longer period of time . If you are a victim of abuse, you may dwell on wondering why this is happening to you. However, dwelling on negative events can lead you to feel sad for longer.
Factors associated with developing depression: You may be wondering why some people become depressed while others don’t, even though they seem to be going through similar situations. In reality, a lot of factors have been associated with the development of depressive symptoms: not only has depression been linked to people’s biology and genetics (for example, some people who suffer from depression also have a close relative that has gone through depression), but also people’s personality, environment, and way of thinking seem to play an important role in causing a person to experience feelings of depression. For instance, people who are generally anxious, insecure, and tend to worry more about things are more likely to experience depression . In terms of environment, people suffering from depression may feel as though they don’t have enough social support because they don’t have a large social network, or because they feel that the networks they have don’t give them a lot of support . Not having enough support from your environment can decrease your ability to deal with negative life events and therefore make you more vulnerable to depression. In fact, it has been found that women, who don’t have a supportive environment to help them cope with a stressful life event, are ten times more likely to develop depression than those who have social support . In many abusive relationships, the abuser will try to isolate his victim from her social network by forbidding her from keeping in touch with her friends, to have a job, to leave the house, or by being present whenever she is meeting with her family so that he will control what she says to them. As a result, this isolation makes it even harder for victims of abuse to deal with depression, or even recognise what they are going through. Additionally, if you have gone through depression in the past and are living with family members, including in-laws, who make snide comments towards you, you are more than twice as likely to become depressed again in the future, than if you were living with people who are accepting of you .
Our way of thinking can also influence whether we will develop depressive symptoms or not. It has been proposed that depression is linked to a combination of negative views of yourself (for example, ‘I am worthless’), your environment (for example, ‘there is no way I can deal with my abusive husband’), and your future (for example, ‘things will always be this bad’). These negative views interact with negative, deep-set beliefs (for example, unconsciously expecting that people in general will intentionally hurt, abuse, or take advantage of you) which can cause a tendency to explain what happens around you in a negative way (for example, paying more attention to negative than positive life events) and can lead you to become depressed .
It has also been suggested that depression can be triggered by the feeling of hopelessness. Feeling hopeless can be caused by low self-esteem. Not surprisingly, abusive relationships can lower your self-esteem as abusers will usually degrade you through their words or actions and then blame you for their behaviour. In addition to this, when a negative event happens (for instance, your husband becomes violent towards you) you may wrongly attribute it to personal causes (for example, ‘I am worthless’), permanent causes (for example, ‘I am always wrong’), and may think that it influences all areas of your life (for example, ‘no one will ever be kind to me’). Blaming yourself in this way can lead you to feel hopeless and make you believe that things will never change for the better. This in turn can make you feel depressed .
Unfortunately, it has been found that negative events have a greater influence than positive ones; that we process negative information more than positive information, and that negative information contributes more to our final impression . In fact, negative events are on average five times as powerful as positive ones . This means that if someone does something bad to you, he will then need to do five good things to you in order for you to go back to your original emotional state. In addition to this, when you are in a bad mood, you are more likely to remember negative past events than positive ones . This in turn can make you feel even more depressed by creating a vicious cycle: you are sad therefore you remember bad memories, which reinforces your feelings of sadness.
Dwelling on negative events and constantly wondering why they have occurred can lead you to feel depressed. For instance, you might find yourself trying to rationalise your abuser’s behaviour, making excuses for it, or even blame yourself for having caused it. Know that nobody deserves to be abused and that nothing you said or did is the reason behind why you are being abused. In fact, no matter how ‘perfectly’ you may try to behave by consciously planning what you will say or do, your abuser will still ‘find reasons’ to continue administering his abusive behaviour. That is because abusive relationships have nothing to do with how you behave; they are about the power and control your abuser has over you. Abusers will use verbal, emotional, or physical abuse in order to get what they want and in order to have their needs met, not because you have done something wrong.
Of course, your abuser will try to rationalise his behaviour by blaming his short-temper or your actions. This, however, is false. If he was unable to control his temper, he wouldn’t make sure to abuse you only when people who love and would stand up for you are not around, he would not pretend to be kind towards you when you are in front of the people who care about you so that they will not believe you if you tell them that he is abusing you, and if he is physically violent towards you, he wouldn’t make sure to only hit you in places where your bruises will not be visible or in places where they can be explained by other means (for instance, ‘I fell down the stairs’). All these show that abusers are in control of their temper.
Moreover, your actions are not to be blamed either, as abusers will act abusively regardless of your behaviour and will at times plan their actions beforehand and even set you up so that they can justify abusing you. In fact, it has been proposed that abuse follows a cycle of three stages :
This cycle of tension, abuse/violence, and seemingly loving period, creates a constant feeling of uncertainty which can be very stressful. Unfortunately, uncertainty has been found to lead to great feelings of attachment and dependence  which could explain why many victims of abuse feel so dependent on their abusers, especially when financial abuse is also involved and the victim has no choice but to depend on her abuser for financial security.
If you suspect that you or someone you know is suffering from depression, do not lose hope as there are ways to treat depression.
Feel free to fill out the following questionnaire to check if you are experiencing normal ups and downs or if you are going through depression: Beck Depression Inventory.
 Nolen-Hoeksema, S. (2001). Gender differences in depression. Current Directions in Psychological Science, 10, 173-176.
 Fergusson, D.M., & Mullen, P.E. (1999) as cited in Fergusson D.M., Swain-Campbell N.R., & Horwood L.J. (2002). Does sexual violence contribute to elevated rates of anxiety and depression in females? Psychological Medicine, 32, 991-996.
 Finkelhor, D., Hotaling, G., Lewis, I.A., & Smith, C. (1990) as cited in Fergusson D.M., Swain-Campbell N.R., & Horwood L.J. (2002). Does sexual violence contribute to elevated rates of anxiety and depression in females? Psychological Medicine, 32, 991-996.
 Hankin, B.L. & Abramson, L.Y. (2001). Development of gender differences in adolescent depression: An elaborated cognitive vulnerability-transactional stress theory. Psychological Bulletin, 127, 773-796.
 Hankin, B.L., Mermelstein, R., & Roesch, L. (2007). Sex differences in adolescent depression: Stress exposure and reactivity models. Child Development, 78, 279-295.
 Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. (1993). Response styles and the duration of episodes of depressed mood. Journal of Abnormal Psychology, 102, 20-28.
 Jorm, A.F., Christensen, H., Henderson, A.S., Jacomb, P.A., Korten, A.E., & Rodgers, B. (2000). Predicting anxiety and depression from personality: Is there a synergistic effect of neuroticism and extraversion? Journal of Abnormal Psychology, 109,145-149.
 Keltner, D., & Kring, A.M. (1998). Emotion, social function, and psychopathology. Review of General Psychology, 2, 320-342.
 Brown, G.W., & Andrews, B. (1986). Social support and depression. In R. Trumbull & M.H. Appley (Eds.), Dynamics of stress: Physiological, psychological, and social perspectives (pp. 257-282). New York: Plenum.
 Buttzlaff, R.L., & Hooley, J.M. (1998). Expressed emotion and psychiatric relapse: a meta-analysis. Archives of General Psychiatry, 55, 547-553.
 Kendall, P.C., & Ingram, R.E. (1989). Cognitive-behavioral perspectives: Theory and research on depression and anxiety. In D. Watson & P.C. Kendall (Eds.), Personality, psychopathology, and psychotherapy (pp. 27-53). San Diego, CA: Academic Press.
 Beck, A.T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row.
 Abramson, L.Y., Metalsky, G.I., & Alloy, L.B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, 358-372.
 Baumeister, R.F., Bratslavsky, E., Finkenauer, C., &Vohs, K.D. (2001). Bad Is Stronger Than Good. Review of General Psychology, 5(4), 323-370.
 Gottman, J. (1994). Why marriages succeed or fail. New York: Simon & Schuster.
 Lewis, P. & Critchley, H. (2003). Mood-dependent memory. Trends in Cognitive Sciences, 7(10), 431-433.
 Walker, L. E. (1979). The battered woman. New York: Harper & Row.
 Fisher, A.E. (1955). The effects of differential early treatment on the social and exploratory behavior of puppies. (Unpublished doctoral dissertation). Pennsylvania State University.
At a Glance: In this Section you will learn what anxiety is, what the symptoms of panic attacks are, what panic disorder is, why we experience these symptoms, what are the risk factors for developing an anxiety disorder, how they are linked to domestic abuse, as well as a link to a self-scored questionnaire which can help one assess their anxiety levels.
Summary: Anxiety is a subjective state of worrying as a reaction to various stimuli that are not truly threatening but which the person experiences as such. When a person’s anxiety levels are higher than normal, they may experience intense worry that they find hard to control, feel restless or on edge, become easily tired, find it difficult to concentrate, become easily irritated, suffer from tense muscles, and/or have problems with sleep. If someone has experienced a period of intense anxiety, terror, and a feeling that something bad was about to happen, together with a variety of physical symptoms and fears, they most probably have had a panic attack episode. Experiencing repeated panic attacks that were not triggered by a specific situation while worrying about going through another panic attack, the consequences of a panic attack, or changing one’s behaviour to avoid triggering panic attacks for at least a month, may indicate that a person is suffering from panic disorder. The symptoms of a panic attack are often mistaken as dangerous situations such as having a heart attack or a nervous breakdown, whereas in reality they are simply the body’s normal response to a perceived threat as it goes into a state of alertness to prepare the person to either face or run away from the threatening situation. Genetic and biological factors, as well as a person’s personality, way of thinking - for instance paying more attention to things that are considered stressful - while misinterpreting situations in a negative manner, and social environment have been associated with anxiety disorders. Domestic abuse in particular is an extremely negative and stressful situation as victims go through traumatic events, thinking they have no control over their environment, and being constantly on edge as they live in continuous fear.
Anxiety in Focus:
When we are facing a dangerous or life threatening situation, our bodies are naturally built to enter a state of alertness. Our heart-rate increases, we start to shake, and we feel nervous or scared. In other words, we experience fear. This alertness prepares us physically in order to either fight the threat, or run away from it . This reaction is not only natural, but also helpful. For instance, if we suddenly see a car quickly speeding towards us while we are crossing the street, we immediately start to run because we fear that it will hit us. In this case, fear saves our life. On the other hand, when we become worried about an issue that will take place sometime in the future, we are experiencing anxiety. Anxiety can also be helpful. For example, if a student is anxious about an exam s/he has the following week, s/he is likely to study hard in order to prepare for it.
However, if you are experiencing extreme, irrational fear, and/or intense worry that affects your everyday life, you may be suffering from an anxiety disorder. To give a few examples, you may experience intense worry that you find hard to control, feel restless or on edge, become easily tired, find it difficult to concentrate, become easily irritated, suffer from tense muscles (for instance, low back pain, headaches or stomach aches), and/or have problems with sleep (for example, finding it hard to fall asleep, or waking up in the middle of the night). These would all indicate that your anxiety levels are higher than normal.
If you want to check your anxiety levels, feel free to fill out the questionnaire at the end of this page.
It is important to note that if you have experienced a period of:
And these were accompanied by at least four of the following symptoms:
You most probably had a panic attack episode.
Panic attack symptoms usually appear suddenly and very quickly and reach their highest intensity within ten minutes. While experiencing a panic attack once or twice in our life can be quite common , you may be suffering from Panic Disorder if:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (DSM-IV). (4th ed.). Washington, DC: Author.
The symptoms of a panic attack are the result of the body going into a state of alertness which, as mentioned above, prepares the person to either face or run away from a threatening situation. But since in Panic Disorder the attacks appear unexpectedly - without a threat triggering them, for someone who doesn’t know that they are having a panic attack experiencing these symptoms can be scary, and because they cannot explain them it is no surprise that many people may mistake their panic attack symptoms as having a heart attack or a nervous breakdown.
Genetic and biological factors have been associated with anxiety disorders, but so are a person’s social environment, way of thinking, and personality. For example, people who are generally anxious, insecure, and tend to worry about things, are more likely to develop an anxiety disorder . It has even been proposed that babies who have a tendency to become stressed and cry when introduced to new toys or people are likely to develop anxiety symptoms later in their childhood .
In terms of social environment, most people have experienced an extremely stressful event in their lives before developing an anxiety disorder . It goes without saying that being a victim of domestic abuse is an extremely negative and stressful situation. Not only do victims of abusive relationships go through traumatic events such as physical and/or emotional abuse, but also they can live in constant fear that their abuser will hurt them or their loved ones at any time. Constantly being on edge, waiting for the next abusive incident to inevitably take place, and always feeling as if you need to walk on eggshells in order to not upset your abuser can lead you to continuously feel anxious.
In fact, in a study that surveyed women who suffered from depression, 63% reported having experienced abuse at some point in their life, with 55% having been abused as adults by a family member or someone they knew well, such as a partner .
Furthermore, thinking or believing that you don’t have control over your environment, can also increase your chances of developing an anxiety disorder . Abusive relationships are all about the control that the abuser has over his victim. Having your abuser control you in any way can make you feel as though you have no control over your own life and that can lead you to become stressed. No one deserves to have others dictate to them how to live their lives or endure constantly threatening events. Find hope in the fact that there are ways to deal with abusive relationships.
People suffering from extreme anxiety have also been found to pay more attention to things that are considered stressful  and have a tendency to interpret situations in a negative manner . Therefore, a person suffering from Panic Disorder can be more likely to notice and pay attention to the initial symptoms of a panic attack (such as shortness of breath and increased heart rate), and wrongly interpret them as a heart attack. Of course, this misinterpretation can make them feel even more stressed. Some people may even begin to avoid engaging in any situations that make their heart race (for example, exercise) because as soon as they feel their heart rate increase, they are scared of an oncoming heart attack. However, this behaviour strengthens and maintains their false belief that the only reason why they haven’t actually had a heart attack is the fact that they avoid engaging in situations that increase their heart rate , and creates a vicious cycle of fear, stress, and avoidance.
It has even been suggested that people can suffer from anxiety because it distracts them from even more intense negative emotions . If this is the case, it could offer an additional explanation as to why women in abusive relationships are more likely to suffer from anxiety disorders: it might be that intense worry feels less damaging than the reality victims of domestic abuse are facing on a daily basis, and therefore could be used as a distraction from the negativity that surrounds their everyday lives.
‘Two men looked out from prison bars, one saw the mud, the other saw the stars.’
As we have mentioned above, in abusive relationships the abuser wants to have total control over his victim. Firstly, it is important to note that even though you may feel that you have no control over the negative situations that occur in your life, know that there are ways to escape this situation and reclaim your right to decide what you do with your life. However, even if you cannot get out of the relationship at the moment, there are still ways to deal with the situation. Even if you cannot control the events that occur around you at the moment, you can still control the way you react to them. Whether you are leaving or staying, it is important that you keep yourself informed.
The first step to dealing with the misinterpretation of anxiety symptoms is to learn what these symptoms are in order to accurately recognise them any time you experience them. This is crucial so that you will break the vicious cycle of ‘anxiety symptoms –> misinterpretation that they are something worse (for example, signs of an oncoming heart attack) –> becoming more stressed –> avoid situations that may provoke anxiety symptoms –> belief that disaster (for example, heart attack) was prevented because of avoidance’. Instead of misinterpreting anxiety symptoms as a sign that something disastrous is about to happen, you should reassure yourself that it is simply your body’s way of telling you that it has gone into a state of alertness, and that the symptoms will go away once you have calmed down.
You also need to stop maintaining the false belief that avoiding to do certain tasks is what has prevented disaster from happening. In order to do this, you will need to start engaging in activities and behaviours you have been avoiding due to your anxiety symptoms. For instance, if you have been avoiding tasks that increase your heart rate, you should start exercising. In fact, exercise has been found to reduce the symptoms of both anxiety and depression .
If you feel that you cannot help but be anxious since you always need to be careful not to upset your abuser, you have to realise the fact that unfortunately, abusers will always find a reason to abuse their victims. In fact, they may set their victims up so as to justify their abusive behaviour . You need to realise that you are not being abused because of your actions, but because your partner is abusive and wants to have total control over you. You are not to blame, your abuser is. Therefore, by being anxious over your behaviour you are only making your life even more difficult than it already is. Instead of maintaining high anxiety levels by falsely believing that by being careful enough, you can keep your abuser from abusing you, you should seek help and deal with your anxiety problems and provide yourself with a better quality of life.
If you suspect that you are suffering from increased anxiety, you can fill out the following questionnaire to check your anxiety levels: BECK ANXIETY INVENTORY
 Cannon, W.B. (1929). Bodily changes in pain, hunger, fear and rage (rev. ed.). New York: Appleton-Century.
 Kessler, R.C., Chiu, W.T., Jin, R., Ruscio, A.M., Shear, K., & Walters, E.E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63, 415-424.
 de Graaf, R., Bijl, R.V., Ravelli A., Smit, F., & Vollenbergh, W.A.M. (2002). Predictors of first incidence of DSM-III-R psychiatric disorders in the general population: Findings from the Netherlands mental health survey and incidence study. Acta Psychiatrica Scandinavica, 106, 303-313.
 Kagan, J., & Snidman, N. (1999). Early childhood predictors of adult anxiety disorders. Biological Psychiatry, 46, 1536-1541.
 Finlay-Jones, R. (1989) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
 Scholle, S. H., Rost, K. M., & Golding, J. M. (1998). Physical abuse among depressed women. Journal of General Internal Medicine, 13, 607-613.
 Mineka, S., & Zinbarg, R. (1998) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
 Insel, T.R., Scanlan, J., Champoux, M., & Suomi, S.J. (1988). Rearing paradigm in a nonhuman primate affects response to B-CCE challenge. Psychopharmacology, 96, 81-86.
 MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional disorders. Journal of Abnormal Psychology, 95, 15-20.
 Hirsch, C., & Mathews, A. (2000). Impaired Positive Inferential Bias in Social Phobia. Journal of Abnormal Psychology, 109, 705-712.
 Clark, D.M., Salkovskis, P.M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: a randomized control trial. Journal of Consulting and Clinical Psychology, 67, 583-589.
 Borcovec, T.D., & Newman, M.G. (1998) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
 Salmon, P. (2001). Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory. Clinical Psychology Review, 21(1), 33-61.
 Walker, L. E. (1979). The battered woman. New York: Harper & Row.
SELF-HARM & SUICIDAL THOUGHTS
At a Glance: In this Section you will learn the reasons for causing an individual to engage in self-harming behaviours and/or suicidal thinking, how self-harm and suicidal thoughts are influenced by domestic violence and related to other disorders, how victims of domestic violence are affected, how therapy can help, advice for people who know someone that is going through self-harming behaviours and/or suicidal thinking, and find contact information where people experiencing self harm and suicidal thoughts can send an anonymous, confidential e-mail for support, as well as a link to information about suicidal thinking.
Summary: Contrary to popular belief, people do not go through self-harm and/or suicidal thinking in order to seek attention or because they are selfish, but out of desperation due to experiencing such intense emotional pain. They feel the only way to handle it is by either transforming it into physical pain, or by escaping the situation. Because they feel trapped in this situation, they believe that the only way of escaping is by ending their lives or causing pain to themselves. Enduring domestic violence is one risk factor for suicide, since being in an abusive intimate relationship can be such a painful and stressful experience that 25% of victims of domestic assault engage in self-harming behaviours. Verbal and emotional abuse (which does not involve physical violence) can also lead to feelings of intimidation, emotional trauma, depression, and suicidal attempts. Those who have experienced more than one form of domestic violence are likely to engage in deliberate self-harm, while victims of domestic violence who are suffering from symptoms of Post Traumatic Stress Disorder have been found to be at an increased risk of attempting suicide. Self-harming behaviours and suicidal thinking can make an individual feel lonely and isolated, and typically appear along with other disorders, including depression and anxiety. Fortunately, this often means that treating those disorders automatically reduces the likelihood of self-harming behaviours and suicidal thoughts. For instance, Cognitive Behavioural Therapy, which focuses on restructuring one’s negative thought patterns and behaviour, replacing them with realistic, positive ones while providing ways of coping with emotional distress, and improving one’s problem solving skills and social support, has been found to be tremendously effective in treating suicidal thinking.
Self-Harm and Suicidal Thoughts in Focus:
Self Harm and Suicidal Thoughts
Practicing acts of self-harm, and having suicidal thoughts can be an extremely painful experience. Contrary to certain myths and misconceptions, people who go through self-harm and/or suicidal thinking are not doing so in order to seek attention. The reason why most people engage in behaviours of self-harm is because they are experiencing such intense emotional pain, that they feel the only way to handle it is to transform it into physical pain. Similarly, most people who have suicidal thoughts do not want to die: they feel that they cannot deal with the intense pain in their life, that there is no solution to the problems they are facing, and think that the only way for them to find relief is to escape the situation. But because they are feeling trapped in this situation, they believe that the only way of escaping is by ending their life. Some people might wrongly accuse those who are suffering from suicidal thoughts of being selfish, for not thinking about the consequences their death would have for the ones they’ll leave behind. But in reality, people who are contemplating suicide are not doing so out of selfishness, but out of desperation. They truly believe that there is no other way for them to escape the pain. Fortunately, there are ways to deal with negative life events and situations, and to overcome suicidal thinking and behaviours of self-harm. And, contrary to ending one’s own life or harming oneself, these are constructive, positive ways.
Being in an abusive relationship can be stressful and painful enough to cause someone to experience suicidal thinking or to engage in acts of self-harm. Indeed, enduring domestic violence has been found to be a risk factor for suicide , and being exposed to a violent intimate relationship is associated with self-harm and attempted suicide  with 25% of victims of domestic assault engaging in self-harming behaviours . Being subjected to abuse by a partner has also been found to be a significant risk factor for suicidal thinking . Most individuals who attempt deliberate self-harm may have experienced more than one form of domestic violence  as we need to bear in mind that apart from physical violence, verbal and emotional abuse is common and these can also lead to feelings of intimidation, emotional trauma, depression, and suicidal attempts . In fact, 64% of battered women were found to be suffering from Post Traumatic Stress Disorder (PTSD), and 48% had depression . This is a very important finding, since suicidal thinking and self-harming behaviours do not appear all of a sudden: in most cases they appear alongside other disorders such as depression and anxiety. For instance, it has been found that victims of domestic violence who are suffering from symptoms of PTSD are at risk of attempting suicide , with PTSD sufferers 15 times more likely to have attempted suicide .
Going through self-harm and having suicidal thoughts can be very lonely. Yet, if you are suffering from such thoughts and behaviours, you do not need to go through this difficult time alone. Even if you are afraid that the people who are close to you will judge you for your feelings, or simply not understand you, know that there are others out there who can and want to help you. Professional psychotherapists will listen to your problems in a non-judgemental, caring manner with complete confidentiality. Because suicidal thoughts and self-harm manifest along with mood and anxiety disorders as we mentioned above, treating those disorders automatically reduces the self-harming behaviours and suicidal thoughts. Cognitive Behavioural Therapy (CBT) in particular has been found to be tremendously effective in treating suicidal thinking . The reason behind this could be the fact that CBT focuses on restructuring our negative thought patterns and behaviours, replacing them with realistic, positive ones. It also helps us realise that things we may perceive to be threatening and cause us fear and anxiety, in many cases are only threatening in our mind. By giving us the skills to retrain our brain into thinking in a realistic manner, the downward spiral of depression and anxiety is broken and we feel more and more empowered. Moreover, through CBT one can learn ways of coping with emotional distress, and improve their problem solving skills and social support so that they no longer feel lost, hopeless, alone, or trapped in any given negative situation .
It has been suggested that the more fear a woman has experienced during a traumatic event, the more powerless she experiences herself to be and the less likely she is to try to defend herself . Thus, victims of abuse should not feel responsible for ‘allowing’ their abuser to mistreat them by not fighting back. Abusers will most of the time, if not always, accuse their victims for their abusive behaviour, claiming that they were asking for it, that they brought it on themselves, that they deserved it. Over time, these utterly false claims can brainwash their victims into believing them to be true and making them feel guilty or ashamed, which can be detrimental in more ways than one. First of all, feeling extreme guilt or shame after experiencing a traumatic event such as domestic abuse, increases the risk of developing PTSD  and, as we mentioned earlier, suffering from PTSD raises the likelihood of experiencing suicidal thinking. Secondly, feeling as though they caused the abusive behaviour, victims of domestic abuse have the false hope that if they are careful enough to not upset their abuser, there will be no more abusive episodes. In reality, abusers will continue to be abusive and will even set their victims up for failure in order to justify their abusive behaviours. Thirdly, by taking the blame and feeling as if they deserve to be treated badly, victims of domestic abuse are less likely to leave the abusive relationship simply because they have come to believe that their abuser is not the problem: they are. Even though this is certainly not true, one can realise how trapped a person would feel while living in an environment such as this.
If you are going through self-harm and/or thinking about suicide, you may feel like you have reached a dead-end, that there is no hope that things will get better. When people have suicidal thoughts or engage in self-harm, the unpleasant emotions they have can nurture negative thoughts that are not true (for example, ‘there is no way to change my life, my only solution is to kill myself’) while blocking the realistic, positive ones (for instance, ‘I am going through a hard time at the moment, but there are ways to deal with it; all I need to do is to make a plan and talk to those who can help me turn my plan into reality’). But you need to remember that emotions change with time: just as there was a time when you didn’t have suicidal thoughts or self-harming behaviours, there will also come a time when you once more won’t have them. Your current situation doesn’t have to predict your future, and you have already taken a step towards improving your future by looking here. People overcome such negative life experiences and there are people who can help you get through this as well. If you want to talk to someone about how you are feeling, contact your local Samaritans or support centre. Some people find it useful to get things off their chest by writing about their feelings, their situation, and anything else that is bothering them.
If you know someone who is suffering from suicidal thoughts and/or is deliberately harming themselves, recognise that they probably feel very lonely and vulnerable, so they need someone they can trust to listen to them in a non-judgemental way. They need to feel that they are not alone, that there are people who care about them and who accept them unconditionally. Please do not try to advise them on what they should and shouldn’t do as that can feel patronising, and don’t ‘shower’ them with questions since that might sound as if you are trying to interrogate them. Furthermore, please don’t buy into the myth that ‘those who truly want to kill themselves, don’t tell anyone about it’ or that ‘if they’ve told you they want to kill themselves, they don’t really mean it; they’re just seeking attention’, because that is certainly not true. In fact, almost three quarters of those who commit suicide have talked about their intentions in advance  . After all, as we mentioned earlier, most people who think about killing themselves do not really want to die. They simply feel that they cannot cope with their life. They are not thinking about committing suicide out of selfishness, but out of desperation. So if someone has confessed to you that they deliberately harm themselves or are thinking about taking their own life, please do not take it lightly and do not scold them for it, because the last thing they need is to feel even more isolated and alone. Remember that this is their cry for help therefore try to approach them with sensitivity. Self-harm and suicidal thinking are not signs of weakness, so the solution for people who go through these situations is not to ‘be tough’, ‘stop complaining’, ‘carry on’ and ‘just deal with it’. These people are overwhelmed by negative emotions and thoughts, and are most likely suffering from depression and/or anxiety. Luckily, with proper social support there are ways to overcome these issues. Have hope and be strong for those you care about who cannot feel strong at the moment.
 Ali, B.S., Rahbar, M.H., Naeem, S., Tareen, A.L., Gul, A., & Samad, L. (2002) as cited in Haqqi, S. (2008). Suicide and Domestic Violence: Could There Be a Correlation? The Medscape Journal of Medicine, 10(12), 287.
 Barrios, L.C., Evertt, S.A., Simon, T.R., & Brener N.D. (2000) as cited in Haqqi, S. (2008). Suicide and Domestic Violence: Could There Be a Correlation? The Medscape Journal of Medicine, 10(12), 287.
 Boyle, A., Jones, P., & Lloyd, S. (2006). The association between domestic violence and self harm in emergency medicine patients. Emergency Medicine Journal, 23, 604-607.
 Plichta, S. B., & Weisman, C. S. (1995). Spouse or partner abuse, use of health services, and unmet need for medical care in U.S. women. Journal of Women's Health, 4, 45-53.
 Stark, E., Flitcraft, A., & Frazier, W. (1979). Medicine and patriarchal violence: the social construction of a "private" event. International Journal of Health Services, 9, 461-493.
 Chowdhury, A.N., Brahma, A., Banerjee, S., & Biswas, M.K. (2009). Pattern of domestic violence amongst non-fatal deliberate self-harm attempters: A study from primary care of West Bengal. Indian Journal of Psychiatry, 51(2), 96-100.
 Sheikh, M.A. (2000, 2003) as cited in Haqqi, S. (2008). Suicide and Domestic Violence: Could There Be a Correlation? The Medscape Journal of Medicine, 10(12), 287.
 Golding, J. M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14, 99-132.
 Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Davidson et al. (1991) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 van der Sande, R., Buskens, E., Allart, E., van der Graaf, Y., & van Engeland, H. (1997) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
 Brown, G.K., Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., & Beck, A.T. (2005). Cognitive therapy for the prevention of suicide attempts. Journal of the American Medical Association, 294, 563-570.
 Joiner, T.E.J., Voelz, Z.R., & Rudd, M.D. (2001). For suicidal young adults with comorbid depressive and anxiety disorders, problem-solving treatment may be better than treatment as usual. Professional Psychology: Research and Practice, 32, 278-282.
 Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.250). Asia: John Wiley & Sons, Inc.
 Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Riggs et al. (1992) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
 Fremouw, W.J., De Perzel, M., & Ellis, T.E. (1990) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
 Shneidman, E.S. (1973) as cited in Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.). Asia: John Wiley & Sons, Inc.
PTSD: POST TRAUMATIC STRESS DISORDER
At a Glance: In this Section you will find what Posttraumatic Stress Disorder is, what the symptoms are, what the risk factors for developing PTSD are, how it is related to domestic violence, how it is affected by social environment, what role avoidance, guilt, and self-blame play in developing and maintaining the disorder, and how it can affect the children of individuals experiencing it.
Summary: PTSD is an anxiety disorder that develops after having experienced a traumatic event that causes feelings of helplessness and extreme fear. A person may be suffering from PTSD if they re-experience the traumatic event (by frequently recalling and thinking or dreaming about it in nightmares, or by becoming extremely upset by situations that remind them of the event), if they avoid situations that remind them of the traumatic event, or if they feel alienated from others and unable to feel positive emotions, along with experiencing increased arousal for more than a month after enduring the traumatic event. Women (especially those who have been victims of domestic abuse), those who are suffering from depression or other anxiety disorders, those who have experienced trauma when they were children, and those who are generally anxious and insecure are more likely to develop PTSD after going through a traumatic event. The isolation from a positive social network, that many times comes with domestic abuse, may maintain the disorder, while avoiding thinking about the traumatic event and feeling extreme guilt after experiencing it has been found to raise the chances of developing PTSD. PTSD can also affect the children of those who suffer from it, especially if they are infants or preschool-age, whereas a child is also likely to develop the disorder later in life.
PTSD in Focus: Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that develops after experiencing or witnessing a traumatic event which involved threat of death or injury to the person or others, and caused feelings of helplessness, horror, or extreme fear. PTSD symptoms include:
If you have been suffering from the symptoms that are mentioned above for more than one month after experiencing a traumatic event, you may be suffering from PTSD.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (DSM-IV). (4th ed.). Washington, DC: Author.
It has been found that women , as well as people who are suffering from depression or other anxiety disorders, people who have experienced trauma when they were children, and people who are generally anxious, insecure, and tend to worry about things, are more likely to develop PTSD after going through a traumatic event . Furthermore, many women who have been victims of domestic abuse have developed PTSD symptoms . Indeed, it has been found that if you have experienced traumatic injuries by another person, you are more likely to develop PTSD than if your traumatic injuries were caused by an accident or natural disaster . This could be because along with the fear for your life, your trust in other people and your sense of safety as a member of a community that is based on rules, are shaken . For instance, a family should provide an environment where people feel safe, respected and loved. But in the case of domestic abuse, this sense of safety within the family and home is shaken and therefore is more likely to lead to PTSD. It is worth noting that the more severe the violence one experiences, the more likely they are to suffer from PTSD, and psychological abuse can cause as much damage as physical violence .
Social environment is also of great importance since a positive social network can help a person deal with PTSD whereas a negative one can maintain the condition . This may happen because positive social support restores our sense of belonging to a social group that takes care and protects its members while negative interactions strengthen the feelings of fear, lack of safety, and the idea that the world is a hostile place . Unfortunately, an abuser will often try to isolate his victim from her circle of family and friends so that she will not be able to seek help from them. Or, he may behave kindly to her when her family or friends are present so that they will not believe her if she tells them that she is being abused. This way he is protecting himself so that he will not suffer the consequences of his abusive actions. Even if you feel trapped in an abusive relationship at the moment, there are people and organisations out there that could help you.
In addition to the factors mentioned above, avoiding thinking about the traumatic event has also been found to raise the chances of developing PTSD , and so is feeling detached (for example as if you were being outside your body, as if the world was not real, as if this wasn’t happening to you) during the event or trying to suppress memories of it afterwards . This could be because such avoidance mechanisms prevent you from facing and confronting the memories of the traumatic event . Lastly, studies have shown that if you are feeling extreme guilt after experiencing a traumatic event, you are more likely to develop PTSD . You need to understand that you are not to blame for your abuser’s behaviour. He may try to convince you that it is your fault and that you have made him act the way he does but this is not true. The reason why your abuser is abusive towards you is because he wants to control you. The reason why he is blaming you is to keep you from leaving him and to give you false hope that if ‘you are good’, he will not hurt you again (emotionally or physically). This is also not true, as abusers will even set you up in order to ‘justify’ their abusive behaviour by putting you in situations where you are bound to ‘fail’ . No one deserves to be treated this way and healthy relationships are about love and respect for one another, not abuse and control.
Traumatic events do not affect just you. If you have children, especially if they are infants or preschool-age, they can also be affected. When both a parent and a child are experiencing the same stressful event, their emotional responses are strongly related, which shows that a parent’s emotional evaluation of a situation influences the child’s emotional reaction . In plain words, if the mother becomes frightened, the child becomes frightened as well. And unfortunately, studies have shown that when a parent is suffering from PTSD, their child is also likely to develop PTSD later in life .
Find hope in the fact that PTSD is treatable and that with the proper treatment you will not spend your life in fear.
 McNally, R.J. (2003). Remembering trauma. Cambridge, MA: Belknap Press of Harvard University Press.
 Breslau, N., Davis, G.C., & Andreski, P. (1995). Risk factors for PTSD-related traumatic events: A prospective analysis. American Journal of Psychiatry, 152, 529-535.
 Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Ann
ual Review of Psychology, 59, 301-328.
 King et al. (1995) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Astin, M.C., Ogland-Hand, S., Coleman, E.M., & Foy, D.W. (1993) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Cascardi, M., & O’Leary, K. (1992) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Hattendorf, J., Ottens, A.J., & Lomax, R.G. (1999) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Houskamp, B.M., & Foy, D.W. (1991) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Khan, F.I., Welch, T.L., & Zillmer, E.A. (1993) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 O’Keefe, M. (1998) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001).
Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Rollstin, A.O., & Kern, J.M. (1998) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Vitanza, S., Vogel, L.C.M., & Marshall, L.L. (1995) as cited in Jones, L., Hughes, M., & Unterstaller, U. (2001). Post-Traumatic Stress Disorder (PTSD) in victims of domestic violence. Trauma, Violence, & Abuse, 2(2), 99-119.
 Koenen, K.C., Stellman, J.M., Stellman, S.D., & Sommer, J.F.Jr (2003) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Sharkansky, E.J., et al. (2000). Coping with Gulf War combat stress: Mediating and moderating effects. Journal of Abnormal Psychology, 109, 188-197.
 Ehlers, A., Mayou, R.A., & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508-519.
 Koopman et al. (1994) as cited in Rachel Yehuda (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17. Washington, DC: American Psychiatric Press, Inc.
 Tichenor et al. (1996) as cited in Rachel Yehuda (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17. Washington, DC: American Psychiatric Press, Inc.
 Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.144). Asia: John Wiley & Sons, Inc.
 Riggs et al. (1992) as cited in Rachel Yehuda (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17. Washington, DC: American Psychiatric Press, Inc.
 Walker, L. E. (1979). The battered woman. New York: Harper & Row.
 Scheeringa, M.S., & Zeanah, C.H. (2001) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Koplewicz, H.S. et al. (1993) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Landolt, M.A., Boehler, U., Schwager, C., Schallberger, U., & Nuessli, R. (1998) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 Laor, N., Wolmer, L., Mayes, L.C., Gershon, A., Weizman, R., & Cohen, D.J. (1997) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
 McFarlane, A.C. (1987) as cited in Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
At a Glance: In this section you will find information on three different types of psychological interventions: Cognitive Behavioural Therapy, Counselling (Person-Centred Therapy), and Interpersonal Therapy.
Summary: Cognitive Behavioural Therapy (CBT) is a brief type of psychotherapy which tries to deal with present symptoms rather than focus on past experiences. Thus, treatment can last from 6 weeks to no longer than 6 months with hour-long sessions typically taking place once a week in the beginning, and then once every two or three weeks. Clients are required to engage in specific ‘exercises’ in their daily life, such as keeping a diary of their negative thoughts and feelings in order to help the therapist 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 challenges these biased and negative thought patterns and exchange them with realistic ones, as well as to help them learn coping mechanisms, problem-solving and social skills, along with strategies that encourage positive and realistic assumptions.
On the other hand, counselling does not involve doing ‘homework’ such as keeping a diary of one’s thoughts and feelings. Instead, the therapist lets the client take the lead. Several techniques are used to help the client investigate the relationship they have with themselves, their feelings, or people in their lives, such as the ‘empty chair technique’ which gives the person the opportunity to explore aspects of themselves or of their emotions, and to confront people in their life that they cannot actually confront for a number of reasons. For a victim of abuse this would mean that they would be able to virtually confront their abuser without feeling afraid, while ultimately regaining their sense of self-worth.
Finally, in interpersonal therapy the therapist’s job is to help the client identify and express the feelings they have regarding their relationships, and then help them solve any problems they may have in their relationships. Interpersonal Therapy’s main focus is on how problems in the client’s current relationships can negatively affect their psychological well-being. The therapist shows the client that improving their way of dealing with enduring patterns in their relationships will decrease their negative emotions. While interpersonal therapy does not involve doing ‘homework’, it is a brief type of treatment in which the therapist will try to improve the client’s communication and problem solving skills, and will encourage new and more positive behaviours to engage in.
Treatments in Focus:
Domestic abuse can have very negative consequences for a person’s mental health  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 . 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.
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 that 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 contradicts 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 .
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 . 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 . 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 something 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” .
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” .
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 . 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 .
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’.
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 . 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  and breathing retraining . 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 .
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 :
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 . 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 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 :
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.
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.
 Fikree, F.F., & Bhatti, L.I. (1999). Domestic violence and health of Pakistani women. International Journal of Gynecology & Obstetrics, 65(2), 195-201.
 Yehuda, R. (2002). Post-Traumatic Stress Disorder. The New England Journal of Medicine, 346(2), 108-114.
 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.
 Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.250). Asia: John Wiley & Sons, Inc.
 Gould, E., Otto, M.W., & Pollack, M.H. (1995). A meta-analysis of treatment outcome for panic disorder. Clinical Psychology Review, 15, 819-844.
 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.
 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.
 Clark, D.M. (1996). Panic disorder: From theory to therapy. In P.M. Salkovskis (Ed.), Frontiers of cognitive therapy (p.330). New York: Guilford.
 Clark, D.M. (1996). Panic disorder: From theory to therapy. In P.M. Salkovskis (Ed.), Frontiers of cognitive therapy (p.327). New York: Guilford.
 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.
 Foa & Jaycox (1999) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
 Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
 Jacobson (1938) as cited in Yehuda, R. (Ed.). (1998). Psychological Trauma, Review of psychiatry series volume 17, Washington, DC: American Psychiatric Press, Inc.
 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.
 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.
 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.
 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.
 Nichol, M. P., & Schwartz, R. C. (2008). Family Therapy: Concepts and Methods (8th ed.) (p.227). New York: Pearson Education.
 Kring, A.M., Johnson, S.L., Davison, G.C., & Neale, J.M. (2010). Abnormal Psychology (11th ed.) (p.43). Asia: John Wiley & Sons, Inc.
At a Glance: In this Section you will learn what Stockholm Syndrome is, what causes it, who is more at risk of developing it, how it can isolate the victim and how it creates feelings of self-blame.
Summary: Stockholm Syndrome is a phenomenon whereby victims feel sympathy and empathy for their abuser that can develop as a consequence of traumatic bonding, whereby reward and punishment create fierce emotional bonds. Stockholm Syndrome can occur in anyone, though it is more common in those who have grown up in abusive households. It can result as a survival strategy for victims of abuse since whenever we are in threatening and survival situations, we look for small signs that the situation may improve, thus interpreting any small kindness as a positive trait of the captor. Furthermore, sympathy toward the abuser may develop as the abuser shares information about their past. However, this sympathy produces no change in the abuser’s behaviour. Taking the abuser’s perspective as a survival technique can become so intense that the victim may develop anger toward those trying to help them. Victims can also turn on their family fearing that family contact will cause additional violence and abuse in the home. This isolates the victim and, in severe cases of Stockholm Syndrome, the victim may have difficulty leaving the abuser and can actually feel the abusive situation is their fault. Some women will allow their children to be removed by child protective agencies rather than give up the relationship with their abuser, which decreases their stress while providing an emotionally and physically safer environment for the children.
Stockholm Syndrome in Focus:
Stockholm Syndrome is a phenomenon whereby victims feel sympathy and empathy for their abuser.
If you have positive feelings towards an abuser, and continue to love them and miss them in spite of how they treat you, this may be a characteristic of Stockholm Syndrome. Do sentiments such as “I know what he’s done to me, but I still love him”, “I don’t know why, but I want him back”, or “I know it sounds crazy, but I miss him” resonate?
It can develop as a consequence of traumatic bonding, whereby reward and punishment create fierce emotional bonds that to others may appear ‘irrational’. Friends and relatives may be shocked when they hear sympathetic comments or witness their loved one returning to an abusive relationship. Stockholm Syndrome can be more common in those who have grown up in abusive households as they see the abuse patterns as ‘normal’ aspects of a relationship, but it can occur in anyone.
Emotionally bonding with an abuser is actually a strategy for survival for victims of abuse and intimidation. In threatening and survival situations, we look for evidence of hope — a small sign that the situation may improve. When an abuser/controller shows the victim some small kindness, even though it is to the abuser’s benefit as well, the victim interprets that small kindness as a positive trait of the abuser.
Victims can look positively on abusers and controllers for not abusing them, when in a certain situations they would expect it e.g. when an opposite-sex co-worker waves in a crowd. After seeing the wave, the victim expects to be verbally battered and when it doesn’t happen, that “small kindness” is interpreted as a positive sign.
Similar to the small kindness perception is the perception of a “soft side”. During the relationship, the abuser/controller may share information about their past — how they were mistreated or wronged. Sympathy may develop toward the abuser e.g. “I know he fractured my jaw and ribs…but he’s troubled. He had a rough childhood!” While it may be true that the abuser/controller had a difficult upbringing, showing sympathy for his/her history produces no change in their behaviour. While “sad stories” are always included in their apologies — after the abusive/controlling event — their behaviour never changes. Keep in mind: once you become hardened to the “sad stories”, they will simply try another approach.
Taking the abuser’s perspective as a survival technique can become so intense that the victim actually develops anger toward those trying to help them. Any contact the victim has with supportive people in the community can be met with accusations, threats, and/or violent outbursts from the abuser. Victims then turn on their family — fearing family contact will cause additional violence and abuse in the home. At this point, victims curse their parents and friends, tell them not to call and to stop interfering, and break off communication with others. On the surface it would appear that they have sided with the abuser/controller. In truth, they are trying to minimize contact with situations that might make them a target of additional verbal abuse or intimidation. If a casual phone call from Mum prompts a two-hour temper outburst with threats and accusations — the victim quickly realizes it’s safer if Mum stops calling.
In severe cases of Stockholm Syndrome in relationships, the victim may have difficulty leaving the abuser and may actually feel the abusive situation is their fault. In law enforcement situations, the victim may actually feel the arrest of their partner for physical abuse or battering is their fault. Some women will allow their children to be removed by child protective agencies rather than give up the relationship with their abuser. For those with Stockholm Syndrome, allowing the children to be removed from the home decreases their victim stress while providing an emotionally and physically safer environment for the children.
The best treatment for Stockholm Syndrome is intense therapy as well as the love and support from the victim’s family. It may take many years for the former “prisoner”/victim to recover from Stockholm Syndrome – these shackles are not easily undone.
MENTAL HEALTH DISORDERS: SYMPTOMS
Sad mood and a loss of interest and pleasure for at least two weeks, and at least four of the following symptoms:
Suffering from the following symptoms for more than one month after experiencing a traumatic event:
At least three of the following:
PANIC ATTACK EPISODE
Experiencing a period of:
Accompanied by at least four of the following:
USING THIS TOOLKIT
The easy-to-follow, educational nature of the Mental Health Toolkit means that it could potentially have dozens of applications by users. Some of the many ways the Toolkit can be used are:
AN ONLINE RESOURCE FOR YOUR WEBSITE
This is one of the main ways that Chayn uses the Mental Health Toolkit. As the purpose of Chayn's regional websites is to help women empower themselves, posting information about mental conditions and illnesses on the websites helps women understand what they are feeling and experiencing in a way that empowers them to take the necessary steps for their own mental health. Women who have come to Chayn Pakistan (chaynpakistan.org) or Chayn India (chaynindia.com) seeking help will read the sections on mental health and will realise that what they are experiencing is normal and is directly or indirectly linked to the abuse they have suffered, as well as learning the steps they can take to get they help they need.
Add: Not everyone who is in need of support will be in a position to ask for it offline, be it due to their own circumstances or
A TRAINING RESOURCE FOR STAFF, VOLUNTEERS & COUNSELLORS
Many organisations simply do not have the resources or funds to train their staff in being able to recognise and provide adequate, meaningful support to victims of abuse and violence that they may encounter. With Chayn's Mental Health Toolkit, support workers will have at least a basic understanding of symptoms, causes, and treatments for the psychological conditions that are experienced by victims of abuse and violence.
A great way to raise awareness of mental health issues is to print off pamphlets and posters with information about common conditions like anxiety and depression. It's an easy way to educate and inform people about the importance of mental health.