Treating Survivors of Intimate Partner Abuse: Forensic Identification and Documentation

Daniel J. Sheridan

Intimate partner abuse has profound physical and psychological health effects on millions of Americans and is now a crime in every state. The objectives of this chapter are to (a) give an overview of the dynamics of domestic abuse, (b) provide a brief legal overview, (c) describe clinical forensic assessments and documentation, (d) identify common domestic violence injuries, and (e) review the principles of forensic photography.

Estimates vary, but each year in the United States at least 4 million women experience ongoing physical, psychological, sexual, and financial abuse from a male intimate partner (1). The number of men abused by female intimates is estimated in the tens of thousands (1), and there is growing recognition of abuse occurring in gay and lesbian intimate relationships (2,3,4).

Although there is overlap in assessment and intervention techniques between these varying types of intimate partner abuse, this chapter will focus primarily on women victimized by male intimates.

Abuse of Women

The battered-women’s movement originally conceptualized domestic violence as a social, public policy, and criminal justice concern (5,6,7,8,9)—a view still strongly supported by many (10,11). However, early in the battered-women’s movement, a few visionaries recognized abuse of women as a major health issue (12,13,14,15,16).

During the past 20 years, as the number of clinical and research articles on the health consequences of abused women has swelled, domestic violence has come to be viewed as a major public health concern. Nevertheless, only a handful of health professionals have examined the health link between abuse, domestic homicide, and the role of clinical forensics, despite growing documentation of the seriousness of physical, psychological, and sexual domestic violence (17,18,19,20,21,22,23,24,25,26,27).

Sequelae from physical abuse of women by male intimates are relatively easy to assess. There are physical findings: bruises, lacerations, sharp injuries, fractures, old and new scars, patterned injuries, pain, and bleeding. Physical injuries from domestic violence can be lavaged, debrided, sutured, x-rayed, scanned, and photographed. However, physical abuse is almost never the first form of abuse experienced by battered women. The first form of domestic violence is a combination of verbal and emotional abuse. These include name-calling, public embarrassment, veiled and explicit threats of harm, harassment, lies, “mind games,” and other psychological manipulations. Sexual assault of women by current or former male intimates is a common yet under-recognized problem (28,29,30). Assessing and intervening in situations of domestic financial abuse is seldom viewed as being in the purview of medical treatment; however, this form of abuse is a common power and control tactic and a major barrier to women leaving abusive relationships (31,32).

For many women, the forms of abuse change and escalate when they attempt to leave the abusive relationship. For thousands of battered women, leaving the abusive relationship is marked by increased harassment and danger. Tragically, for more than 2,000 women every year, leaving an abusive relationship results in their death and sometimes in the deaths of their children at the hands of their abusive male partners (20,21,22,23,24,25,26,27,28,29,30,31,32,33,34). Data from three domestic homicide studies (33) demonstrated that estrangement from the abusive relationship disproportionately explained the risk of homicide in women, especially between 2 months and a year following separation. These data support the assertion that the first year out of an abusive relationship is the most deadly for battered women. Wilson and Daly (33) concluded that physically leaving an intimate relationship was a risk factor for homicide and that beginning the process of leaving was “an important risk factor in uxoricide” (33). They also stated that countless more women are subjected to near-lethal and increased violence, jealousy, coercion, threats, and other control tactics during the process of leaving relationships.

“If I Can’t Have You, No One Can”

Wilson and Daly (33) prefaced their paper with a quotation from a man who killed his wife after being separated for a month, saying that if he could not have her, no one could. That same threat has been echoed in hundreds of the domestic violence histories given to this author in clinical practice. Campbell (20) titled her discussion of power and control in homicides of female partners “If I Can’t Have You, No One Can.” Homicide data from police files in Dayton, Ohio, from the 1980s, demonstrate that more than 64% of the 28 women killed by an intimate or formerly intimate male partner had a history of being physically abused. In the same percentage of cases, the police reports indicated that male jealousy was a primary motive (19). This finding supports arguments that male jealousy connotes male control and ownership (20).

Campbell (20) also reviewed domestic homicides against women who had either left the relationship or had expressed an intention to leave. Thirteen (46%) of Campbell’s sample of murdered women had actually left the relationship (n = 11) or had threatened to leave (n = 2). All four of the male victims of homicide in Campbell’s study used violence against their estranged wives just before the wives’ use of homicide. The police records reported that the murdered men had expressed jealousy toward the women having a new male intimate and were trying to get back together at the time of the deaths. Campbell cited one case in which a man “constantly harassed his ex-wife and returned many times to the house to violently accost her for months after the divorce” (20). On one such occasion, the ex-husband was let into the home by one of his children. The woman locked herself in her bedroom, and then shot and killed her ex-husband when he kicked down the bedroom door and came toward her. Despite what appeared to be a case of self-defense, the woman was convicted of voluntary manslaughter and sentenced to 20 years in prison (20).

The Process of Leaving an Abusive Relationship: Reasons for Staying Versus Barriers to Leaving

It is common for health care providers who treat severely abused women to wonder why a woman would stay in an abusive relationship. Why would she return time and time again? Why does she stay? When one questions why a woman stays in an abusive relationship, in essence, the health care provider is holding the battered woman accountable for her abuser’s behavioral choices. Unfortunately, health care providers rarely say to the abusive male, “Why do you abuse?” Instead of questioning why she stays, it is better to reframe the question as, “What are her barriers to leaving?”

Psychological Barriers to Leaving

Several psychological explanations for why women stay in abusive relationships have been developed. They include brainwashing (35), mind control and active recapture techniques (36), the Stockholm syndrome (37,38), and traumatic bonding (39,40).

Sonkin (35) and many others (41,42,43,44) have compared psychological abuse in domestic violence with brainwashing of war and political prisoners, for example, Biderman’s chart of coercion, which depicts eight brainwashing techniques used on prisoners of war and political prisoners—isolation, monopolization of perception, induced debility and exhaustion, threats, occasional indulgences, degradation, demonstrating omnipotence, and enforcing trivial demands (45).

On the basis of decades of clinical counseling experience, Boulette and Andersen (36) believe that cult members and battered women experience similar forms of brainwashing and mind control and share many common characteristics. Using parallels from cultic mind control and brainwashing techniques, they hypothesized that women often become trapped in abusive relationships. They describe cultic systems as exerting totalistic and demanding degrees of extreme control over an
individual’s freedom through various degrees of psychologically coercive and deceptive behaviors, including social isolation, confusion and guilt, threats of harm, love with strings attached, lying, and distortions of reality.

Battering that includes mind control, according to Boulette and Andersen (36), includes early verbal and/or physical dominance that can begin during or shortly after the courtship phase. Gradually, the batterer emotionally and geographically isolates and sometimes literally imprisons the woman, cutting her off from family and friends. During this process, the batterer weakens the woman’s access to a support network, minimizes her escape options, and fosters the development of his partner into a more docile and behaviorally malleable person. To enforce this process, the abuser uses fear arousal and maintenance techniques that include actual and verbal threats of physical harm, direct threats with weapons, humiliation, public embarrassment, and intimidation by fear (36).

So often are the women blamed for causing the violent and coercive behaviors by their male abusers that the women begin to self-blame. This induction of guilt by the battering male toward the woman is occasionally softened by his contingent expressions of love. If she does not adequately acknowledge his love for her, he continues to degrade, devalue, and malign her until she capitulates (36). The abusive male is often jealous, accusing the woman of infidelity even while blatantly flaunting his own promiscuity. The problems within these violent relationships and dysfunctional families are expected to be kept secret at all costs. Breaking the family secret has been accompanied by the male abusers’ threats of increased or lethal harm (36). To compensate for the cognitive dissonance resulting from experiencing the above behaviors, many battered women develop an enforced loyalty to the abusive male partners, exaggerating the socially acceptable behaviors and verbalizing a need to change and rescue the men from their violent actions (38). Women have described this behavioral pattern as cyclic, noting that it leads to feelings of powerlessness and helplessness (9,36), alternating with a sense of hopefulness when the abuser exhibits some positive behaviors. The abusers temporarily modify their behavior so that the women believe there is hope that the violence, threats, manipulations, and isolation will eventually end (36).

The brainwashing of battered women, whether conceptualized as being similar to that of a prisoner of war or a cult member, often occurs insidiously and over an extended period. This gradual process provides a partial explanation for the difficulty some battered women have in objectively assessing the severe levels of abuse and danger and in questioning their capacity to leave their abusers. However, these techniques are less explanatory for battered women who begin experiencing severe physical, sexual, and psychological abuse early in the intimate relationship before brainwashing occurs. A frequently asked question is, “Why don’t these women just leave?” Two highly related models have been used to explain this phenomenon: the Stockholm syndrome (38) and traumatic bonding (39,40).

The Stockholm Syndrome: Bonding with Your Captor

The Stockholm syndrome represents an attempt to explain the seemingly paradoxical response of some hostages to their captors. First attributed to a hostage situation in a bank in Stockholm, and subsequently identified in multiple hostage and kidnapping situations, hostages sometimes develop a significant fondness and attraction to their captors. The Stockholm syndrome (38) is characterized by four conditions:

The captor threatens and has the capacity to kill the captive.
The captive cannot safely escape; therefore, he or she is totally dependent on the captor.
The captive is isolated from others outside the hostage situation and is dependent on the captor.
The captor is perceived as showing some degree of kindness or benevolence toward the captive.

When the Stockholm syndrome is applied to battered women, the captive (battered woman) accurately identifies that the aggressor (the abuser) has the power of life and death and actively identifies with the aggressor through pathologic transference and traumatic psychological infantilism (38). Women in ongoing abusive relationships with male intimates experience varying levels of physical abuse interspersed with transient periods of kindness and benevolence from their abusers. Battered women are sometimes literally held hostage by their abuser at knifepoint or gunpoint. Many home hostage situations that result in police intervention and media coverage involve domestic violence. When battered women say, as they often do, that they feel as if they are prisoners in their own homes, they may be struggling with the dynamics of brainwashing, mind control, and the transference effects of the Stockholm syndrome.

Traumatic Bonding: Intermittent Good–Bad Behavior

Women in abusive relationships frequently minimize the seriousness of the abuse and tend to justify and defend the severe abusive behaviors of their abuser. This seemingly illogical connectedness with the aggressor, especially after severe trauma, has been
explained by a model of traumatic bonding (39,40), which was developed to explain powerful emotional attachments in abusive relationships created by intermittent abuse and power imbalances. Traumatic bonding can quickly solidify as the subjugated person develops a continual lowering of self-esteem and decreased ability to live independently. At the same time, the abusive person develops an inflated sense of power. The stronger person becomes increasingly dependent on the weaker to maintain the feeling of power, a feeling the abuser does not want to relinquish.

The unpredictability of this intermittent abuse, coupled with periods of reconciliation, feigned (or partially sincere) contrition, and isolation from the reality checks of family and friends, is a catalyst that accelerates traumatic bonding and the battered women’s fantasies of loving partners (40). Traumatic bonding can occur early in a relationship (39,40); in fact, it appears to occur for some women during the dating relationship (46). Intermittent abuse, in which women separate the “good-man image” from the “bad-man image,” was identified (46) in a sample of 90 college students, 43% of whom reported a history that experts interpreted to be psychologically abusive.

Active Recapture Measures

From their extensive clinical practices, Boulette and Andersen (36) recognized that many battered women struggle to shed the traumatic bonds that make them feel like prisoners in their own homes. This can be a difficult and, at times, immobilizing process that requires overcoming multiple barriers to leaving, including active recapture techniques such as cocky disbelief, confused searching, bargaining, pleading, threatening, and revenge (36).

Initially, an abusive man is shocked that his wife or girlfriend would dare to leave him. He is convinced that she cannot exist without him, and sometimes he has so thoroughly convinced her that she cannot make it without him that she does return to him, begging his forgiveness (36).

If she does not reenter the relationship, he begins a period of anxious and/or panicked searching (36). When he discovers where she is staying, he sends bargaining messages that include promises of changed behavior, highlighting future love, fidelity, and kindness (36). Most women, from this researcher’s clinical experience, do not want the relationship to end. They want to return to an ideal relationship full of love, fidelity, and kindness. Promises of change can be an effective recapture technique (9,36).

Over time and after multiple broken promises of change by the abuser, the battered woman stops being swayed by his bargaining tactics. The abuser then often activates the recapture technique of pleading, during which time he pleads and begs for another chance, frequently shedding tears and exhibiting physiologic signs of remorse (36). The woman may interpret tears and sobbing as signs of love. She feels sorrow and pity for the man and guilt for precipitating his tears. Men who are successful with the recapture technique of pleading often have brief periods of improved behavior (36), which Walker (9) described as the honeymoon phase. However, when pleading fails to recapture the abused woman, the abusive man can quickly escalate to the recapture techniques of threats and revenge (36). Threats of physical, sexual, and financial harm to her, the children, and family escalate. He may threaten to kidnap the children or have her institutionalized. Interspersed in the threats are instances of physical abuse and destruction of property and/or pets (36). If she persists in her efforts to stay out of the abusive relationship, the batterer plans revenge tactics that could culminate in the woman being severely injured or killed. Johnson (47) described severe threats and serious abuse as patriarchal terroristic control intended to control women and keep them from leaving the abusive relationship. These recapture and patriarchal terroristic methods help perpetuate the woman’s sense of being a prisoner in her home and help facilitate the processes of mind control, brainwashing, and traumatic bonding (36,38,40,47).

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