Understanding behavior change for women experiencing intimate partner violence: Mapping the ups and downs using the stages of change

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Abstract

Objective

For women who are experiencing intimate partner violence (IPV), making changes toward safety is often a gradual process. When providing counseling and support, health care providers may benefit from better understanding of where women are in their readiness to change. Our objective was to apply the transtheoretical model's stages of change to the experiences of women who experienced IPV and map their experiences of change as they moved toward increased safety.

Methods

A multi-disciplinary team designed a qualitative interview process with 20 women who had current or past histories of IPV in order to explore their experiences.

Results

The women in our study (1) moved through stages of readiness generally in a nonlinear fashion, with varying rates of progression between safe and nonsafe situations, (2) were able to identify a “turning-point” in their situations, (3) attempted multiple “action” steps and (4) were influenced by internal and external factors.

Conclusions

Our study suggests that focusing on the transtheoretical model to develop stage-based interventions for IPV may not be the most appropriate given the nonsequential movement between stages and influence of external factors.

Practice implications

The “change mapping” technique can be used as an educational and counseling tool with patients, as well as a training tool for health care providers.

Introduction

Intimate partner violence (IPV) is a health care problem associated with significant morbidity and mortality affecting approximately 1.5 million women annually in the United States [1], [2]. While many advocacy groups and health organizations have issued policy statements and recommendations that health care providers assume a role in identifying and counseling women experiencing IPV, most of these guidelines have focused on screening with very little guidance on how a health provider should counsel patients once they have been identified [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13].

To ensure safe and appropriate counseling, it is essential to incorporate a good understanding regarding the issue of IPV, particularly the changes that women experiencing IPV undergo in their efforts to manage/escape the violence and improve their safety. There is a growing body of research indicating that how women make changes to improve or seek safety is likely a gradual process involving multiple steps and/or strategies [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]. Among various published reports that describe behavior change factors that have then led to the development of counseling strategies and tools [16], [17], [19], [24], [25] the transtheoretical model (TTM) [26], [27], [28], [29] has received the most attention [21], [22], [23], [30], [31], [32], [33], [34], [35], [36], [37]. Prochaska and DiClemente's transtheoretical model involves a method of understanding stages of behavioral change including the motivational and developmental aspects of change. Within each stage of the TTM are affective, behavioral and cognitive elements that influence progression through the stages. TTM posits that most people move through predictable stages in their efforts to change behavior: from “precontemplation” – a stage in which the individual either does not recognize a need to change or feels unable to change; to “contemplation” – a stage in which the individual recognizes that change may be needed; to “preparation” – when a decision to change has been made and plans formulated to make a change; to “action” – when the desired behavior change is made; and then to “maintenance” – when efforts are made to reinforce and sustain the desired behavior [26], [27], [28], [29]. Movement is not necessarily linear. In moving through these stages, individuals may experience a “relapse” during which they move backward to an earlier stage and thus may “recycle” through the stages of change multiple times before achieving sustained change [38], [39].

Brown was among the first to adapt the TTM to women experiencing IPV and expanded the definition of precontemplation beyond denial of the problem to include a woman's belief that the violence is her fault [21]. Anderson used a Delphi technique to test the TTM with a small sample of women with a history of IPV and found that the women broadly described stages consistent with the TTM [31]. Zink et al. performed qualitative analysis on interviews with women experiencing IPV and likewise found they could apply the TTM to the women's descriptions of their cognitive, affective and behavioral changes in the experience of dealing with the IPV [34]. In each of these studies, however, there was no specific examination of the order in which the women progressed through the stages of change over time. Additional information regarding the chronological sequence of these stages would provide greater insight to understanding how and how well the TTM applies to the experience of change for women dealing with IPV.

Our study objective was to understand the experiences of women with a current or past history of IPV regarding the various safety-seeking behaviors they considered, attempted and used in their attempts to improve their safety and/or end the abuse by applying the TTM to their narratives of these experiences and then mapping their course of change chronologically. Our overall objective for this project was to use this “change mapping” procedure as one step in developing a health care intervention for women experiencing IPV.

Section snippets

Study design

This paper is a part of a larger study designed to learn what types of interventions within health care settings were desired by and helpful to women experiencing IPV [14], [40]. Using a qualitative approach, we conducted semi-structured individual interviews with women who had either a current or past history of IPV to explore their IPV experiences and various safety-seeking behaviors. Qualitative research methods are helpful when seeking in-depth understanding of particular individuals’

Participants

Although 21 women participated in the larger study, the beginning portion of one interview was not recorded due to a technical malfunction with the audiorecorder. The analysis for this paper then focuses on the remaining 20 participants. In addition to physical violence, all 20 had also experienced emotional abuse and 11 had suffered sexual violence from an intimate partner in their lifetime. Nine women described current (within the past 12 months) physical and/or sexual abuse. Seven of the 20

Discussion

After applying the TTM to the women's narratives, we found the process of visually representing these stages across time to be a valuable method of gaining additional information regarding these women's experiences of cognitive, attitude and behavior change in dealing with IPV. This “change mapping” provided illustration of the variety of paths women take as they move towards increased safety and highlighted the idea that movement toward increased safety is a process characterized for most

Acknowledgements

This study was supported by a grant from the Scaife Family Foundation to Magee-Womens Hospital of the University of Pittsburgh Medical Center in Pittsburgh, PA, USA. The authors wish to recognize LeeAnn Ranieri, Benita Valappil, Elizabeth Larsen, Betsy Bledsoe, Pamela Dodge and Carolyn Hughes for their support of and contributions to this project. We also thank the survivors who told us their stories and the domestic violence advocates from the Women's Center and Shelter of Greater Pittsburgh

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