• Research article
  • Open access
  • Published: 06 August 2019

A qualitative exploration of ‘thrivership’ among women who have experienced domestic violence and abuse: Development of a new model

  • Isobel Heywood 1 ,
  • Dana Sammut 1 &
  • Caroline Bradbury-Jones   ORCID: orcid.org/0000-0002-5237-6777 1  

BMC Women's Health volume  19 , Article number:  106 ( 2019 ) Cite this article

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Domestic violence and abuse (DVA) is a serious public health issue, threatening the health of individuals the world over. Whilst DVA can be experienced by both men and women, the majority is still experienced by women; around 30% of women worldwide who have been in a relationship report that they have experienced violence at the hands of their partner, and every week in England and Wales two women are killed by their current or ex-partner.

The purpose of this study was to explore the concept of thrivership with women who have experienced DVA, to contribute to our understandings of what constitutes ‘thriving’ post-abuse, and how women affected can move from surviving to thriving.

Thirty-seven women took part in this qualitative study which consisted of six focus groups and four in-depth interviews undertaken in one region of the UK in 2018. Data were analysed using a thematic analysis approach. Initial findings were reported back to a group of participants to invite respondent validation and ensure co-production of data.

The process of ‘thrivership’ – moving from surviving to thriving after DVA - is a fluid, non-linear journey of self-discovery featuring three ‘stages’ of victim, survivor, and thriver. Thriving after DVA is characterised by a positive outlook and looking to the future, improved health and well-being, a reclamation of the self, and a new social network. Crucial to ensuring ‘thrivership’ are three key components that we propose as the ‘Thrivership Model’, all of which are underpinned by education and awareness building at different levels: (1) Provision of Safety, (2) Sharing the Story, (3) Social Response.

Conclusions

The study findings provide a new view of thriving post-abuse by women who have lived through it. The proposed Thrivership Model has been developed to illustrate what is required from DVA-services and public health practitioners for the thrivership process to take place, so that more women may be supported towards ‘thriving’ after abuse.

Peer Review reports

In 1993 the UN Declaration on the Elimination of Violence against Women recognised the gendered nature of violence stating that

“violence against women is one of the crucial social mechanisms by which women are forced into a subordinate position compared with men” [ 1 ].

In all countries, most gender-based violence (GBV) is carried out against women by their – predominantly male – intimate partners, in a domestic setting [ 2 ]. Almost a third of women worldwide report that they have experienced a form of physical and/or sexual violence by their partner, and approximately 38% of murders of women globally are committed by their male partner [ 3 ]. Men, boys and those who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) can also be victims [ 4 ] of GBV, though it is widely recognised that the majority is experienced by women and girls [ 5 ]. Moreover, women and girls as victims of GBV suffer specific, long-term consequences of gender discrimination [ 4 ]. Thus, GBV can be viewed as a structural mechanism used to sustain male dominance [ 4 ]; equality between women and men cannot exist when women continue to experience gendered violence [ 6 ].

In the UK, the term domestic violence and abuse (DVA) is used more commonly than ‘gendered violence’ or ‘intimate partner violence’, and refers to “any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality” [ 7 ]. Abuse can be psychological, physical (such as slapping, or kicking [ 8 ]), sexual (such as forced intercourse [ 8 ]), financial, or emotional, and can involve controlling behaviour - designed to make a person subordinate and/or dependent by isolating them from sources of support – and coercive behaviour, which is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten the victim [ 7 ]. In the UK women continue to experience more DVA than men; from March 2017 to March 2018 7.9% of women (1.3 million) and 4.2% of men (695,000) experienced DVA in some form, and since the age of 16 28.9% of women had experienced DVA compared to 13.2% of men [ 9 ]. The latest Femicide Census reports that 139 women were killed by men in England and Wales during 2017, with 40% of cases featuring ‘overkilling’; where the force and/or methods used to kill a victim was greater than that required to kill them [ 10 ]. Three quarters (76%, 105) of women were killed by a man they knew, and almost half (46%) were killed by a current or former intimate partner [ 10 ]. Statistics such as these give us some idea of the prevalence of violence against women, though underreporting continues to be an issue [ 11 ].

Gendered violence causes substantial harm to women’s physical, mental, sexual, and reproductive health [ 12 ]. The physical injuries, fear and stress associated with DVA can result in chronic health conditions including gastrointestinal issues, cardiac symptoms and gynaecological problems [ 13 ]. DVA is also a major cause of poor mental health [ 13 ] including depression and anxiety [ 3 ]; it is estimated that 13% of suicides and suicide attempts by women in the UK may be attributed to domestic violence [ 14 ]. Evidence also suggests that victims often struggle with drug and alcohol misuse, as a mechanism for coping with their experiences [ 13 ]. DVA has been identified as an adverse childhood experience (ACE) that has a direct graded relationship with health problems in later life including alcoholism, depression and suicide, ischaemic heart disease, and cancer [ 15 ]. It is clear then, that DVA is a serious public health issue that crosses geographical and demographic boundaries [ 16 ].

During the late 1980s Gondolf and Fisher developed their ground-breaking “survivor theory” [ 17 ], arguing that “battered women” are not “passive victims” but are in fact “help-seekers” who show significant strength in their situation through adopting survivor-tactics, and making attempts to gain help from support services that are unsuccessful due to institutional failure [ 18 ]. Instead of women being viewed as victims with “learned helplessness” [ 17 ], ‘survivor’ became the dominant terminology in the field. However, Wuest and Merritt-Gray [ 19 ] argue that assuming the identity of a survivor may not represent the optimal outcome for healing as the term centralises abuse in the lives of women, despite that no longer being the case; whilst for some ‘survivor’ may feel like a badge of honour, for others it may serve as a constant reminder of past negative experiences. It also fails to explore the more long-term recovery from abuse focusing instead on more immediate freedom [ 20 ]. ‘Thrivership’ offers a resolve to these issues; if someone is ‘thriving’ they are “prosperous, growing, or flourishing” [ 21 ]. Thus, thriving exceeds the absence of problems to signify vigorous, even superlative health and well-being [ 22 ].

Much academic focus on DVA has emphasised the role of ‘inner resources’ of individuals in dealing with stressful situations; resilient people, for example, tend to present a high tolerance of distress, or trauma [ 23 ]. Resilience has been found to be a positive personality characteristic that enhances adaptation; individuals can present psychological distress juxtaposed with resilience, indicating that resiliency enables women to survive abuse, though nothing beyond that [ 24 ]. Whilst these findings contribute to our knowledge of how women may survive trauma, it does not explore what happens afterwards.

Tedeschi and Calhoun [ 25 ] advocate the term ‘post-traumatic growth’ to describe the elevated level of functioning that can be experienced following trauma. ‘Thriving’ they argue, does not connote the existence of threat or the shattering of fundamental schemas [ 26 ] whereas ‘post-traumatic growth’ indicates that the individual has not only survived but has experienced important changes beyond the previous status quo [ 25 ].

We argue though, that ‘thriving’ and ‘post-traumatic growth’ advocate a similar process; when people are thriving, they are not merely surviving or getting by [ 27 ], but rather they are growing on an “upward trajectory” [ 28 ], and this growth can be in response to trauma experienced.

Thus, studying the ‘thrivership’ process – how someone moves from ‘surviving’ to ‘thriving’ after trauma - allows us to go further with our exploration of how women recover long-term from DVA, so that we may enable others to achieve the same sense of thriving. Thriving may even invite a more complete paradigmatic shift in the investigation of health [ 22 ] through furthering our knowledge of adaptive responses to challenges [ 29 ] with “an eye toward enhancing health and well-being” [ 29 ].

Studies by Paula Poorman [ 22 ], Janette Taylor [ 30 ], and Wozniak and Allen [ 20 , 31 , 32 ], provide some insight into ‘thriving’ post-DVA, predominantly as a ‘transformative’ process rather than an outcome. ‘Thriving’ or “survivorship-thriving” [ 30 ] is a transformative process that represents more than just a return to ‘normal’ [ 30 ]; ‘thriving’ denotes active, positive psychological health [ 22 ], led by a type of “life energy” [ 22 ] that indicates growth and enhanced functionality. The defining and contributing properties of thriving included individual perceptions, motives, and resources; the nature of the relationship a woman has with adversity; and properties of the environment vis-a-vis interpersonal relationships [ 22 ]. There is commonly an element of spirituality to findings or approaches: at the ‘thriver stage’ women feel healed, are no longer defined by the abuse, and take care of their physical, emotional and spiritual self [ 20 , 31 , 32 ].

Beyond this however, available literature offers little about how women can be supported through this process by services or practitioners, and what ‘thriving’ means to women beyond a spiritual or theory-based experience. For example, what are the practical implications of ‘thrivership’? What do women need to thrive? How can public health and DVA professionals provide support and services through which thrivership can be attained? The theory of ‘thrivership’, then, is an emerging field; more research is needed to develop an in-depth understanding of what constitutes thriving post-DVA, and what is needed for the thrivership process to take place, according to those who experience it; hence the importance of our study.

This was a qualitative study undertaken in a sub-urban setting of one large urban conurbation in central England. Qualitative focus groups were used in order to obtain an insight into the world as experienced by participants [ 33 ]; qualitative methodology - crucially for studies around DVA - ‘gives voice’ to people and enables a rich understanding of a phenomenon that cannot be achieved through numbers [ 34 ]. Qualitative focus groups were used to ensure in-depth, co-production of knowledge around ‘thriving’ after DVA according to participants. Interviews were offered as an alternative only for those women who were unable to make focus groups, for their convenience.

Recruitment

Recruitment began in December 2017 and was completed in March 2018. All participants were recruited through a charitable DVA-service that delivers 10–12-week awareness and empowerment programmes for women affected by domestic abuse in the region. Co-author IH conducted recruitment via several visits to the service over the period of 3 months during which potential participants (service users) were approached and information about the study given. In order to be eligible to be involved in the study, participants had to be currently attending at least one programme at the DVA-service. Letters of invitation were distributed in person to women who expressed an interest in being involved, and some Participant Information Sheets were left with the service so that more potential participants could read them when attending service sessions and contact the research team separately. Following initial recruitment, participant contact details were collated so that they could be contacted regarding convenient focus groups dates by the service facilitators. All those who expressed interest were involved in the study except for two women who initially requested phone interviews but did not respond to phone calls or messages. It is not clear why these women did not respond to our attempts to contact them, but for their safety this was not explored in further detail.

Participant details

A total of 37 participants were involved in the study. All participants were women who had experienced DVA in some form, were attending at least one of the four programmes offered by the DVA-service, and were all (except for one) no longer living with or intimately involved with the perpetrator; service users are only able to move beyond the principal programme delivered at the DVA-service once they have separated from the perpetrator, for safety and recovery reasons. The one participant who was still living with the perpetrator was attending the principal programme and was working with the facilitators at the organisation to plan a safe exit for her from the relationship. Her data was included in the study as we felt it would add a richness to the data to include women at various stages in their recovery and thrivership journey. When asked, women identified as either ‘survivor’ or ‘thriver’, though data on how many identified as each has not been included due to the fluidity of the thrivership process (see findings) which meant that sometimes participants experienced ‘victim days’. Whilst personal data were not gathered specifically for the study as it was not deemed necessary, it was ascertained during focus groups that women were from a range of socio-economic, professional and ethnic backgrounds, and ages ranged from late-teens to sixties. Participants were attending the service due to experiencing DVA at the hands of a male intimate partner; different forms of violence had been experienced by participants, all of which were referred to during discussions, including psychological, emotional, physical, sexual and financial. Whilst focus groups were collated randomly, all women knew someone in their group due to attending programmes together. Whilst levels of engagement in conversation varied - some individuals dominated conversation and others were quieter - all seemed keen to have their voices heard.

Ethical considerations

Ethical permission was granted from the University of Birmingham (Grant reference ERN_17–1418). Informed written consent was obtained from all participants. Consent forms were collected for each participant and signed by IH, then stored in a locked cupboard in the university. To protect the identity of the participants, all personal data was anonymised upon transcription of the audio data by replacing women’s names with numbers, and ensuring personal data was omitted. Once data analysis had taken place, all transcripts and recordings were deleted permanently. All participants were provided with the NSPCC and Women’s Aid helpline numbers and encouraged to seek support if needed. They were also made aware that extra support could be sought by the DVA-service they attended, as the service staff were trusted individuals known to them.

Data collection

The intention was to conduct six focus groups each with six participants. However, the first focus group consisted of ten women, which is larger than most focus group sizes. The women had all chosen to stay on to participate after a service programme session and were keen to be involved. Three other groups consisted of six women, and one had five. Four one-to-one interviews were also conducted. The average duration of a focus group was 2 h (with a halfway break) and interviews on average lasted thirty-five minutes.

All focus groups and interviews (apart from one phone interview) took place at the site of the DVA-service, whose programme sessions take place in a group setting. Participant familiarity with the set-up aimed to provide a space where they felt safe and able to share their experience and listen to other women’s views.

Focus groups and interviews were all conducted by co-author IH, who used an interview schedule designed for the study as a guide (see Supplementary Information). Each discussion began with an ice-breaker activity based on Wozniak and Allen’s [ 32 ] work. Participants were asked to share feelings or words associated with the terms ‘victim’, ‘survivor’ and ‘thriver’: this encouraged all participants to get involved from the start in the focus groups, provided a good initial overview of the end-to-end recovery process, and enabled a discussion about recovery stages and their labels. During these activities the participants wrote their responses on post-it notes and added them to a large poster, or IH wrote their responses directly onto a poster. These were analysed alongside transcripts of focus group discussions and interview responses.

The same questions were asked in both focus groups and interviews. A scoping review [ 35 ] of previous literature in this area was undertaken to form a framework for discussion topics and the questions in the right-hand column were used flexibly as the basis for the interviews (see Table  1 ). This also enabled the comparison of participant views with those from previous studies (see discussion), whilst the use of focus groups still allowed for the introduction and exploration of new concepts. Qualitative research papers were selected for the scope if they featured an exploration of the concept of ‘thriving’ post-DVA or used the term in relation to DVA recovery. The focus groups and interviews were audio-recorded using a device owned by the University of Birmingham. Recordings were transcribed on to a laptop protected with a password and anti-virus software.

Data analysis

Transcription of the audio data was undertaken by IH; a verbatim account of all verbal and non-verbal utterances [ 36 ] was produced in order to keep data true to its original nature. This process also enabled IH to familiarise herself with the data prior to analysis and coding. Data from the ice-breaker activity at the beginning of each focus group was also transcribed into word documents and included in the data analysis. Braun and Clarke’s thematic analysis [ 36 ] was used to analyse the focus group discussions and responses to interview questions. In the analysis a systematic process was undertaken to find patterned responses or themes within the narrative data set. Initial analysis was conducted by IH, and then DS and CBJ independently validated the emerging themes by examining the data and contributing their own analytic lens. Initial framing of the discussion topics following the scoping review [ 35 ] of previous literature in this area, created a good origin for “identifying, analysing, and reporting patterns (themes) within data” [ 36 ]; with further themes and ‘sub-themes’ emerging throughout analysis. Three rounds of coding were undertaken to ensure rigorous analysis. All team members have expertise in public health, nursing and/or qualitative research methods.

Six-steps to thematic analysis provided the guide for data analysis [ 36 ], with the following specific processes (1) All transcripts were read repeatedly by the research team members to ensure all were familiar with and had obtained a sense of the breadth and depth of the data (2) Initial code generation was performed by IH. Data were organised into meaningful groups that related to the research question and labelled (3) Initial codes were organised into a table using Microsoft Excel. The team met to discuss, verify and sort initial codes into themes based on code similarities. Visual representations were used to explore relationships between codes within themes (4) The themes were reviewed and revised by the team and organized into a coherent pattern, with sub-themes identified and themes that did not have enough data to support them removed. The team then re-examined the data set as a whole to ensure saturation of the data was reached (5). The themes were named and then defined and refined. The scoping review [ 35 ] of previous literature in this area was used as a comparator for themes identified during data analysis to assess for similarities (6). A final report was prepared giving a detailed account of each theme. This was primarily produced by IH, with checks and contributions by DS and CBJ.

To validate the findings of this study and continue the ethos of data co-production, a sixth focus group was conducted once initial data analysis had taken place for a feedback session which ran for 2 hours. The group consisted of eight women, all of whom had attended a previous session. Initial findings were presented via PowerPoint presentation and participants provided feedback, amendments or additions. Participants gave positive feedback during the session, reporting that they agreed with our initial findings. There was significant discussion around use of language, particularly the term ‘victim’ (see findings section below).

Findings are presented under the key themes derived from the analysis, with italicised words spoken by women supporting these themes with the participant number alongside shown as ‘P [number]’.

The Thrivership process

All except two women said that ‘victim’, ‘survivor and ‘thriver’ were appropriate titles for the stages of recovery and both ‘survivor’ and ‘thriver’ had positive connotations. Many women said the term ‘victim’ was stigmatised within society, and made them feel weak (P11, P12, P14, P24) , thus it was difficult for them to accept initially in recovery. However, as they progressed into the ‘survivor’ phase of their recovery journey (P25) , accepting that they had been victims became easier.

The two women who disagreed with the label titles were in the same focus group; P19 said that she wouldn’t identify with those labels, with P24 adding I agree with you… But I think they are states of mind at certain points . P19 then concluded It is a mix… It’s like well I’m quite a lot of that but I’m still a bit here and there’s a bit of thriver in me. The other members of the group agreed with use of the language. A short while later, P24 stated I’m trying to think if I’ve ever identified as a victim…probably not… to me it feels weak. This prompted P22 to say it’s because we don’t know [that we’re a victim at the time] . The issues raised by these participants were presented to the validation focus group for discussion; all members of the group reported feeling strongly during experiencing their ‘victim’ stages they had – similarly to the two participants – disliked use of the word ‘victim’ because of its negative connotations, and that by the time they had reached the ‘survivor’ and ‘thriver’ stages they were able to accept the term ‘victim’ and recognise that they had indeed been victims in some capacity. This was something also highlighted by participants who identified as thrivers in focus groups 1 and 2. It is perhaps worth noting that both participants who raised concerns regarding the labels were attending the principal programme at the DVA-service at the time (thus were early on in their recovery stage), and one was the participant still living with the perpetrator. Importantly their comments highlight the fluidity and personal nature of the recovery and thrivership process.

During the ‘victim’ stage women said they had no self-esteem (P4, P16, P32) , felt powerless (P11, P12, P17, P19) , believing that the abuse was their fault and reporting that they felt confused (P17) , helpless (P2, P15, P24) , lonely (P10) and isolated (P3, P16, P22, P24) .

The ‘survivor’ stage was more positive; they had escaped (P29, 30) or were no longer with the abuser and thus experienced freedom (P24) , they were coping (P3, P19, P24) , recognising their own strength (P21) and feeling resilient (P22, P23) , but continued experiencing guilt (P33, P35) and hardships (P18) .

By the ‘thriver’ stage, all associated emotions or experiences were positive; women reported that they felt acceptance (P35) , were  free (P11) and safe (P17) , could have fun , experienced a clear-mind (P11, P15) , clarity (P17) , self-confidence (P18) and growth (P18) ; ultimately women were empowered and in control of their own life (P17) .

Participants described a fluid and non-linear recovery pathway from ‘victim’ to ‘thriver’ that is vulnerable to triggers. Some used words such as spectrum (P17) or spiral (P18) to describe the process, and one group used the metaphor of a three-point turn. When thriving they were better equipped to recognise triggers and guide themselves back to a positive mental space.

Participants in two interviews and three focus groups drew parallels between thrivership and the grief and loss process and emphasised the subjective nature of the thrivership process; DVA, they said, takes different forms and severities (P30) - people cope differently. Thus, it was important not to feel pressure to recover by a certain point in time.

P29 – I found it really difficult to view myself as a victim because… I only have recently accepted that I was abused um and by default it makes you a victim. Yeah, so it’s a hard term to accept… it makes you feel weak… P27 – Victim for me… people around me would say or use the term really lightly like ‘oh she’s playing the victim’…so to hear people’s own associations with that word and then to see it like related to something like this, I never wanted to be called that because I thought people would think that it came with an act… P3 – I’ve been through everything in a year…and it’s very easy to move from being a victim to survivor to thinking that you’re there and thriving and then it’s…so easy for that to be knocked right back to the beginning. P31 – You only became a victim because you went through quite psychologically damaging stuff, yeah? Obviously because you’ve got those scars…things can come along and sort of knock you off your thriver line…And I think it’s like real life. Things come along, life comes along. P25 - It’s not a definite thing in the grief and loss process. Like when I split up with him there was times where…I wanted him and I felt like I needed him…then I realised you’ve got grief, loss, acceptance and they fluctuate as well.

Characteristics of thriving after DVA

Positive outlook and future plans.

Women reported that a thriver has a significantly more positive outlook than someone in the other stages; when someone was thriving, they were aware that emotional ‘dips’ or victim days (P16) were normal and would not last. Thriving was accepting that it is okay to feel shit (P11) ; a change in outlook due to acceptance and moving on (P21) .

P29 – You know as a thriver that this bad day is not gonna last. I can have this bad day and it’s okay and it’s not gonna last whereas when you’re a victim everything is a bit rubbish. P6 – We’ve also learnt that life is a journey, not just after domestic abuse, for everybody, and there are dips in the road…bereavements...money issues…ill health, whatever.

Acceptance existed conjointly with the belief that the past doesn’t define the future (P4) . Participants in three focus groups said thrivers have a newly discovered ability to dictate their life moving forward, take opportunities and make plans due to new-found freedom.

P25 – I am a thriver, I don’t need to look back. P18 – Well I’d say someone who’s thriving…they’ve got more of a positive outlook or not even just positive but being able to see further into the future and have a long-term plan whereas when you’re not thriving, you’re just surviving - you’re not looking long-term you’re just looking to get through the here and now. P21 – That’s how I see a thriver…accepting where you are. It’s acceptance and moving on.

Improved health and well-being

Women reported that a thriver’s physical and mental health are significantly improved compared to other stages. During the ‘victim’ stage, many women and their children had experienced long-term chronic health conditions because of the abuse, including digestion issues, asthma and mental health issues:

P6 – I think health issues…the depression, the IBS, the asthma, is all part of …when you’re a victim.

Once women had escaped the abuse, their health improved due to them no longer being reliant on coping mechanisms or experiencing fewer illnesses (P36) because the abuse-induced health conditions disappeared or were manageable. Improved self-care (P14) – including exercise - also contributed to improved health for some:

P4 – I need to get fit, I’ve got myself a mountain bike…I’m gonna start swimming…I’m starting to look after my health now…I’ve got a life to live. P17 – [My health has] completely transformed. I mean for one my physical health, you know I think a lot of my issues still if I’m perfectly honest are about coping mechanisms and dealing with the abuse, so you know I drank heavily, I smoked, you know all of the self-harm things really that you do to cope with what’s gone on.

Thrivers experienced a positive change in mental state and emotional well-being due to feeling calmer, having a clear mind (P15, P11) , and experiencing more balanced emotions. They were better equipped to recognise and address anxiety or stress, particularly compared to previous stages when women felt mentally incapacitated…in a constant state of confusion (P23) .

P35 – [I’m] less stressed. You’re more able to relax in your circumstances…while I was in denial, I’d flare up and I’d start shouting an’ stuff, but now… I’ve moved forwards, and now there’s no arguing, no shouting – it’s calmer. P18 – I’d say your mental health improves – you’re more positive, more balanced…the slightest thing doesn’t feel like the end of the world.

One interviewee and women in three focus groups shared experiences of themselves or their children being misdiagnosed, or unnecessarily diagnosed, with mental health conditions rather than having their symptoms viewed as reactions to abuse. Two women referred to social workers enforcing medical tests via general practitioners for mental health disorders.

P33 – They’re too quick to put a stamp on it, medicate you out of your eyeballs, because it’s so fast for them to just write a prescription...A lot of the time professionals…they lack so much information about the impact… P25 – We had a lot of problems around social services, they put a lot of blame on me…. my doctor put me on the anxiety tablets, but this was all because of social services that I had to do all of these medical analyses. P32 – I was diagnosed with borderline personality disorder while I was with my ex by the mental health team. And if you read up on it so many women who have been in domestic abuse situations or were abused as children, like it’s commonly known that you get it from being abused as a child… they are jumping to diagnose women with this - what I’ve been told is an incurable mental condition – when really it is just an extreme version of PTSD brought on by what you’ve been through.

Thriving also featured improved health-related help-seeking behaviours; women were more likely to seek help for illness; go for routine appointments (e.g. dentist); or seek counselling support. Management of health-conditions also improved.

P14 – …and even if you still have depression, you’re probably taking your medication…you’re probably going to counselling…and probably if you did have any health issues you would go and seek healthcare about it whereas as a victim, you’re probably too scared to go to the doctors…or you just weren’t allowed.

Reclamation of self

In all groups, participants discussed thrivership as a journey of self-discovery featuring significantly improved self-worth, confidence, and self-esteem.

Freedom was a crucial element of ‘thriving’; women delighted in the newly discovered power they now had over their lives, after feeling powerless (P11, P12) as victims. Thriving was being able to do things for yourself (P14) such as re-entering education, getting a job, or being able to express emotions openly. Ultimately, women were taking power back (P34) .

P33 – You know that you’re allowed to be happy. You can cry. P17 – It’s just freedom. That’s what it feels like, I’m free…it’s a sense that I’m back in control of my life and I’m in charge of my destiny which is really empowering. P2 – I’ve got a job I’m starting in a couple of weeks and I wouldn’t have done any of that 15 months ago. P32 – Surviving is you do it, thriving is you enjoy doing it…like you’re not just doing it because ‘well I know if I was a normal functioning human being I should be doing it’ but you’re doing it because you get up and you’re like ‘yeah I’m having a fucking great day, and I’m gonna do that and I’m gonna have fun doing it'.

New-found freedom and empowerment correlated with a deep and powerful journey of self-discovery. For some, this was a re-birth as they figured out who they would be happy as (P3) and could reinvent (P4) themselves. Others used the opportunity to discover everything they liked and disliked.

P15 – Self-discovery, like finding out about yourself and who you are again. It’s like reminding yourself who you are. P24 – Oh my god – to make decisions for yourself. Like what food do I like? I mean that took me two years to work out what food do I like, what films do I like, and what music do I like because I just didn’t know before.

Overwhelmingly, thriving was characterised by a realisation or significant increase in self-worth, self-love and believing in yourself (P11) . This had a hugely positive impact on women's lives, enabling them to: be more assertive, advocate for themselves or their children (e.g. in court or with social workers), go out in public alone and have more faith in their own capabilities.

P4 – Confidence, self-esteem…is massively improved when you’re a thriver. P2 – I could quite happily now go and sit with a group of strangers…whereas that would’ve been unheard of before I would never have done that.

Social networks

‘Thrivership’ featured a changed social network for all women, and an end to the isolation (P24) they had experienced previously. Social circles expanded due to re-connecting with friends or family they’d lost contact with, and as they gained confidence, they felt more comfortable meeting new people. Negative relationships (P11) left their lives, particularly when setting healthy boundaries.

P29 – … My family relationships have changed because they weren’t allowed to get very close to me so it changed all of those relationships and for about 15 years they felt like I was stolen from them, so now we have that relationship back. P11 – …And thriver as well is meeting new friends, it’s having a new family, that I-and it’s a new family of women you can identify with...Because my, like my old friends don’t understand me now. I’ve grown, the person I was two years ago they don’t understand me and they probably wouldn’t like me.

Women reported that at the ‘thriver’ stage, all their relationships should also be thriving, i.e. more productive…equal…[and] healthier (P17) . Two interviewees and all focus groups discussed improved relations with family, friends and children. Several groups referred to how their newly-developed knowledge of the signs of abuse contributed to healthier relationships.

P21 – Some of my friendships are deeper and more solid because this journey from victim to survivor…there’s only two of them, and they’ve walked that bit with me. I call them my sisters now and they will be with me for life, and I couldn’t have said that when I was a victim… P4 – And my relationship with my children as well there’s been a massive change. I’ve got more patience, I’m more forgiving, I’m more thoughtful, they have a voice now.

Within the context of these new social networks, women reported that as thrivers they felt more available to help other people (P36) , than in the victim stage. For some this took the form of social activism (e.g. volunteering at a women’s centre), though most instead offered informal support to other women. E.g. Passing on new knowledge, information and tools, or referring others to the DVA-service.

P11 – I worked really hard on myself to believe in myself, and to you know pass the knowledge on to other women and learn to empower other women and that’s what I want, to see other women…grow. P29 – …For me thriving is all about sharing and as a woman empowering another woman…when I’m in my thriver state I am sharing.

The conditions for Thrivership

Provision of safety.

Women in all groups reported that the provision of physical safety was vital in ensuring victims could progress towards ‘thriving’ and typically came via having a safety bubble (P31) - usually their home. Three women mentioned practical elements such as security locks offered by Women’s Aid.

P6 – When I first came here…there was some charity scheme, to get new front doors that were safe…it was to keep you out of having to go in to refuges really but the police came round and assessed the house…that’s an early one, to make you feel safe, you know to be safe…I think without that it would be harder to thrive. P18 – It’s just having my own space you know and knowing that I’m the only one that has keys to that front door. So, I can lock the door and keep the rest of the world out. P14 – [You need a] safe place to talk and to share, get better.

Emotional safety (P30) or psychological safety was mentioned in relation to acquiring knowledge of how to protect oneself against future abusers and via building self-worth. Safety was also mentioned in relation to having a ‘safe space’ to share their story. All women reported that to thrive it was vital that an individual was taught the appropriate knowledge (P28) and given tools (P1, P18) to recover, including how to develop internal resources (such as resilience and courage), and assertiveness skills. Participants in all groups said that crucial to the thrivership process is education on perpetrator behaviour including the common signs of abuse and the impact of DVA on victims; this provided empowerment, enabled women to make sense of what they had experienced and ensured they didn’t repeat the cycle of abuse.

P29 – I feel like I’m safe now because I feel I’ve got the knowledge that I need to protect me. P27 – I feel safer in my own decisions and I can rationalise them a lot better. I’ve never felt physically unsafe, but now I’m more aware like in my head of what’s going on. P37 - You don’t have the strength and courage if you can’t build up your self-esteem, and I thought that was just something that you could innately build yourself but it’s not… you do sometimes need to learn how to be stronger. P31 – I was with my husband for 20 years and…I mean I knew there was something wrong, but I was like ‘is it me, is it him’…I have that knowledge now and so in another relationship that would empower me. P37 – …previously I was just continuously going from, it was almost like a cycle – relationship to relationship to relationship and ending up with the same result…I understand what’s going on and I understand what changes need to be made...

Sharing the story

Three interviewees and all focus groups reported discussing their experiences with someone – i.e. ‘sharing’ their stories – contributing to thriving. This was commonly mentioned within the context of a group setting; many had shared their experiences within the safety of a ‘peer group’ of other women who had also experienced DVA. Through sharing their DVA ‘story’, the abuse no longer defined women, and gave them ownership over the past so they could start healing. It also contributed to a feeling of mutuality - that they were not alone in their experiences.

P27 – It’s through talking to people that I have accepted it…it’s my story now, it’s not just something where I wasn’t sure what was going on like it’s actually defined, it’s a defined story but it hasn’t defined my personality. P18 – …By talking about it you then realise that actually you are believed and actually that is a big deal because a lot of the time you downplay it and then it makes you see that it has been a big deal.

Social responses

Women in all groups discussed mixed experiences with ‘professionals' they had contact with, including general practitioners, social workers, and the police. Positive interactions included professionals recognising the signs of abuse and supporting women via signposting or providing content for police statements. Negative interactions were commonly due to doctors mis-diagnosing due to missing signs of abuse, or due to criticism from social workers.

Participants in all groups and two interviewees spoke about the need for a society-wide response to DVA, to include: educating professionals on the signs and impact of abuse; ACEs; and teaching in schools about healthy relationships.

P18 – …I think it should all be widely known about with the professionals you know because there’s so many times when the signs of it are all missed and so many women and children are left in these situations that aren’t picked up on or aren’t felt to be serious. So I think that social workers need more training, doctors need to be more aware of it, psychologists, everywhere really, in schools they need to be able to pick up the signs, I think it’s been missed a lot. P4 – [the social worker] said ‘how could anyone like you be ever be considered a good mom…with your horrific background’. P20 – My next-door neighbour was a GP and he had to write a court statement, a witness statement, and the judge quoted him saying ‘if you don’t know to look for domestic violence you won’t see it’. And I actually thought that was a really good point…

Forgiveness, acceptance and spirituality

Women reported feeling shame as victims or survivors; they believed they allowed the abuse to happen. Women in two focus groups, and one interviewee, referred to an element of ‘self-forgiveness’ that was required to move forward. However, women in the validation group said that self-forgiveness was irrelevant; the abuse was only ever the fault of the perpetrator as he chose you, you didn’t choose him (P33) . They reported that to truly thrive a victim had to have their eyes opened to the fact that the abuse had never been their fault.

All except three participants said that they could never forgive their abuser(s) for what they had done to them or their children, and that this was not necessary to thrive. Instead, women said a level of ‘acceptance’ and ‘letting go’ of the past was required for them to move on, and to thrive.

P25 – I didn’t forgive myself…because I felt for so long that I allowed it, that’s why I hated myself…you don’t think anyone else is going through it. P36 – I think there’s some things you can forgive and other things you can’t …some things you can just forgive because of the circumstances. But then there’s some things the way people treat people, or things that someone’s done…I just don’t think they deserve forgiveness. P3 – I guess it kind of depends on what you mean by forgiveness because I mean, letting go and forgiving are two different things…because forgiving says it’s okay, what you did to me is okay, and actually it’s not.

Of those who did wish to forgive, one felt that an element of spirituality helped her through this process, and another mentioned a spiritual cleansing enabled her to forgive in order to ‘move on’:

P17 – We are spiritual beings all of us. And I’m not talking about religion either, you know it’s about a higher self and bigger picture stuff. And that eventually does aid my healing process and my freedom because eventually…I want to forgive.

Beyond forgiveness, ‘spirituality’ had also played a part in the recovery for two interviewees and women in two focus groups and was often discussed in relation to therapeutic techniques and coping mechanisms such as mindfulness (P17) or breathing exercises.

Spirituality and religion were usually mentioned alongside each other, but women were keen to separate the two concepts, and these conversations did not always focus on forgiveness but rather hope or support; three women spoke about the role that religious faith played in their recovery via the provision of ‘hope’, or practical support (P35) from people within their religious community.

P31 – Well I don’t really do religion much these days as I don’t go to church but yeah, I’m a committed Christian and that helped me immensely. I don’t think it’s necessary for everyone, I think it’s a personal thing.

However, two participants were openly critical of religion, arguing that religion often supports domestic violence (P31) .

As with previous studies, women likened thrivership to that of a fluid [ 20 , 31 , 32 ] ‘journey’ [ 20 , 31 , 32 , 37 ] with a vulnerability to triggers [ 37 ]. Healing from abuse is not prescriptive; rather it is a non-linear process with a variable time-scale [ 37 ]. DVA services and professionals should consequently acknowledge the long-term process of overcoming abuse [ 37 ] and ensure women are not pressured to recover within a certain time, as this may be detrimental to their well-being.

Thriving featured an element of helping others, as in previous studies [ 22 , 30 , 37 ]. For the minority this took the form of social activism [ 30 ], though this was not deemed necessary for thriving. Instead, all had helped others via the transference of new knowledge and tools gained through programmes, to other group members, friends and family. This dedication to supporting other survivors, and the wealth of knowledge thrivers have around DVA, implies they are ideally equipped as programme delivery staff, and for informing service-design.

A ‘reclaiming self’ model of thriving emerged in the current study as in others [ 19 , 20 , 30 , 32 ]. In line with previous findings, women reported a re-construction of identity [ 38 ]; returning to skills and hobbies [ 20 , 31 , 32 ], work and education [ 38 ]; an increase or return of self-confidence [ 22 ], self-worth, and “knowing who you are and what you want” [ 38 ]. Women experienced empowerment and control over one’s life [ 20 , 31 , 32 , 37 ].

Unlike previous literature on thrivership, findings of the current study revealed detailed insight into how an individual’s health differs when ‘thriving’ post-DVA. Wozniak and Allen [ 20 , 31 , 32 ] refer to psychological well-being with a spirituality-based focus of “developing inner peace and serenity” [ 32 ], but little beyond this. Some results that emerged were like those by Flasch [ 37 ] on long-term recovery; women reported improved health and well-being including healing from mental and physical symptoms of the abuse, recognising the health consequences of the abuse, and the steps they took to promote optimal health (e.g. exercise). Beyond this, women in the current study reported: specific examples of dissipated abuse-related health-conditions (e.g. IBS); being better-equipped with new tools and techniques to manage mental well-being; developing new help-seeking behaviours; and negative experiences due to misdiagnoses and social worker approaches. Further research is recommended into how health-services can be suitably optimised to ensure women can easily and quickly access help when needed.

Thriving was characterised by a social network in line with previous findings [ 37 ]; women repaired damaged relationships with family and friends [ 20 , 31 ], reconnected with those they’d lost, and cut out negative relationships [ 37 ]. These networks offered positive social support [ 37 , 39 ] and ultimately enabled women to re-join their community [ 20 , 31 , 32 ].

As with previous research women reported a more positive outlook: ‘thrivers’ can find joy in everyday circumstances [ 22 ] and inspiration in the future [ 30 ].

Unlike previous studies, women actively chose not to forgive the abuser as they did not deserve forgiveness (P36). This did not prevent them from thriving. In a similar vein, whilst self-forgiveness was thought to be necessary during early recovery, by the ‘thriver’ stage women had acknowledged that the abuse was solely the fault of the abuser, thus self-forgiveness was not necessary; a finding that is also different to those of previous work in this area.

Again, unlike previous studies that reported thriving as featuring a “renewing [of] the spirit” [ 30 ] and “healing your soul” [ 20 ], most women did not feel that spirituality was necessary to thrive. Similarly, religion, whilst deemed necessary for women in previous studies, was not considered fundamental to thriving for women here.

The proposed model

The proposed Thrivership Model (Fig.  1 ) offers a brand-new and unique model that further contributes to our understanding of the theory of thrivership. It illustrates the fundamental requirements for thriving post-DVA, by women who have experienced it.

figure 1

The Thrivership Model with ‘key conditions’ required

The proposed model’s key components are: (1) Provision of Safety, (2) Sharing the Story, (3) Social Response (to DVA). ‘Education’ and building awareness around DVA at either an individual, community or national level is required within all three components of the proposed model. All components contribute to ensuring a woman can reach the ‘thriving’ stage of recovery, with each of the features outlined in the findings section, and below.

Women reported – in line with previous findings [ 20 , 31 , 32 ] - that physical safety is required early on for thrivership to occur; physical safety provides the crucial foundation for the thrivership process. However, women experiencing DVA who seek safety continue to experience a range of barriers to accessing refuge spaces, which leaves them vulnerable to further abuse from the perpetrator, at risk of sleeping rough and often left dependent on their social networks for a place to stay [ 40 ]. Focus from government policy and funding in these areas is crucial if women are to thrive after DVA.

Women spoke of the need for emotional safety or psychological safety, that could be developed via the acquisition of knowledge and understanding of perpetrator behaviour, common signs of domestic abuse and its impact, and how to recover via the development of internal resources (such as resilience and courage), and assertiveness skills. Education of survivors in this way has not been referred to in previous thrivership research, though empirical evidence has shown that women who have experienced DVA do not always recognise their experiences as abusive and thus need help and support to name the abuse [ 16 ]. Additionally, equipping individuals with boundaries and knowledge of early warning signs can help survivors navigate future relationships and break the cycle of abuse [ 41 ]. The Freedom Programme – usually delivered as a standalone course - is successful [ 42 ] in this area.

As in the current study, previous research has highlighted the impact that relaying ‘positive coping mechanisms’ such as cognitive strategies, relaxation, and coping skills to survivors can have on women’s mental health and well-being [ 43 ].

Like previous study findings, “shattering [the] silences” [ 20 , 31 ] that exist around abuse through sharing one’s experiences with others was reported as key to thriving; ‘sharing the story’ of abuse (see Fig.  1 ), particularly in the context of support groups, contributes to validation and feelings of mutuality. Crucial to this component is the availability of services (e.g. peer support groups, counsellors) and a culture within which women feel they can share their story free from judgement. The recent draft Domestic Abuse Bill from the UK government set out government plans to raise public awareness of DVA via working with community groups and running media campaigns [ 44 ], which may go some way in creating a culture where people who experience DVA feel safe to share their stories.

A social response

Women said a ‘Social Response’ is necessary for DVA to be tackled long-term. This component provides a societal ‘backdrop’ for the thrivership process, and education of professionals at victim ‘touch-points’ is crucial to this.

Due to the volume of women who attend healthcare services, primary healthcare professionals are well-placed to identify cases and be a valuable resource for victims via sign-posting to specialist services [ 45 ] and  addressing health-related issues to support women towards safety. Previous studies have shown primary healthcare-professionals’ attitudes towards women experiencing DVA are positive, but many continue to only have basic knowledge of the area [ 46 ]. Thus, general practitioners and nurses need more comprehensive training on DVA assessment and interventions. Schemes such as IRIS (Identification & Referral to Improve Safety) are already succeeding in this area [ 47 ] though funding and sustainability continue to be a concern [ 47 ]. We would encourage use of the proposed model in professional teaching programmes for those who come into contact with women who experience DVA, to provide guidance on how women can be supported towards ‘thrivership’ in their recovery journey. The proposed model could also be used to inform the planning and commissioning of services and be used as a framework for support programmes delivered by DVA-specific and charitable organisations so that women receiving the programmes can see the hope for thrivership. Central to meeting the needs of those who experience DVA is that healthcare services acquire good relations with refuges and other non-governmental organisations working on DVA [ 48 ], to ensure up-to-date knowledge and pooling of available resources.

Similarly, collaboration between DVA-services and public health bodies could provide educational sessions for those working in social services, to build a culture of understanding around abuse that no longer problematises the mothers [ 49 ], whilst still prioritising the children’s safety. Women’s reports of distressing experiences with social workers are in-line with previous research [ 49 ]; this must be addressed if women with children are to thrive. Equally, school-based campaigns teaching children about healthy relationships and how to stay safe were highlighted as crucial to preventing the transmission of DVA to future generations and ultimately contributing to the ultimate goal of eliminating DVA altogether. Indeed, the draft Domestic Abuse Bill released in January 2019 has confirmed government plans to make the provision of relationship and sex education compulsory in primary and secondary schools, though this will not be rolled out until September 2020 [ 44 ]

This study was undertaken alongside a service evaluation of a women-only service, and thus male ‘victims’ of DVA have not been included. Further research around thrivership to include the viewpoint of male victims, and victims from the LGBTQ+ community may be appropriate, to identify its relevance to these communities and how it can feed into services established to meet their needs. However, it is important to note that DVA continues to be an example of gendered violence in that women predominantly suffer at the hands of men.

Limitations

Whilst focus groups were the most suitable methodology for this study, they were not without their disadvantages. It became clear throughout the study that the emotional state of a participant could easily impact their interactions with the group, and the information they shared. Several women who identified as ‘survivors’ had recently got divorced, or been in court, and another informed IH that her perpetrator had emailed her during the focus group; all of these women were emotional during sessions and had more negative views than others. Emotional contagion took place in two groups, particularly when talking about experiences with social workers and past abuse.

Though it is clear from the data what is needed for someone to thrive after DVA, how ‘well’ or quickly a person thrives may also depend on the type, amount of, and quality of external support they receive (e.g. counselling, family).

Domestic abuse continues to be one of the most widespread human rights abuses and public health problems in the world today [ 38 ]. As with previous studies on this topic, women who participated in this study had a wealth of experience and understanding of the impact of DVA [ 49 ]. Attending to the words of thrivers in this way offers access to this knowledge pool and facilitates the empathy needed from professionals who work with them and wider society.

The findings of this study provide a new view of thriving post-DVA by women who have lived through it. Beyond that, a new and unique model has been proposed that illustrates what is required for the thrivership process to take place. Qualitative research such as this can consequently contribute to the development of effective intervention strategies; inform policy, legislation and training; and shed new light on implementation of effective services, treatment, resources, and community support for survivors - something that is particularly relevant in this age of patient-centred services.

Further notes

This research project was conducted alongside a qualitative evaluation of the DVA-service from which the participants for this study were recruited. The Birmingham Freedom Project (BFP) deliver a unique combination of 10–12-week awareness and empowerment programmes for women affected by domestic abuse in the region. The programmes are delivered by two female facilitators who have also experienced abuse themselves. The service offers long-term, ad hoc support to women who attend or have attended their programmes, and free, unlimited access to their programmes; women are able to return to the project as many times as they feel is necessary for them to thrive long-term. It is clear then, that attending the BFP has a direct relationship with the sense of survivorship and thrivership of the participants of this study.

Availability of data and materials

To protect the identity and safety of the participants, all transcripts and recordings were deleted permanently following data analysis. The authors can be contacted if readers would like further discussions around data and findings.

Abbreviations

Domestic violence and abuse

Gender-based violence

Lesbian, gay, bisexual, transgender, and queer

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Acknowledgements

Thank you to all the women who participated and who so candidly shared their experiences. Thank you to our colleagues from Birmingham Freedom Project, UK for facilitating the recruitment of women to the study.

This research project was undertaken alongside an evaluation of the Birmingham Freedom Project which was funded by the service itself.

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Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

Isobel Heywood, Dana Sammut & Caroline Bradbury-Jones

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Contributions

The idea for the study on ‘thrivership’ was developed for a Master’s thesis in 2018 by CBJ and IH. IH conducted data collection, analysis and completed the initial draft of the paper. Analysis was then checked by CBJ and DS. All authors have contributed to and approved the final paper.

Corresponding author

Correspondence to Caroline Bradbury-Jones .

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Heywood, I., Sammut, D. & Bradbury-Jones, C. A qualitative exploration of ‘thrivership’ among women who have experienced domestic violence and abuse: Development of a new model. BMC Women's Health 19 , 106 (2019). https://doi.org/10.1186/s12905-019-0789-z

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  • Correction: Qualitative study to explore the health and well-being impacts on adults providing informal support to female domestic violence survivors - May 01, 2019

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  • http://orcid.org/0000-0002-4768-1574 Alison Gregory 1 ,
  • Gene Feder 1 ,
  • Ann Taket 2 ,
  • Emma Williamson 3
  • 1 Centre for Academic Primary Care, University of Bristol , Bristol , UK
  • 2 School of Health and Social Development, Deakin University , Burwood, Victoria , Australia
  • 3 Centre for Gender and Violence Research, University of Bristol, Social Science Complex , Bristol , UK
  • Correspondence to Dr Alison Gregory; alison.gregory{at}bristol.ac.uk

Objectives Domestic violence (DV) is hazardous to survivors' health, from injuries sustained and from resultant chronic physical and mental health problems. Support from friends and relatives is significant in the lives of DV survivors; research shows associations between positive support and the health, well-being and safety of survivors. Little is known about how people close to survivors are impacted. The aim of this study was exploratory, with the following research question: what are the health and well-being impacts on adults who provide informal support to female DV survivors?

Design A qualitative study using semistructured interviews conducted face to face, by telephone or using Skype. A thematic analysis of the narratives was carried out.

Setting Community-based, across the UK.

Participants People were eligible to take part if they had had a close relationship (either as friend, colleague or family member) with a woman who had experienced DV, and were aged 16 or over during the time they knew the survivor. Participants were recruited via posters in community venues, social media and radio advertisement. 23 participants were recruited and interviewed; the majority were women, most were white and ages ranged from mid-20s to 80.

Results Generated themes included: negative impacts on psychological and emotional well-being of informal supporters, and related physical health impacts. Some psychological impacts were over a limited period; others were chronic and had the potential to be severe and enduring. The impacts described suggested that those providing informal support to survivors may be experiencing secondary traumatic stress as they journey alongside the survivor.

Conclusions Friends and relatives of DV survivors experience substantial impact on their own health and well-being. There are no direct services to support this group. These findings have practical and policy implications, so that the needs of informal supporters are legitimised and met.

  • TRAUMA MANAGEMENT
  • MENTAL HEALTH
  • PRIMARY CARE
  • PUBLIC HEALTH

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2016-014511

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Strengths and limitations of this study

This study provides an indepth exploration of the health and well-being impacts experienced by friends and family members supporting a woman who is experiencing domestic violence (DV).

A key strength of this research is the novelty of perspective, because it accessed the experiences of friends and relatives directly, which is vital if we are to understand the wider context and implications of DV.

The data came from face-to-face interviews, but the main researcher (AG) also kept a reflective diary and fieldnotes. AG also carried out a member-checking process during the interviews to increase rigour and validity of results.

This study shows that friends, colleagues and relatives of survivors experience substantial impact on health and well-being and may, in some cases, be experiencing secondary traumatic stress.

One of the limitations of this research was that the sample lacked breadth, particularly in terms of ethnicity. It will be important to try to address this in future research.

Introduction

Domestic violence (DV) is a global issue to which no age group, culture or socioeconomic group is insusceptible. 1 The United Nations Development Fund for Women estimates that, throughout the world, one in three women will experience violence in their lifetime, and in most cases, the abuser will be a family member. 2

The Council of Europe, the WHO and the United Nations have all identified violence against women as a major public health issue. 2–4 The most obvious health consequence is physical injury, with 70% of DV incidents resulting in injury. 5 Less apparent are chronic health problems which result; research demonstrates links between DV and gynaecological problems, 6 chronic pain, 7 gastrointestinal disorders 8 , 9 and cardiovascular conditions. 10 There is also substantial evidence for the harmful consequences on mental health, with depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse and suicidal ideation commonly experienced by survivors. 11 , 12

Research suggests that the majority of female DV survivors choose to access support (practical and emotional) from adults around them. 13–16 In a study by Parker and Lee, 14 89% of DV survivors disclosed the abuse they were experiencing to friends and relatives. While many survivors rely on informal support alongside professional and specialist services, there are a large number who rely initially, predominantly or exclusively on friends, relatives and colleagues. 13 , 16 , 17 Research has demonstrated that positive social support buffers against effects of abuse on survivors' physical health, mental health and quality of life, and that it can be preventive against them experiencing further abuse. 18–21

Exposure to violence can be traumatic in its own right. 22–24 Indeed, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 25 recognises the experiences of people who have witnessed traumatic events, and those who have learnt about events that have happened to close relatives and friends. Historically, this idea of secondary traumatic stress (STS)—sometimes referred to as indirect trauma, compassion fatigue or vicarious trauma—has only been applied to people working as professionals with traumatised patients or clients. More recently, however, researchers have begun to direct attention towards those providing support in an informal capacity, noting the overlap with impacts that professionals in caring roles experience. 26

In summary, there is substantial evidence that women experiencing DV draw support from people in their social network and that, when this is positive, there are important benefits. However, because the direct study of people in DV survivors' social networks is rare, little is known about the possible diffusion of impacts, including the possibility of STS. 17 , 27 , 28

This qualitative study was conducted in the UK. The aim of the research was exploratory, with the following research question: what are the health and well-being impacts on adults who provide informal support to female DV survivors? Owing to the emotive nature of the topic, individual interviews were considered the most appropriate mode of data collection.

Participants

Maximum variation sampling was used to recruit participants with a range of experiences, attitudes and beliefs. It is an approach which aims to capture and describe themes that cut across a great deal of participant variation, so that common patterns that do emerge are of value and interest. In order to access a diverse range of people, advertisement of the study included: posters in local healthcare and community settings, social media and web-advertisement, and promotion on local radio. Particular emphasis was placed on attempting to recruit participants with an ethnic background other than White British, in recognition of the general under-representation of individuals from minority ethnic backgrounds in health research. 29 For this reason, the study was also advertised by agencies in Bristol working with black and minority ethnic groups.

Participants were eligible if they had had a close relationship with a female survivor of DV, and were aged 16 or over during the time they knew the survivor.

DV was defined according to the UK Home Office definition: Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological, physical, sexual, financial & emotional. 30

Owing to the gender asymmetry around DV, particularly in terms of impact, 31–33 and because much less is known about the ways men experiencing DV interact with their social networks, 34 , 35 it was decided to focus this work on the friends and relatives of female survivors, though the perpetrator could be of either gender.

Twenty-three participants were recruited and interviewed. A further 63 people expressed an interest in the study: 33 were ineligible (27 were survivors rather than informal supporters, 5 had been exposed to DV during childhood rather than adulthood, and 1 was not based in the UK), 28 made no further response after initial contact and 2 were recruited but failed to attend the arranged interview. The relationships that participants had to a survivor were: mother (4), father (2), sister (2), niece (1), daughter-in-law (1), current partner (3), friend (15) and work colleague (2). There were more than 23 different relationships described, because some participants had known multiple survivors. The majority of participants were women (18), most were white (including ‘White British’, ‘White European’ and ‘White Other’ ethnicities) and their ages ranged from mid-20s to 80.

Procedures and data collection

People who were interested in taking part, having seen the posters or online advertisements for the study, contacted the first author (AG) by telephone or email. They were given a study information leaflet and a copy of the consent form (via email or mail) at least 48 hours prior to participating in an interview. Written consent was obtained from each participant. For safety, face-to-face interviews took place in university buildings or community premises (eg, private rooms in local council offices). Participants also had the option to be interviewed over the telephone or using Skype. Only AG and each participant were present during the interviews, and participants were only interviewed once. Sociodemographic data were collected to inform the analysis, contextualise participants and guide recruitment strategies. Participant confidentiality and anonymity were of paramount importance, thus only AG knew who had participated in the study. Transcripts of the data were cleaned to remove identifying information prior to sharing with the team for analysis, and all data were held securely in accordance with University of Bristol regulations. The limits of confidentiality, particularly reporting requirements for safeguarding issues, were explained to participants. To reduce the likelihood of distress, the voluntary nature of the research was emphasised throughout, and the researcher was attentive to participants' emotional state.

The interviews were conducted between August 2012 and April 2013 by the first author. A topic guide (which had been pilot tested) was used, with questions and prompts to elicit information pertinent to the research question. In addition, a form of member-checking was undertaken by AG throughout the interviews, by restating and summarising information to check accuracy of understanding with participants. Interviews were audio-recorded, transcribed verbatim and imported into NVivo10 software. The interviews ranged in length from 35 to 90 min, and saturation of themes was reached after 23 interviews. Following the interviews, an information sheet detailing local and national DV services and counselling services was shared with participants.

Researcher reflexivity

Part of ensuring the rigour of qualitative research is for investigators to recognise that they themselves necessarily form part of the context for interactions with participants, and that they bring their traditions, values and personal qualities to each aspect of the study. 36 For this reason, it is also important for the reader to have an understanding of who conducted the research: the first author (AG) is a woman, white and was in her late 30s when she carried out the interviews as part of her PhD. She had been a senior research associate for 4 years prior to her PhD studentship, and continued to work as a counsellor alongside her research (participants were informed that AG was a PhD student, but not that she had an additional counselling role). AG had had no prior contact with participants. Reflexivity also involves an active noticing by the researcher as she journeys through the research process, which for this study included keeping a reflective diary and detailed fieldnotes to capture reflections on: context, interview process, thoughts about participants, and about the relationships created during the interviews. At the interview stage, the recording of these reflections helped AG to consider what had gone well and what could have been performed differently, in order to hone interview skills and use of the topic guide. At the analysis stage, the noted descriptions of key messages from the interviews were revisited, in order to check that the developed themes reflected these.

Data analysis

A thematic analysis of the data was carried out and was undertaken in parallel with the interviews. In thematic analysis, transcripts are read multiple times in conjunction with fieldnotes, and key concepts noted. 37 These concepts form a list of initial codes which are applied line-by-line to the transcripts (for this study, using NVivo10 software). Initial descriptive codes are grouped into themes which were refined using constant comparison : a process throughout the analysis of comparing units of data with the entire data set and emerging theories, to modify constructs and relationships between them. 38 For this study, AG analysed all of the transcripts, and EW and GF each analysed a subset. The researchers familiarised themselves with the data, identifying text that was relevant to the research question. AG generated initial descriptive codes, a vast index to encompass everything that might be of interest. AG then collated linked codes in tentative groupings at the broader level of themes. The themes were honed, through discussion, until consensus between the authors was reached, and any relationships between the coded data were noted—this was an iterative process which distilled and refined in a cyclical fashion. 39

In the end stages, fieldnotes were revisited to check whether the honed themes reflected the key messages recorded immediately postinterview.

In the presentation of findings, illustrative quotes from participants' narratives are used. The parentheses after each quote contain the participant's pseudonym and their relationship to the survivor.

The generated themes described a variety of different types of impact on health and well-being experienced by informal supporters of survivors. For clarity, the impacts on psychological and emotional well-being have been split into two sections. The first describes the impacts people experienced following the witnessing (either visually or by description) of incidents, such as shock, fear and panic. The second relates to impacts that were connected with the overall strain and pressure of the situation, including: anger, frustration, anxiety, distress, sadness, confusion and guilt. In the final section of the findings, the impacts on physical health are described; where the stress of the situation had begun to take a toll on people's functioning and physiology.

Psychological and emotional impacts

A large theme that emerged from the interviews was the impact on psychological and emotional well-being, which one participant described as the emotional burden. People talked about the recurrence or persistence of these impacts, with several suffering ill-effects long after abusive relationships had ended. Many of the impacts were experienced concurrently or in succession; thus, there was a cumulative effect on people's well-being.

Impacts following the witnessing of incidents

Shock and horror.

Several participants spoke of their shock when they first heard about the abuse, witnessed it first-hand or witnessed the aftermath. For a few participants, this shock was particularly triggered by seeing survivors' injuries following physical violence, or by unfolding revelations about the extent of the violence.

Fear and panic

This shock, at what the perpetrator was capable of, could lead to fear and panic, in response to a sense of threat that participants felt for their own safety: Suzie (a mother to a survivor) spoke about how frightened she was when the perpetrator was threatening to kill her . For Vicky, it was a growing sense that the perpetrator was a very dangerous man: I thought, ‘If he's worked out that I'm interfering and trying to pull her away from him, trying to help her to escape, he may well do anything irrational to me to stop me from interfering.’…I had to really train myself to remember that the bogey man wasn't there, [the perpetrator] wasn't there, I'd parked my car, there was nobody around, walk with purpose, be confident, he's not gonna attack you. (Vicky, Work colleague)

For other people, fear was linked with situations they recognised as highly dangerous for the survivor. These fears were proportional and realistic about potential outcomes, including: the abduction or harming of children and the death or serious injury of the woman. Emily described how panic could ensue during periods when the survivor's future was in doubt: I was kind of living on adrenalin, I was sort of just walking from room to room. I couldn't sit down, I couldn't concentrate. My mind was just racing, I was just in a state of panic. (Emily, Mother)

Impacts resulting from the overall strain of the situation

Anger and frustration.

Most participants talked about feelings of anger and frustration. For people who felt these emotions, the predominant cause was the perpetrators' behaviour towards survivors and children: I felt this anger welling up inside of me, and I just felt that I needed to sort of move away from him. … It's building up, and I can feel it. I just feel that, I mean I want to go round there and give him a good hiding, and I'm 70. (Eric, Father)

Several people also mentioned anger towards professionals or relatives, who they felt had responded insufficiently. Often tied with these feelings was a strong sense of injustice; that what was right had not prevailed: I feel very angry that no one helped her. And now I know that it was Social Services' responsibility to help the child and to help her. It was their responsibility… I still feel angry, because I think the way they did it, the baby could have died, they were putting the baby at risk. (Zakia, Friend)

For many, there was nothing short-lived about their anger, particularly where the perpetrator continued to be abusive towards the survivor via his contact with their children. In addition to anger, people often mentioned a level of frustration they felt towards the survivor, largely when they believed she was not using her capacity to act.

Anxiety and worry

All of the participants described feeling anxious or worried about the situation, and for many people, these feelings, and the associated thoughts, pervaded their lives for a period of weeks, months or even years. Some people described worry in the initial stages of the relationship, before they knew about the abuse, which manifested as nagging concern: It was when we were on holiday and I saw how he was towards my granddaughter that I was very worried, and when we came home I said to my husband that I was very concerned… (Eve, Mother)

Others described anxiety about their interactions with the survivor, or the perpetrator, wanting to guard against making the situation worse. People also mentioned ongoing concerns they had for the survivor after the abusive relationship ended, particularly the continuing potential for harm: I still worry now that he'll hurt her, I don't ever feel 100% that something bad isn't gonna happen. (Gwen, Sister)

Fear, following exposure to abuse, could manifest as anxiety longer term, as people began to imagine all the possible outcomes of the situation. This was true for Emily, who had feared that her daughter would re-enter the abusive relationship: I was just pacing the floor, just crying, just hysterical, I was like close to the edge. I couldn't go to work, I had to take weeks off work, ‘cos I couldn't focus, I couldn't go to work; I was just beside myself, absolutely beside myself. I really thought that there was a possibility my daughter would end up dead, if she went back, to that relationship. (Emily, Mother)

For many participants, anxious thoughts had persisted, particularly where the survivor was viewed as vulnerable, for example: by being young, by living far from their support network or by having recently exited the relationship.

Distress and upset

The feelings of distress and upset that people described were sometimes connected with changes in their relationship with the survivor, and sometimes with thoughts about the abuse the survivor had suffered. For Stacey, it was her friend Hannah's decision to remain in the relationship that was incredibly upsetting: I haven't been able to contact her, because it's just too upsetting to me… ‘He's now hurting you. How's it gone from there to there?’ And then I've told her, and then that's all I can do. I can't do anymore ‘cos I'm just so upset. (Stacey, Friend)

In describing what her team of colleagues had been exposed to, Vicky spoke metaphorically of a little container of terrible distress , an awfulness that was not easy to shake, due to the nature and frequency of abuse their colleague suffered.

Several participants talked about the longevity of distress. Suzie, for example, spoke of continued pain evoked by memories of harrowing times while supporting her daughter. People who had been in an abusive relationship themselves, or who had been exposed to DV during childhood, spoke of their distress as memories of their own past resurfaced: To watch it happening to somebody else I found very distressing…I was very frightened of my father at that age. (Lily, Friend)

Overwhelm and saturation

Some participants spoke about having reached a point where they felt overwhelmed or saturated, using words like, breaking point , exhausted and drained to convey the all-consuming nature of the situation. Others described peaks and troughs of intensity, and the need to take time out on occasion, to protect their own sense of well-being.

Tension and turmoil

Linked with feelings of shock, that some people experienced when they first heard about the situation, several participants also described the longer term challenges to their core beliefs about: humanity, justice and safety in the world. The way people described these impacts intimated the unsettling nature of having foundational assumptions called into question. Josie discovered that three women she knew had been abused by partners, which challenged her ideas about DV not happening to women who were professional or strong . Lily also struggled with the idea that her intelligent and dynamic friend chose to remain in an abusive relationship, and Emily was unsettled by the idea that DV could happen to people who were like her. For others, it was the fact that the survivor was prepared to remain with a violent man that led to their bewilderment : I didn't know how people could live like that, how you could treat someone like that, or even how you could go back to someone after they'd treated you like that. (Anne, Friend)

Many participants also described inner dissonance; conflicting pressures within themselves, leaving them ill-at-ease. Before they had understood the situation, Sally and Eric experienced tension between their love for their daughter, and frustration at the way Amanda was behaving towards them. A few participants also spoke of the tension between the desire to intervene and the need to respect the survivor's wishes: She had her plan and we wanted to respect that. But the stress that came with not hiring a van, going there, dealing with him … the stress of that was monumental at times. (Louise, Friend)

Sense of responsibility

Some participants found themselves in a position of feeling a burden, a duty or a weight of responsibility because of the nature of the situation. These people spoke of putting their own priorities on hold, of substantially altering life-plans and of the all-consuming nature of supporting a survivor through intense periods. Where there was complexity in the situation, the sense of responsibility was compounded; for example, where the survivor had an addiction, had children with the perpetrator, had a mental health condition or where she lacked additional social support.

Feeling disempowered

Another description which appeared in people's narratives was disempowerment. Participants spoke about feeling impotent to intervene during the relationship, and to protect and support sufficiently in the aftermath: I felt really helpless that she was going back to situations where we knew she was gonna be hurt, but by then understanding domestic violence, knowing that for her safety that's what she wanted to do. And we only had to go with what she wanted … (Gwen, Sister)

Several people spoke about the persistence of this sense of powerlessness; that months or years after the end of abusive relationship, they still felt unable to stop the perpetrator impacting on the lives of their loved ones: I just feel as if I want to protect my daughter and my grandchildren … it's very, very painful, very painful. But I don't seem to be able to do anything about it. My hands are tied and I need to get her out of this mess. (Eric, Father)

There was also a sense that some people lacked voice; that their experiences and their viewpoints were often disregarded, seen as unimportant or invalidated. Silencing came in many forms; sometimes it was professionals or employers not acting on information, and sometimes the survivor herself, either intentionally or unwittingly, prevented expression. Occasionally, participants silenced themselves by questioning the legitimacy of their feelings: I do [get opportunity to voice those thoughts] a bit, but I guess to some extent I feel that I should be supportive of Judy, because she is the victim and I kind of think I should just be able to be a bit more detached, not feel that way myself, and just be there to support her. (Richard, Partner)

Sadness and depression

Many participants spoke of having felt low at some point; most of these people described a dip in mood that indicated despondency or a temporary sense of hopelessness, but some had been diagnosed with depression, taken antidepressants or had had suicidal thoughts. Suzie mentioned taking antidepressants at a point where she had started to feel numb: I just I remember sitting in an armchair in my living room, literally with the duvet over me and I just couldn't move or I just lost it, I didn't really feel anything and then depression … (Suzie, Mother)

During this time, Suzie considered ending her life, because the circumstances felt so desperate. Likewise, Sally hit a similar point where she could not see a way forward: I decided I'd kill myself (crying) … I felt just done with everything; I was just going to jump in the sea … I remember going, choosing the place. (Sally, Mother)

Confusion and uncertainty

All participants described periods of confusion, not only about the situation itself, and what the trajectory might be, but also about how to best support the survivor and protect themselves. At the point where people knew very little, they described feeling in the dark and trying to work it out ; a piece-meal process to draw their own conclusions about the relationship, which they often discovered were inaccurate or partial: I thought perhaps I'd upset them in some way and I wasn't sure what or how … my assumption was that they had financial troubles, and I was trying to probe to see what it was … I was worried about her. But I didn't know what I was worried about. (Barry, Father)

Stacey made the point that with health conditions, it was possible to have some sense of trajectory and outcome, unlike DV: I think if you have a friend who's got cancer or diabetes or something like, you kinda know what's happening next…But when you're supporting someone who's in a violent relationship, you don't really know when it's gonna end, how long they're gonna need you to support them, or how much worse it's gonna get. (Stacey, Friend)

Guilt and self-blame

The most frequent causes of guilt described by informal supporters were not having known sooner about the DV, and not having understood what the behaviours they had witnessed meant: I'm sad, that we couldn't help her sooner, or that we didn't prevent it from happening, it makes me sort of sad with myself really, I think, and angry at myself and, for not being supportive sooner, and doubting her. (Gwen, Sister)

Several people also described guilt they felt in relation to offering support that felt inferior. This was especially the case where their relationship with the survivor had become strained, or was lost completely. For Kate, a sense of guilt, which had persisted for many years, was her over-riding emotion: I felt really guilty about that … I didn't feel like I could be honest with her anymore… I felt bad about it. Which was horrible of me, I still feel I've been horrible to her, because I didn't, well I don't know if I did the right thing, I still don't know if I did the right thing. (Kate, Friend)

For others, there were feelings of guilt when positive things happened in their own lives, for example, Anne described feelings akin to survivor guilt because she had fled an abusive relationship, started a new relationship, and become a mother, while her friend Sarah remained with her partner, and had been coerced into having an abortion.

Physical health impacts

In addition to psychological and emotional impacts, many people talked about the stress of the situation; a summary term, which they used to describe some of the physical health impacts they experienced.

Physical symptoms and ailments

Mostly, the health repercussions participants mentioned were those which had resulted from heightened states of panic, anxiety, fear, powerlessness and anger, describing feeling sick, shaky and physically unsettled: For me that comes with a physical feeling of almost not being able to breathe and feeling churned up inside… (Suzie, Mother)

A few people mentioned less transient physical ailments that they felt had resulted from the stress of supporting a survivor: back and neck tension, migraines, shortness of breath and tight-chestedness. Eric, in particular, felt his symptoms (similar to those of a heart attack) were connected with the anger and powerlessness he felt.

Sleep difficulties

Friends and relatives of survivors described broken sleep for a period of time, linked with relentless concerns for the survivor, or worries regarding their role. Relatives and partners, in particular, reported loss of sleep at critical times: I was close to breaking point, I didn't sleep. … And I thought, this means she'll go back to him, and I remember I didn't sleep at all that week, I was just pacing the floor. (Emily, Mother)

People who mentioned sleep difficulties talked about the impact of late evening communication with the survivor, or with others involved. Some proposed an association between reduction in quality of sleep and the intense emotions experienced.

Appetite and weight loss

Mark and Emily mentioned loss of appetite and weight loss when discussing their health, describing it as their bodies' default response to stressful events. For Mark, it was triggered when he tried to relieve the pressure on his wife by dealing with reams of solicitor correspondence. For Emily, it happened during a time of huge anxiety, while trying to persuade her daughter from returning to the perpetrator.

The interviews highlighted that impacts on health and well-being of informal supporters of DV survivors were many and varied. There was a spectrum of experience in terms of severity and longevity of impact, with informal supporters describing different impacts from one another, and also changes in impact at different stages in their individual journeys. The identification of subgroups of participants with differing experiences was complex, for example, while the relationship between the informal supporter and the survivor was important, it was not whether they were relatives, friends or colleagues, but rather the quality of the relationship which mattered. The gender of the informal supporter, whether or not the survivor had children, and the level of abuse the informal supporter knew about were additional mediators of impact. Further research is needed for a greater understanding of how variance in the DV situation and in the characteristics of informal supporters influence impact.

Many of these impacts, such as anger, fear, sadness, helplessness and disruptions to sleep and to core beliefs, are sequelae of trauma; the same symptoms as those known to be experienced by people following direct exposure to traumatic events. 40 , 41

One of the suggested mechanisms through which traumatic experiences have health implications is the stress-process framework. 42 , 43 Within this framework, external stressors provoke physiological and psychological responses, 43 , 44 which impact on health and well-being, particularly if the stressors are over a long period. Given that the average length of an abusive relationship is 5 years, 45 those involved are certainly at risk of chronic stress and its sequelae. More than 20 years ago, Figley 46 , 47 suggested that these effects were not limited to the person experiencing traumatic events; that emergency responders and therapists could also be affected, particularly when repeatedly exposed to incidents or disclosures over time. More recently, changes to the DSM-5 have drawn attention to those providing informal support as well as those providing professional support. 25 The findings from this study add weight to the idea of risk of STS for people providing informal support in the particular scenario of DV. In addition, research suggests differential experiences of traumatic stress dependent on factors such as personal characteristics, sociodemography, social support and aggregate life events. 42 , 43 , 46 , 48 The variation in reported impacts (in terms of type, severity and longevity) by participants in this study lends support to this idea.

Moreover, there is overlap between the findings from this study, and research with people providing informal support to relatives or friends who have experienced other forms of trauma. For example, one in three spouses of Holocaust survivors were found to be suffering from psychological distress and STS symptoms, 49 and Christiansen et al 24 reported that relatives, friends and partners of men and women who had been raped showed ‘significant levels of traumatization’ , with 25% suffering from PTSD.

Implications for policy, practice and research

The findings from this research indicate that the health and well-being of informal supporters are affected in situations of DV. In terms of policy, the social context of survivors is rarely visible, which needs to be addressed, so that the needs of informal supporters are considered. In addition, there is need for professionals who work in positions where they routinely come into contact with survivors to attend to other people within the situation; reflecting on who might be experiencing impact, and providing opportunities for disclosure, and for legitimisation of concerns. Healthcare providers, in particular, are well placed to respond to all parties affected by DV, which is why training around this issue for doctors, nurses and allied health professionals is vital. 50–52

Research about informal supporters is crucial for understanding the context of survivors' lives. 53 Specifically, with the intention of improving outcomes for informal supporters and for survivors, research is needed to develop and test interventions directly targeting those in the social networks of survivors.

Strengths and limitations

One of the limitations of this research is that the sample lacked breadth for certain sociodemographic characteristics, ethnicity in particular. People from minority ethnic backgrounds are frequently under-represented in research 29 and, while substantial effort was made to recruit people from a variety of ethnic backgrounds, this was not especially successful. Moreover, though a wide definition of DV was used (to include perpetrators who were other family members), the experiences captured were almost exclusively those of informal supporters of survivors of intimate partner violence. The reported findings relate specifically to this sample, so it is possible that the experiences of other people providing informal support to a survivor would differ.

A key strength of this study is the novelty of perspective because it accessed the experiences of informal supporters of survivors directly, which is vital in order to understand the wider context and implications of DV.

Research has drawn attention to the extent to which women experiencing violence seek support from their friends, colleagues and family members, and the advantages this can have for their well-being and safety. The impact that this has on the health and well-being of people providing informal support has previously been unexplored. Findings from this study indicate the physical, psychological and emotional impacts on people providing informal support, suggesting that this is a group of people who may be at risk of STS. In order to prevent and reduce these impacts, informal supporters of survivors would benefit from recognition of their predicament, and provision of support, so that their own well-being, quality of life, capacity and coping are not diminished. These findings have practical and policy implications, so that the experiences and needs of the full range of people in DV scenarios are legitimised and met.

Acknowledgments

The authors would like to acknowledge and sincerely thank all the participants who took part in this research.

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Contributors As part of her PhD, AG secured the funding, designed the reported study and carried out the data collection. AG analysed the data in collaboration with EW, AT and GF. AG wrote the first draft of the manuscript. All authors critically revised the manuscript and approved the final version.

Funding This research was conducted as part of PhD study which was funded by the National Institute for Health Research (NIHR) School for Primary Care Research and was hosted by the University of Bristol.

Competing interests None declared.

Ethics approval Research Ethics Committee in the School for Policy Studies at the University of Bristol.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Linked Articles

  • Correction Correction: Qualitative study to explore the health and well-being impacts on adults providing informal support to female domestic violence survivors British Medical Journal Publishing Group BMJ Open 2019; 9 - Published Online First: 30 May 2019. doi: 10.1136/bmjopen-2016-014511corr1

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Who Gets heard/hurt in Gender-Based Domestic Violence Research: Comparing Ethical Concerns in Three Qualitative Research Designs

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qualitative research methods domestic violence

  • Blanka Nyklová   ORCID: orcid.org/0000-0003-1369-2408 1 ,
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The study presents the ethical concerns the authors have identified as necessary to address for methodologically sound qualitative research with survivors of gender-based violence. The aim is to define questions that need to be addressed before research with this vulnerable and diverse group can be considered so that the threat of inflicting further harm is mitigated and the possible positive impact of research is increased. We outline and compare the merits and possible drawbacks of three different approaches to research with gender-based violence survivors.

We compare the ethical/methodological rationale and approaches used in three different projects employing mixed-method exploratory research, survivor-centered qualitative interview-based research and experimental research through practices from the theatre of the oppressed. The comparison centers on showing the relative advantages of individual approaches in terms of ethics in practice.

The individual studies and their comparison confirm the ongoing salience of ethical considerations outlined by, e.g., proponents of feminist participatory action research; our findings also underline the necessity of considering the social contexts of violence and the need to adjust research design to ethics.

Conclusions

Our study shows that using research designs that do not lead to direct empowerment of survivors should only be considered after other options have been tried and proven inefficient. Ethical considerations need to be holistic, focusing on preventing further harm and paying attention to the social contexts of violence and the impact of representing the research results.

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qualitative research methods domestic violence

Engaging in Gender-Based Violence Research: Adopting a Feminist and Participatory Perspective

qualitative research methods domestic violence

participation in practice: a case study of a collaborative project on sexual offences in South Africa

Survivor-centered research: towards an intersectional gender-based violence movement.

The English version of the Code is available online: https://www.avcr.cz/en/about-us/legal-regulations/code-of-ethics-for-researchers-of-the-czech-academy-of-sciences/ (Cited on March 24, 2023).

The English version of the Code is available online: https://cuni.cz/UKEN-731.html (Cited on March 24, 2023).

In March 2021 – a month after publishing research report - 25 media outputs were scored by the press department of Faculty of Humanities, Charles University of Prague.

Interviews are collected by the second author, Dana Moree, at the time of writing of this article.

One of the authors is trained in the method and has worked with a wide range of marginalized groups for ten years.

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One of the authors, Blanka Nyklová, was previously approached by another NGO to help design a quantitative questionnaire and later edit an extended research report from a mixed-method research project into sexualized violence. Her involvement was less direct and we therefore do not detail it here, although it did impact her work with NGOs working with survivors.

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The research presented in the paper was funded by an Iceland, Liechtenstein and Norway Funds grant no. LP-HRMGSA-009 Research Center for Domestic and Gender-Based Violence (ReCeGe).

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Nyklová, B., Moree, D. & Kubala, P. Who Gets heard/hurt in Gender-Based Domestic Violence Research: Comparing Ethical Concerns in Three Qualitative Research Designs. J Fam Viol 38 , 1127–1138 (2023). https://doi.org/10.1007/s10896-023-00589-5

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Identified in the late eighties as the number one public health risk to adult women by the Surgeon General of the United States, domestic violence remains the leading cause of injuries to women, ages 15 to 44, more common than muggings, auto accidents and cancer deaths combined (U.S. Senate Judiciary Committee, 1992). Academics and practitioners have assessed the problem and its potential solutions using both quantitative and qualitative research methods. Yet, how far have we come and how much do we really know? This paper will attempt to answer these questions by critiquing the "current state of affairs" of domestic violence research. Common theories of causation and their applications to social work theory and practice will be delineated and an ecologically based intervention for domestic violence will be proposed.

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AU - Wodarski, John S.

PY - 1995/6/1

Y1 - 1995/6/1

N2 - Identified in the late eighties as the number one public health risk to adult women by the Surgeon General of the United States, domestic violence remains the leading cause of injuries to women, ages 15 to 44, more common than muggings, auto accidents and cancer deaths combined (U.S. Senate Judiciary Committee, 1992). Academics and practitioners have assessed the problem and its potential solutions using both quantitative and qualitative research methods. Yet, how far have we come and how much do we really know? This paper will attempt to answer these questions by critiquing the "current state of affairs" of domestic violence research. Common theories of causation and their applications to social work theory and practice will be delineated and an ecologically based intervention for domestic violence will be proposed.

AB - Identified in the late eighties as the number one public health risk to adult women by the Surgeon General of the United States, domestic violence remains the leading cause of injuries to women, ages 15 to 44, more common than muggings, auto accidents and cancer deaths combined (U.S. Senate Judiciary Committee, 1992). Academics and practitioners have assessed the problem and its potential solutions using both quantitative and qualitative research methods. Yet, how far have we come and how much do we really know? This paper will attempt to answer these questions by critiquing the "current state of affairs" of domestic violence research. Common theories of causation and their applications to social work theory and practice will be delineated and an ecologically based intervention for domestic violence will be proposed.

UR - http://www.scopus.com/inward/record.url?scp=21844516861&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=21844516861&partnerID=8YFLogxK

U2 - 10.1007/BF02191682

DO - 10.1007/BF02191682

M3 - Article

AN - SCOPUS:21844516861

SN - 0091-1674

JO - Clinical Social Work Journal

JF - Clinical Social Work Journal

A qualitative quantitative mixed methods study of domestic violence against women

Affiliations.

  • 1 School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran. [email protected].
  • 2 School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran.
  • 3 Amir Al Momenin Hospital, Social Security Organization, Ahvaz, Iran.
  • 4 Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran.
  • 5 Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran.
  • 6 Clinical Research Development Unit, Kowsar Educational, Research and Therapeutic Hospital, Semnan University of Medical Sciences, Semnan, Iran.
  • 7 Student Research Committee, School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran.
  • PMID: 37340321
  • PMCID: PMC10283315
  • DOI: 10.1186/s12905-023-02483-0

Background: Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today's world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

Methods: This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi's 7-step method.

Results: In qualitative study, seven themes were found including "Facilitators", "Role failure", "Repressors", "Efforts to preserve the family", "Inappropriate solving of family conflicts", "Consequences", and "Inefficient supportive systems". In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions: Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Keywords: Cross-sectional studies; Domestic violence; Iran; Qualitative research.

© 2023. The Author(s).

  • Cross-Sectional Studies
  • Domestic Violence*
  • Interviews as Topic
  • Middle Aged
  • Qualitative Research

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ADVANCING THE STUDY OF VIOLENCE AGAINST WOMEN USING MIXED METHODS: INTEGRATING QUALITATIVE METHODS INTO A QUANTITATIVE RESEARCH PROGRAM

Maria testa.

Research Institute on Additions, University at Buffalo, 1021 Main Street, Buffalo NY 14203, (716) 887-2560, ude.olaffub.air@atset

Jennifer A. Livingston

Research Institute on Additions, University at Buffalo, 1021 Main Street, Buffalo NY 14203, (716) 887-2380, ude.olaffub.air@tsgnivil

Carol VanZile-Tamsen

University at Buffalo, 115 Fargo Quad, Buffalo NY 14261, (716) 645-3511, ude.olaffub@3vmc

A mixed methods approach, combining quantitative with qualitative data methods and analysis, offers a promising means of advancing the study of violence. Integrating semi-structured interviews and qualitative analysis into a quantitative program of research on women’s sexual victimization has resulted in valuable scientific insight and generation of novel hypotheses for testing. This mixed methods approach is described and recommendations for integrating qualitative data into quantitative research are provided.

Since first identified as a problem worthy of study in the 1970’s, tremendous progress has been made in understanding physical and sexual violence against women. Increasingly sophisticated quantitative studies have identified predictors and mechanisms underlying violence and its subtypes and provided support for theoretically derived hypotheses. Qualitative research has provided important insight into the subjective experience of violence and a greater understanding of the context and meanings associated with it. Independently, quantitative and qualitative studies can contribute much to the understanding of this complex phenomenon. However, it is the combination or integration of the two approaches, known as mixed methods research ( Creswell, 2009 ; Creswell & Plano Clark, 2007 ; Tashakkori & Teddlie, 2003 ), that offers perhaps the best and most thorough means of understanding violence against women (see Murphy & O’Leary, 1994 ). This paper describes a program of mixed methods research on women’s sexual victimization and highlights the synergy resulting from the simultaneous integration of these two different approaches. This hybrid, mixed methods approach has resulted in triangulation of quantitative and qualitative findings, novel insights, and testable hypotheses that have greatly enhanced our program of research.

Mixed methods research can benefit any area of study, from persuasion ( Cialdini, 1980 ) to workplace drinking ( Ames & Grube, 1999 ). However, the use of mixed methods is particularly appropriate for studying physical and sexual violence against women. Violence against women is a complex, multi-faceted phenomenon, occurring within a social context that is influenced by gender norms, interpersonal relationships, and sexual scripts. Many have argued that women’s experiences of violence cannot be understood in a purely quantitative manner, divorced from their context (e.g., Gavey, 2005 ; White, Smith, Koss, & Figueredo, 2000 ). Because they typically occur in private and cannot be observed or manipulated in a laboratory setting, understanding of these experiences of violence is dependent on the subjective meaning for the woman and cannot easily be reduced to a checklist. For example, in the case of sexual violence, a behavior that may be appropriate and welcome in one context (or by one woman) may be viewed as coercive in another.

Mixed Methods Research: Integration of Quantitative and Qualitative Approaches

Quantitative and qualitative research involve very different approaches. Quantitative research begins with pre-determined, instrument-based questions, designed to test a priori hypotheses. In contrast, qualitative methods typically involve naturalistic or holistic collection of data through observation or from the perspective of the participant. At the end of this continuum is ethnographic or participant-observer research, in which the researcher observes an unfamiliar culture, without preconceived notions ( Lofland, 1971 ; Spradley, 1980 ). Qualitative approaches are usually inductive, in that they involve deriving meaning or theory from the data (see Boyatzis, 1998 ; Miles & Huberman, 1994 ; Spradley, 1980 ; Corbin & Strauss, 2007 ). Specific methodology is needed to analyze qualitative data in a rigorous manner, for example, thematic analysis is a commonly used, flexible technique that involves “identifying, analyzing and reporting patterns or themes within data … to find repeated patterns of meaning” ( Braun & Clarke, 2006 ).

Mixed methods research involves the integration of these two very different approaches. Qualitative and quantitative data can be integrated in different ways and at different points in the research process ( Creswell, 2009 ; Maxwell & Loomis, 2003 ; Miles & Huberman, 1994 ). For example, it is becoming increasingly common to conduct a small number of interviews or focus groups ( Krueger & Casey, 2000 ) as an initial pilot step before beginning a full-scale research project in a new area (e.g., Noonan & Charles, 2009 ). Alternatively, interviews or focus groups can be conducted to follow up on quantitative findings, particularly those that are surprising (e.g., Peterson & Muehlenhard, 2007 ). Although we have used both approaches, we have found qualitative data to be most valuable when integrated or embedded within a larger quantitative program of research. This simultaneous integration has not only helped to establish convergent validity between qualitative and quantitative findings but has been invaluable in the generation of hypotheses and new ways of thinking. It is this process that we describe in this paper.

Although the term “mixed methods” may be fairly new, it is not a new approach. In fact, well-known social psychologists including Sherif, Milgram, Cialdini, Festinger and Zimbardo all integrated qualitative data into their famous studies, both concurrently, as well as sequentially (see Fine & Elsbach, 2000 ; Milgram, 1974 ). The integration of qualitative and quantitative can be quite natural, as for example, when observation of a naturally occurring phenomenon leads to hypotheses and experimentation (and back to external validation), a process described as “full-cycle social psychology” ( Cialdini, 1980 ). We believe that many quantitative researchers probably engage in some form of implicit, mixed methods research, as they draw research ideas from naturalistic or clinical observation or seek confirmation or validation of their quantitative results in the real world. However, many quantitative researchers lack familiarity or appreciation of qualitative methods, and consequently dismiss these approaches as foreign and not applicable, or worse, as inferior. Our goal is to convince these researchers of the value of integrating qualitative data and data analysis into their quantitative research. To do so, we document our personal experiences in a program of research in which the decision to supplement a quantitative program of research on women’s sexual victimization with semi-structured interviews resulted in invaluable scientific insight.

A Mixed Methods Approach to Women’s Sexual Victimization

As is common in many graduate psychology programs, the bulk of training and research experience for all three of us was quantitative rather than qualitative. My own experience (MT) with qualitative data began serendipitously. As an experimental social psychologist, my only familiarity with qualitative research was an introduction to ethnography in a graduate methodology course. It seemed like an exotic, Margaret Mead-type of endeavor that I was unlikely ever to undertake. Then, just as I was completing graduate school I accepted a job as a project director on one of the first studies to examine the interrelationships among women’s alcohol use and their experiences of victimization, a topic about which I knew nothing at the time. Data were collected in person, and tape recorded, and often involved long, emotional interviews in which participants revealed experiences of childhood sexual abuse and victimization by intimate partners which in many cases they had never previously disclosed. Whenever I had the time, I listened to the tapes of these interviews, as I struggled to try to understand the circumstances by which something so horrific could occur. Twenty years later I can still recall many of the stories that I heard. There was something about hearing about these experiences in the participant’s own voice (literally) that went far beyond what any quantitative relationships among variables could reveal. Although the data were never formally analyzed, they provided me with a “feel” and an insight for what these experiences were like, how they came about, the context, and how women were affected by and coped with them. They were, in a sense, subjected to a sort of rudimentary thematic analysis in my head as I sought to make sense of them.

In the early 1990’s, I began an independent, funded program of research on women’s alcohol use and sexual risk taking. Although I operationalized sexual risk in terms of HIV risk behaviors (e.g., failure to use condoms, sex with partners not well known), I had a vague notion that similar processes might be involved in women’s vulnerability to sexual victimization as well and decided to include the Sexual Experiences Survey (SES, Koss, Gidycz, & Wisniewski, 1987 ). For women who reported any victimization experiences on the SES, the measure was followed by a semi-structured interview regarding these incidents. Most of these interviews were conducted by Jennifer Livingston, then a graduate student in educational psychology, who was the head interviewer on the project. Although interviews were originally intended to provide information for quantitative analysis of the events (e.g., alcohol use, relationship to perpetrator), the interviewer began by asking the woman to describe in her own words how the event came about, as a way of facilitating recall and helping her to fix the event in her mind. These descriptions of victimization incidents, from the victim’s perspective, provided a critical window into understanding sexual victimization that could not be obtained through quantitative description alone. I did not realize at the time I began that I was designing mixed methods research nor did I anticipate conducting thematic or other qualitative analysis. Rather, it was a sincere desire to understand a phenomenon that motivated the simultaneous collection of qualitative data and the later analysis of it. Although we were not the only ones to integrate qualitative and quantitative data in the study of sexual victimization (see Norris, Nurius, & Dimeff, 1996 for an excellent example), we began our inquiry at a time when the body of research was limited, particularly with respect to understanding of alcohol and victimization. Thus, qualitative analysis was particularly well suited to this early stage of investigation.

The original study yielded 100 transcribed descriptions of incidents of sexual assault which we analyzed using a combination of content analysis, thematic analysis, and quantitative comparisons. For 6 months, we (MT and JL) read and took notes on index cards and discussed and shuffled index cards and read and discussed some more. 1 We knew the descriptions so well that we could refer to “Hands” and the other would immediately recall the whole story. The paper that resulted from our immersion in the data ( Testa & Livingston, 1999 ) offered unique insight into sexual assault incidents and how they come about from the perspective of the victim. For example, although the term “date rape” was frequently used by researchers at that time, the majority of incidents did not occur on dates, even within this sample of young, sexually active, single women. Coercion incidents stood apart from most others in their absence of force or obvious pressure, and led us to study this phenomenon further in a later qualitative investigation ( Livingston, Buddie, Testa, & VanZile-Tamsen, 2004 ). Importantly, the analysis made clear the heterogeneity of sexual assault incidents. At that time, the first round of quantitative studies was attempting to identify quantitative risk factors for women’s sexual victimization, frequently with disappointingly weak results for individual variables such as women’s drinking (e.g., Gidycz, Hanson, & Layman, 1995 ; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997 ). Our initial qualitative analysis of sexual assault incidents suggested the reason: sexual assaults arose from several very different circumstances and situations, some involving heavy drinking at parties, some reflecting a pattern of coercive sex within an intimate relationship, and others arising “out of the blue” within non-sexual situations. Thus, it was plausible that these different types of sexual assault would be associated with different risk factors.

Based on the notion of heterogeneity that arose from our initial qualitative analysis, we subsequently tested a set of hypotheses that risk factors would be specific to different types of sexual victimization. For example, using quantitative data from the same study, we tested the hypothesis that sexual assertiveness should be more predictive of coercion than rape whereas alcohol consumption should be more strongly associated with rape ( Testa & Dermen, 1999 ). In the longitudinal “Women 2000” study that followed, we examined similar hypotheses regarding heterogeneity of types of sexual assault resulting in different risk factors. We found that sexual assertiveness was a significant prospective predictor of victimization from intimate partners (often verbal coercion) but not victimization from non-intimate perpetrators. In contrast, frequency of heavy episodic drinking predicted the latter but not the former ( Testa, VanZile-Tamsen, & Livingston, 2007 ).

At about the time the Testa and Livingston (1999) paper was published, we were launching the “Women 2000” study, a larger version of the previous work, using a representative local sample of 1,014 women. Again, we collected descriptions of incidents of sexual victimization, to enable both quantitative and qualitative analysis, having been convinced by the earlier study of the value of qualitative inquiry. Because of the much larger sample size, interviews with women who had experienced sexual victimization yielded 361 interview transcripts, some with multiple incidents. To manage this daunting pile, we divided the workload initially into coercion incidents and rape incidents. Analysis of the coercion incidents was headed by JL, whereas the rape incidents were given to CVZT, who had recently joined the project as a quantitative data analyst but also had some training and experience with qualitative analysis.

Soon after beginning what we intended to be thematic analysis of rape incidents we identified a cluster of incidents that clearly stood apart from the rest. These incidents all seemed to involve the same story: excessive alcohol consumption, resulting in the victim having only vague awareness of a man having sex with her, while being unable to speak or resist. In contrast to the other rape incidents, which were emotionally draining to read because of the horror and trauma conveyed by the victim, these had a fuzzy, dreamlike quality to them as the trauma was dulled by alcohol. The difference was so striking that we abandoned the thematic analysis and focused on contrasting these “incapacitated rapes”, as we came to call them, from the forcible rape incidents. Consistent with the heterogeneity of sexual victimization notion, quantitative analyses revealed that incapacitated rape, but not forcible rape, was associated with substance use ( Testa, Livingston, VanZile-Tamsen & Frone, 2003 ). However, more importantly, the identification of incapacitated rape as an additional subcategory marked an important shift in thinking about alcohol and rape for us, if not for others since. That is, it led to the insight that the association between alcohol and rape was probably driven by alcohol’s association with incapacitated rapes, since most forcible rapes did not involve victim alcohol use, or if they did, it was at more moderate levels. Accordingly, in many cases of alcohol-involved rape or sexual assault, women’s vulnerability does not stem from impaired judgment or risk perception resulting from drinking ( Steele & Josephs, 1990 ) as many had theorized, but because alcohol has rendered the victim unconscious or unable to move or speak, far beyond the impaired judgment stage.

Meanwhile, qualitative analysis of the sexual coercion incidents revealed a significant difference in tactics depending upon sexual precedence. Perpetrators who already had a sexual relationship with the woman used primarily negative coercive tactics (e.g. threats against relationship), whereas those who had not already had sex used positive tactics, such as sweet talking the woman into having sex ( Livingston et al, 2004 ). Sexual precedence implied subsequent entitlement to sex, leading men to berate and threaten women who failed to comply with these social and cultural norms regarding sexual relationships. The notion of sexual precedence as a key variable in determining sexual aggression tactics and outcomes was not one that had occurred to us a priori . Previous quantitative research had considered the level of acquaintance between victim and perpetrator and failed to find consistent effects of this variable on event-level sexual assault outcomes (e.g. Ullman et al, 1999a , 1999b ). Since sexual precedence often coincides with relationship status, it was not obvious that precedence was the underlying mechanism. It was qualitative analysis that made it clear that it was sexual precedence, rather than the nature of the acquaintance that was a key variable to consider. We subsequently included sexual precedence in a quantitative analysis of sexual assault outcomes and found that it was the best predictor of whether penetration occurred ( Testa, VanZile-Tamsen, & Livingston, 2004 ).

While conducting the qualitative analyses of rape and coercion incidents, we were faced with a perplexing issue. The event-based interview upon which our qualitative analyses were based was initiated based on women’s responses to a slightly revised Sexual Experiences Survey (SES) administered using computer assisted self-interviewing (CASI). The interviewer was able to access the woman’s SES responses and began the interview by reminding her which items she had endorsed and clarifying what items occurred on the most recent occasion. Then she asked the woman to describe what had happened in her own words. It became clear very early in the study that what the woman reported on the SES and what she actually described as happening did not always match. Errors in reading or marking answers didn’t seem to account for the substantial number of discrepancies. We began an “error log”, in which the interviewer logged the discrepancy between what the woman reported on the SES and what she seemed to be describing. In generating lists of transcripts for the rape and the coercion analyses, we found even more cases of apparent mismatches – for example, penetration occurred although the woman had reported an attempted rape item. In our quest to provide the most accurate estimate of prevalence of different types of sexual assault, we began to make “corrections” to the data to reflect what we thought the woman was really describing, rather than what she actually reported on the SES. However, in reading these transcripts over and over and thinking in depth about the incidents, we began to question and then abandon this approach. For one thing, we started to notice some systematic patterns in the discrepancies. For example, incidents in which the perpetrator was an intimate partner tended to be assigned by the woman to a less severe category than when the same behavior was perpetrated by someone less well known. This led to testing – and support - of the hypothesis with experimental data ( VanZile-Tamsen, Testa, & Livingston, 2005 ).

Eventually, we began to see that what we originally saw as errors or noise was actually something much more interesting, suggesting individual differences in interpretations of SES items. We realized that we were “correcting” the respondents reports based on our own interpretation of the SES items. We tended to agree amongst ourselves as to what the “correct” labels for the women’s experiences were; however, it remained an empirical question whether others who are not sexual assault researchers view the items the same way. As researchers, we strive to create items that capture the subtleties of definitional or legal aspects of different types of sexual aggression. However, it is easy to lose sight of the fact that these items will be read and interpreted by a wide range of people who have not spent years studying sexual assault, and whose experiences might not exactly match the wording of the items (see Hamby & Koss, 2003 , Thoreson & Overlien, 2009 ). Once again, the qualitative data and our immersion in it led us to an insight that we never would have had otherwise. The result was a paper in which we consider the match between the labels that respondents use for their experiences of sexual victimization and those applied by independent coders ( Testa, VanZile-Tamsen, Livingston, & Koss, 2004 ). We found that SES rape and coercion items elicited respondent recall of events that independent coders generally agreed reflected rape and coercion, respectively. However, with contact and attempted rape experiences, agreement between respondents and coders, and among coders, was much lower. Although the published paper reflects a quantitative presentation, it was actually the qualitative data that led us to this analysis.

Conclusions

Qualitative analysis of our data has resulted in numerous “a-ha” types of insights that would not have been possible had we relied solely on quantitative data analysis (e.g., identification of incapacitated rape and sexual precedence, heterogeneity in the way that sexual assaults arise) and also helped us to understand puzzling quantitative observations (e.g., the mismatch between SES reports and descriptions of incidents). These insights, in turn, led to testable, quantitative hypotheses which supported our qualitative findings, lending rigor and convergence to the process. We never could have anticipated what these insights would be and that is what is both scary and exhilarating about qualitative data analysis, particularly for a scientist who has relied on quantitative data analysis and a priori hypothesis testing. The lengthy process of reading, coding, rereading, interpreting, discussing, and synthesizing among two or more coders is undeniably a major investment of time. However, we believe that it is time well spent if the goal is deeper understanding of data. The use of multiple coders and reliability checks (see Miles & Huberman, 1994 for a more detailed discussion of reliability) not only prevented the analysis from being biased by a single person’s perspective, working collaboratively was a great advantage in that it fostered deeper and more creative thinking than working alone. It is the process of doing qualitative analysis – immersive, iterative - that is critical in developing ideas and making intellectual leaps. Because it is more time consuming and more personal than quantitative analysis, the synthesis and analysis that result become so integrated into one’s brain – or in our case, into our collective brains – that it becomes difficult to recall where these ideas and hypotheses arose in the first place.

In an ideal mixed-methods world, quantitative and qualitative data would be integrated and proceed together as a field of study develops. This integration has occurred to some degree within the study of women’s sexual victimization, which has been fairly friendly to qualitative inquiry and mixed methods research. However, this has not been the case in all areas of violence research. We believe that it is not too late to introduce qualitative methodology in these areas and that such inquiry may help to lend new insights to long-standing controversies. For example, interpretation of the high rates of female relative to male partner aggression in non-clinical samples has been highly controversial (see Dutton & Nicholls, 2005 ), with feminist researchers citing the limitations of objective, act-based measures such as the Conflict Tactics Scales (CTS-2, Straus, Hamby, Boney-McCoy, & Sugarman, 1996 ) to portray the context and meaning of these acts (see White et al., 2000 ). Qualitative research designed to understand violence from the perspective of the men and women who experience and perpetrate it would seem an ideal means of shedding light on this issue. However, despite qualitative studies of partner violence incidents among battered women samples (e.g., Allison, Bartholomew, Mayseless, & Dutton, 2008 ; Downs, Rindels & Atkinson, 2007 ), there is a surprising absence of such inquiry in non-clinical populations. Using arguments similar to those presented in this paper, I was, in fact, able to convince a senior colleague who had previously conducted only quantitative research on intimate partner violence of the potential value of qualitative data. In-person data collection efforts now include semi-structured interviews regarding incidents of psychological and physical aggression on the CTS by both male and female partners (separately, of course). Preliminary thematic analysis suggests a tendency for both male and female respondents to downplay or excuse physical aggression ( Testa, Derrick & Leonard, 2010 ); however, data collection and analysis are ongoing.

Integrating Qualitative Data into Quantitative Studies: Some Practical Issues

For the quantitative researcher who has not yet collected qualitative data but is considering it, we offer some suggestions and practical issues to consider based on our own experiences, which have involved primarily semi-structured, event-based interviews. We emphasize that we do not consider ourselves experts in qualitative or mixed-methods research and that this brief paper cannot convey all the methodological concerns that should be considered. Accepted methods of qualitative data analysis are rigorous and it will be necessary to consult established methodological resources and, if possible, to consult or collaborate with someone with qualitative data analysis experience before beginning. We have included throughout the paper references to many seminal and comprehensive resources on qualitative data collection and analysis for readers who wish to pursue these issues in more depth.

Perhaps it goes without saying, but the quality of any qualitative analysis is dependent on the quality of the data available, which for us results from the quality of the interview questions and the interviewers’ skill. Questions need to be crafted so that they yield not one word answers, but sufficient information to understand the participants’ perspective. Asking about specific events is preferable to asking about general events or asking about how one felt, since in providing details, important information about the respondent’s perspective will be revealed ( Matthews, 2005 ). Quantitative researchers typically ask a large number of questions, perhaps hundreds within a survey. However, a semi-structured interview may focus on one major question – “how did this event come about?” - followed by probe questions that are shaped by the initial response (e.g., “can you explain what you mean by …?”). When beginning a qualitative analysis, it is frustrating to read interview transcripts that reveal incomplete probing, interviewers putting words in the respondents’ mouths, or seemingly irrelevant or repetitive questions. Ideally, transcripts should reveal big blocks of text from the respondent, rather than a lot of back and forth questions and short answers. As aptly stated by Matthews: “Researchers ask questions not to elicit answers to specific questions but to make it possible for social actors to tell about something in their own words” (2005; p. 800). The best probe questions are formulated so as to clarify and elicit additional information from the respondent’s perspective . Breaking the flow with a lot of short, closed-ended questions diminishes the data’s qualitative value and makes it too much like a quantitative questionnaire.

Obviously, monitoring interviewer effectiveness is important in any research project; but particularly so if good quality open-ended data is the goal. To avoid being disappointed with the quality of interview transcripts, it is critical to determine as early as possible whether open-ended data elicited by the questions and by the interviewers appear to be of sufficient richness and quality and if not, to make adjustments to either the questions or the interviewer technique. Interviewing people about their experiences of violence requires special attention to both the phrasing of questions and interviewer skill, so as not to make people defensive or suggest they are to blame. It is important that interviewers are comfortable and matter-of-fact in their approach to discussion of topics and incidents that are typically private and not frequently discussed. If the respondent detects that the interviewer is uncomfortable or that the incident reflects something socially undesirable then she will not be forthcoming or worse, will describe the incident not as she truly sees it but to “please” the interviewer. The interviewer must refrain from interjecting herself while listening in a non-judgmental manner and asking appropriate follow-up questions. Selecting interviewers who are not easily made anxious, and who have a calm manner is important as is emphasizing that research interviewing is not a conversation. By way of analogy, the role of the research interviewer is rather like that of a medical professional seeking information about a patient’s physical problem. Although many physical complaints and symptoms are not topics of polite conversation, it is perfectly appropriate to discuss these within a specific context, in which the important details are elicited for a specific purpose and in a respectful manner.

Research shows that trauma survivors see their participation as important in helping science and other women (see Becker-Blease & Freyd, 2006 ; Campbell & Adams, 2009 ; Newman & Kaloupek, 2009 ) and we have generally found women to be forthcoming and willing to discuss their victimization experiences with a research interviewer. However, we always remind the respondent that she has the right to refuse to answer any question and can choose not to continue the interview or to stop at any time; a few do decline. If a woman becomes upset during the interview, the interviewer must offer the opportunity to take a break or discontinue. In our experience, it is quite rare for a survivor to decline or stop an interview, even when the experience is upsetting to discuss. It is also important to consider the impact on the interviewers of hearing about numerous incidents of rape and violence; Campbell (2002) provides an eloquent discussion of this often overlooked aspect of research on violence and provides helpful advice.

Over the past several years there has been a trend away from in-person data collection as researchers rely increasingly on web-based, CASI, and interactive voice response (IVR) technology. Although such “remote” approaches make it less likely that qualitative data can or will be collected, some types may still be feasible, for example, written responses to open-ended questions. Written narratives have certainly provided valuable data for some violence researchers, for example, college women’s written responses regarding why they found it difficult to answer questions regarding victimization ( Thoresen & Overlien, 2009 ). However, in our experience, written descriptions of sexual victimization experiences have tended to be curt and lacking in detail and there is no opportunity for probing to get more information. We speculate that it may be more natural to discuss these experiences with a trained and socially skilled interviewer, after the building of rapport, than to describe such experiences in writing. Moreover, verbal responses – even when transcribed – can convey the affect behind the information in a way that a written narrative cannot.

In-person data are admittedly more expensive to collect, since they require face-to-face contact with each respondent. However, if the decision has been made to collect data in person then it is not that much more difficult or expensive to add a qualitative component by including some open ended questions. Transcribing each tape-recorded interview requires a significant amount of person-hours. However, it may be valuable for a graduate student or beginning researcher to spend some time doing this, since listening to each tape can be a learning experience and the first step in the process of qualitative data analysis. Our own approach has been to have research assistants do transcriptions during the “down time” that inevitably occurs on large research projects, thus making efficient use of their time. Using interviewer notes rather than verbatim transcripts has its limitations, but can also provide valuable open-ended data (e.g., Weiss, 2009 ).

There is no way around the fact that qualitative data analysis is time consuming, given the collaborative, iterative process of reading, coding, discussing, and interpreting. We believe that this is time well-spent if one’s goal is truly to understand a process or phenomenon, particularly at the early phases of a research program or for an early-stage researcher. Even if there isn’t the time to conduct a proper or publishable thematic analysis, it can still be quite worthwhile to spend some time reading (or listening, or viewing) these rich sources of data. Reading through multiple transcripts can lead to recognition of commonalities and insights not otherwise possible. The one caution that we offer is to spend enough time, and cover enough cases, so that one is not relying too heavily on a few vivid and possibly unrepresentative cases in forming a picture of the phenomenon. It is human nature to rely too heavily on vivid anecdotes or readily available information (e.g., Nisbett & Ross, 1980 ) whereas the goal of thematic analysis is to capture a holistic picture. A useful guideline in conducting qualitative research is that the sample size should be large enough to achieve theoretical saturation, that is, no new ideas emerge ( Krueger & Casey, 2000 ; Corbin & Strauss, 2007 ).

Admittedly, quantitative researchers often harbor prejudices against qualitative research as “soft” and unrepresentative that can make it more difficult to fund or publish qualitative research. The mixed methods approach that we have used has diminished many of these difficulties, since funding can be obtained for the quantitative study and publications can include both types of data. In fact, qualitative components and the convergent validity that is a hallmark of mixed methods research are frequently recognized as strengths by grant and journal reviewers. Although a qualitative purist might object, we have typically reported the percentage of the sample who discussed a given theme, to provide a sense of how common or representative it was in our sample. Finally, quantitative researchers may fail to understand that theoretical saturation and conceptual power, not statistical power or generalizability, are the guiding principles behind sampling and hence dismiss qualitative research as relying on small, unrepresentative samples. However, collecting qualitative data from a relatively large community sample (or a subsample) in conjunction with a larger quantitative study can eliminate the objection that qualitative findings are derived from a small, unrepresentative sample.

Violence against women is a complex and multifaceted phenomenon that we believe can benefit from multi-modal, mixed methods research. As described above, integration of quantitative and qualitative methodology creates a synergy and leads to a deeper understanding than is possible with exclusive use of a single orientation. Qualitative data can complement and enrich a program of quantitative research and can be implemented at different stages of a research program. Quantitative researchers need not abandon their methodological approaches, but rather can supplement them with some additional tools. The resulting mixed-methods approach is stronger than either method on its own and can greatly enhance understanding of violence against women.

Acknowledgments

This research was supported by grants K21 AA00186, R01 AA12013, and K02 AA00284 from the National Institute on Alcohol Abuse and Alcoholism.

1 Although we have always used index cards for coding, there are many software packages available to assist in qualitative coding and data analysis, such as NVivo (QSR International) and ATLASti

Contributor Information

Maria Testa, Research Institute on Additions, University at Buffalo, 1021 Main Street, Buffalo NY 14203, (716) 887-2560, ude.olaffub.air@atset .

Jennifer A. Livingston, Research Institute on Additions, University at Buffalo, 1021 Main Street, Buffalo NY 14203, (716) 887-2380, ude.olaffub.air@tsgnivil .

Carol VanZile-Tamsen, University at Buffalo, 115 Fargo Quad, Buffalo NY 14261, (716) 645-3511, ude.olaffub@3vmc .

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