INTRODUCTION
The World Health Organization describes the violence as “the knowingly / intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (1). In case of domestic violence, the violence is directed from the powerful to the powerless and women are mostly abused by their life partners (2,3).
Domestic violence against women may be grouped under 4 headings. According to this classification; physical violence is defined as using brute force as a tool of intimidation, suppression and sanction, sexual violence is defined as using sexuality as a tool of intimidation, suppression and sanction and controlling. While psychological or verbal violence is defined as intimidation, punishment and control of the opposite partner using behaviors and conversations, economic violence is defined as using economic sources and money as a tool of intimidation and control (4).
In a study conducted in Virginia Medical School, the oldest finding concerning domestic violence against women was the detection of the rate of lethal cranial fractures in 2000-3000 years old female mummies as 30-50%, while the same rate was 9-20% in male mummies. One of the best examples concerning the support to wife-beating by the prevailing public rules or even by the laws is the Pennsylvania State Law, forbidding husbands to beat their wife after 10.00 pm and on Sundays which was in force until 1970s (5,6).
In a study conducted by Altınay and Arat (7) in 2007, 35% of the female interviewees stated that they had been exposed to physical violence by their husbands at least once, 1 out 6 men having a university degree were reported to apply physical violence to their spouse and gaining more money for the family than husband increased the risk of being beaten two fold.
In a study conducted by Karaçam et al. (8), 27.8% of the women defined violence acts occurred against them at any time of their married life and when they were asked the person(s) using violence, 92.6 % of the abused pointed out their husbands, 3.7 % pointed out their husbands as well as their mother-in-law and father- in-law and 3.7% pointed out their mother-in-law and father-in-law. 40.7% of the women participating in a study conducted by Güler et al. (9) defined that they were exposed to violence by their husband.
The “attachment”, first conceptualized by Bowlby, is defined as a consistent and permanent affectional bond manifesting itself as the quest of the children for feeling safe, provision of their needs and affections intimacy (10,11). One of the underlying hypothesis of the attachment theory is the need of the babies for a figure providing their safety, security and protection requirements since they need a long lasting care and protection (12).
Based on the theory of Bowlby, Batholomew and Horowitz, examining the role of the attachment, suggested a new model called the “4-group Model of Attachment” that made significant contributions to the understanding of attachment in adulthood (13,14).
These Attachment Styles May Be Summarized
As Follows:
Secure Attachment: In this attachment style self-image and the others model is positively perceived. Securely attached individuals see themselves as worthy to be loved and easily develop intimate relationships with the others. They do not worry about being alone or being accepted.
Preoccupied Attachment: It can be described as a combination of the negative self and and the positive other models. They are seriously worried about not being accepted and not being loved.
Dismissive Attachment: It is a combination of the positive self and negative others models. They feel themselves worthy of being loved, however they keep themselves away from intimate relationships due to their thoughts and negative expectations from the other people. Dismissively attached individuals do not want to establish intimacy, they protect themselves from disappointments by avoiding intimate relationship and they maintain their independency and invulnerability.
Fearful Attachment: It is a combination of negative self and negative others. They feel themselves unworthy, they worry about being hurt, losing or being rejected, consequently they avoid developing intimacy with the others.
In this study, it is aimed at analyzing the psychological symptoms, attachment styles, the factors those may affect them and their interactions in battered women staying at shelters or living with their spouse.
MATERIALS AND METHOD
A total of 81 women were included in the study. The study sample was constituted by 40 women exposed to violence and continued to live with their spouse, attending one of the Psychological Counseling Centers established by the Metropolitan Municipality of Istanbul in 10 counties of Istanbul between January 2011 - May 2011, and 41 women staying at three different shelters in Istanbul. The institutions where we conducted the study were selected as the possible medium for the women to express the violence that they had been exposed. In addition, these places were considered to contribute to the analysis of the effects of the attachment styles on the ability to move away from the violence medium and the effects of moving away from the violence medium on the psychological symptoms of the women.
40 women attending the Municipality Counseling Centers and 41 women staying at shelters, were interviewed and the volunteers were informed about the questionnaires and measures that would be administered and due the privacy sensitivity, their verbal consents were obtained. All of the interviewees were included in the study.
Symptom Check List (SCL-90), Relationship Scales Questionnaire as well as Individual Identification Chat prepared by the investigator were used in the study.
Symptom Check List (SCL–90-R): SCL–90-R is constituted by quadripartite Likert type responses varying from “not to extremely” and while this test measures the stress level manifesting as psychological symptoms, high scores indicate functional impairments. The SCL-90-R test was finalized by Deogatis (15) and the study on the validity-reliability of Turkish version was performed by Dağ (16). The test is constituted by 10 symptom groups in 9 subscales and one additional item. The Relationship Scales Questionnaire: It was developed by Bartholomew (13) in order to measure attachment styles in adults and the study of the validity-reliability of Turkish version was performed by Sümer and Güngör (17). This process consists of the assessment of the answers of the participants on how they define themselves in 17 situations stated in the scales. The participants assessed the items in terms of how the items described them and their relationship upon a Likert type scale (as I am not agree at all=1, I am completely agree=4). Determination of the type of attachment that the participant was close, was essential.
Individual Identification Chart: Individual Identification Chart was developed by the investigators in order to determine the sociodemographic characteristics including the age, marital status, the way of the marriage, educational status, working status, personal income, number of children, their inmates, the duration of the violence exposure, the frequency of the violence exposure, family history of violence before her relationship.
Statistical Analysis
The results were assessed using the Statistical Package SSPS WINDOWS 15.00, by Pearsons’ Correlation analysis, independent groups’ t test, Mann-Whitney U test and Kruskal Wallis-H test and the significance level of the analysis results was tested at the level of p<0.05.
RESULTS
In our survey, the average age of the women living in the house where they were exposed to violence was 34.85 years. While 2 women were single and lived together with their partner without bonding by marriage, 9 had imam marriage and seventy women were legally married. All women mentioned their partners as their spouse, for this reason the word of “spouse” was used instead of partner in our study. 37.5% of the women living in the house where they were exposed to violence and 56% of the women staying at the shelters stated that they had been exposed to violence also by their family in their childhood. 21.9% of the women staying at the shelters and 20% of the women living in the house where they were exposed to violence, stated that they had a paid job.
While 2.43% of the women staying at a shelter stated that they had flirted before getting married, 21.95% of them stated that they had a prearranged marriage, 17.07% of them had been compelled to get married by their family, 19.51% of them had eloped to marry to their spouse and 14.63% had been abducted by their spouse.
35% of the women living in the house where they were exposed to violence stated that they had flirted before getting married, 45.5% of them stated that they had a prearranged marriage, 7.5% of them had been compelled to marry by their family, 12.5% had eloped to marry to their spouse. When the battered women staying at shelters were asked the time they decided to apply to a shelter, the answers were “when I saw that my family would not be supportive” in 31.7% of the women, “when a life threatening danger emerged” in 19.5% of the women, “when the frequency of the violence exposure increased” in 12.2% of the women and “when the violence was directed towards the children” in 12.2% of the women.
14.63% of the women staying at shelter stated that the average duration of the violence exposure was 1 to 5 years, 63.4% of the women were exposed to violence by their spouse for a length of time longer than 5 years, the ongoing violence exposure for 1 to 5 years was reported by 27.5% of the women staying in shelter, 25% reported a period of time longer than 5 years and 27.5% stated that violence exposure still continued.
17% of the women staying in a shelter, stated that they had been exposed to violence once, 7.3% of the women stated the violence exposure 2-5 times a year, 12.2% of the women stated the violence exposure 5 to 10 times a year, 29.3% of them stated once a month or more frequently and 34% of the women had been exposed to violence every day. Among the women who lived in the house where they had been exposed to violence, 5% reported physical violence once, 42.5% 2 to 5 times a year, 15% 5-10 times a year and 35% of the women reported violence once a month or more frequently.
When the psychological symptoms of the women exposed to spouse violence were assessed, subscales scores and an overall symptom level of 1.52 to 2.50 indicated a high level of complaints related to the psychological symptoms. Somatization, obsessive compulsive features, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid thoughts, psychoticism, additional scale (symptoms related to sleep and eating disorders, guilt feelings) and overall symptom levels were observed as high. Fearful attachment scores (2.84) and dismissive attachment scores (2.67) were determined as high.
The psychological symptom subscales scores and overall symptom levels of the battered women living at shelters were also found as 1.51-2.50 similarly to the other group. Somatization, obsessive compulsive features, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid thoughts, psychoticism, additional scale (symptoms related to sleep and eating disorders, guilt feelings) and overall symptom levels were observed as high. Fearful attachment scores (2.96) and dismissive attachment scores (2.92) were determined as high.
Although not statistically significant, the higher levels of obsessive compulsive features and anger-hostility scores were determined in the prearranged marriage group and the higher scores of anxiety, phobic anxiety, paranoid thoughts, psychoticism and overall symptom level scores were found in the women getting married after being abducted.
In a study conducted by Altınay and Arat (7), considering the interpretation about the women with higher education and income level who may pretend not to tell their complaint too much due to the shame and worry for infamizing their name, the educational and working states were thought to affect the level of psychological symptoms. No significant difference was found when the psychological symptoms of the women who were exposed or continued to be exposed violence were assessed according to their educational status. A statistically significant difference was found between the averages of range when the psychological symptoms of the women who were exposed or continued to be exposed violence were assessed according to their working status (p<0.05). Among the battered working women, the level of somatization, obsessive-compulsive disorder and the levels of additional scale and overall symptoms were found higher than the battered women in the non-working group. Among the other subscales; the levels of interpersonal sensitivity, depression, anger-hostility, phobic anxiety, paranoid thoughts and psychoticism did not differ according to the working state. According to the variables of the duration of the violence exposure and the frequency of the physical violence, no statistically significant difference was found between the averages of the psychological symptoms of two groups (Table 1).
As a result of the independent group t test performed to determine whether the level of psychological symptoms and overall symptoms differed between the battered women staying at shelter and battered women living with their spouse, no statistically significant difference was found between the levels of psychological symptoms and overall symptoms between two groups (Table 2).
Apart from the secure attachment style, no statistically significant correlation was found between the attachment styles and psychological symptoms. A statistically significant negative correlation was found between the secure attachment style and somatization, obsessive-compulsive disorder, sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid thoughts and psychoticism and overall symptom level. According to this result, the increased level of secure attachment in battered women was associated with the lower psychological symptom level.
A significant difference was found in terms of the average of range of the secure attachment scores between the group of the women who left home and the group who did not. Aformentioned difference occurred in favor of the group of the women who had left their home after being exposed to violence. According to this result, the significantly higher levels of secure attachment were found in the group of the women who left their spouse after being exposed to violence (Table 3).
DISCUSSION
This study differs from the previous studies in terms of being the first study assessing the effects of the ongoing violence and terminated violence on the psychological symptoms and attachment styles. On the other hand, the study sample remained limited to 81 individuals due to the difficulties in achieving to the sample group. The lack of the assessments of the factors such as the relationship between the sheltering duration at shelter and psychological symptoms and attachment styles, the presence or absence of the life threatening danger, are the other restrictions of the study. Since the sheltering durations at the shelter were not declared by the shelter administration and the doubtful accuracy of the information obtained from the women, the sheltering duration was not stated clearly. Since the life threatening danger is a subjective expression and physical violence is perceived as a life threatening danger by almost all women, life threatening danger could not be assessed in an objective and medical way. The detection of the high level of the complaints related to the psychological symptoms in both groups is also supported by many other studies. In a study conducted by Vahip and Doğanavşargil (18) among the patients attending psychiatry outpatient clinics, it was determined that while 73.9% of the women exposed to the physical violence were diagnosed with depression, 6.5% of them were diagnosed with anxiety disorder.
Medical conditions such as depression, anxiety, psycosomatic symptoms, loss of self esteem, suicide attempt and eating disorders in women exposed to violence reported by Karaçam et al. (8) were also consistent with the high level of somatization, depression, anxiety, eating disorders detected by SCL-90 in our study (8).
While the increased level of secure attachment was associated with decreased levels of psychological symptoms in both groups, this finding shows similarity with the results of the studies conducted by Ergin (19). Ergin pointed out that the individuals having secure attachment style revealed lower anxiety, depression, negative self, somatization and hostility scores than the individual who have insecure attachment style; in addition a higher correlation was found between the high scores in the anxious attachment dimension and psychological disorder symptoms when compared to the correlation between the high scores of avoidant attachment dimension and psychological disorders. This finding also shows similarity with the significant inverse correlations between the secure attachment and depression, anxiety, anger-hostility, overall symptom level detected by SCL-90 and Relationship Scales Questionnaire in our study.
In the studies conducted by Murphy and Bates (20) assessing the relationship between the adult attachment styles and depressive personality tendency, a significant correlation was also found between the high scores of fearful and pre-occupied attachment styles and depression and negative self model. On the other hand Meyers (21) determined that securely attached individuals revealed a higher degree of personal perfection and lower degree of psychological restlessness compared to the avoidant and anxiously attached individuals.
In conclusion, according to the findings of our study, apart from the secure attachment style of the women staying at shelters, no statistically significant relationship was found between the other attachment styles and psychological symptoms. There was an inverse correlation between the secure attachment and somatization, obsessive-compulsive features, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety and paranoid thoughts, psychoticism and overall symptom level and consequently the level of psychological symptoms decreased when the secure attachment level increased among the battered women living at shelters.
Anger-hostility, phobic anxiety and paranoid thought levels decreased also in battered women living with their spouse, when the secure attachment level increased.
