Until the 1990s there was little professional or scholarly attention paid to the problem of intimate partner abuse among people with disabilities. Since that time, attention to the problem of the abuse of individuals with disabilities has increased rapidly. Although much has been written on the topic of the abuse of people with disabilities in general, there is relatively little research on abuse among people with mental retardation or other developmental disabilities. Moreover, more has been written about sexual abuse than physical abuse in people with mental retardation, although there is almost nothing written about emotional or psychological abuse of people with mental retardation in intimate relationships. The focus here will be on intimate partner abuse as it affects adults with mental retardation, although the broader literature on intimate partner abuse among people with physical disabilities is also relevant (e.g., Hassouneh-Phillips and Curry 2002) to the extent that individuals with developmental disabilities are more likely than others in the population to have a co-occurring physical disability in addition to their cognitive impairment.
One of the factors that differentiates people with disabilities, including mental retardation, from nondisabled individuals is the extensive contact they have with others who provide personal care services and who exert significant power over them. Despite this contact, this research paper will address intimate partner abuse—physical, sexual, or emotional abuse—in adults who have mental retardation in the context of intimate or romantic relationships rather than professional relationships, recognizing that the line between professional and intimate relationships often is blurred in this population.
Attention to the problem of intimate partner violence among people with mental retardation has become more pressing as such people have been moved out of institutions and into the community, thereby allowing for more normalized social interactions. At least half a million persons with mild or moderate mental retardation are said to be living in U.S. communities (Groce 1988). Thus, they are more likely than ever before to have intimate relationships with romantic partners, including dating relationships, cohabitation, and marriage.
- Risk Factors
- Sequelae and Consequences of Intimate Partner Violence
- Terminating the Abuse: Reporting and Disclosure Issues
- Implications for Prevention
- Implications for Intervention
- Implications for Social Policy
There is very little published research on the incidence or prevalence of intimate partner violence among those with developmental disabilities or mental retardation. To date, virtually everything that has been written on the topic, some of which is based on anecdotal reports rather than scientific research, notes that rates of physical and/or sexual abuse are higher among people with developmental disabilities (e.g., Strickler 2001). Although no specific prevalence rates are available, some have concluded that the majority of people with developmental disabilities will be sexually assaulted in their lifetimes, although not all of this abuse will necessarily be inflicted by romantic partners. Furey (1994) studied 171 cases of sexual abuse reported over a five-year period and learned that the majority of victims were female (72 percent). A survey of disabled women, some of whom had cognitive disabilities, found that 67 percent reported physical abuse and 53 percent reported sexual abuse (Power, Curry, Maley, and Saxton, 2002). Carlson (1998) found that physical abuse severity ranged from mild to severe, and frequency ranged from onetime events to daily occurrences.
Very little is known about emotional or psychological abuse among people with mental retardation. Professionals from the developmental disabilities field in Carlson’s (1998) qualitative study perceived emotional abuse to be even more prevalent among this population than physical violence. Types of emotional abuse reported by participants with mental retardation included forced isolation, restricted contact with others, destruction of personal property, extreme controlling behavior, verbal abuse such as name calling (e.g., ‘‘retard’’), and intimidating behavior such as threats with weapons. Almost half had been threatened with death, and all but one had been blamed for things they did not do (Carlson 1998).
Perpetrators of abuse toward persons with mental retardation are generally individuals known to the victim, usually a man with whom they have a trusted personal or professional relationship (Furey 1994). Almost half the abusers in one study also had mental retardation (Furey 1994). Research available at the time of this writing does not permit conclusions about how much abuse of mentally retarded people is perpetrated in the context of a romantic relationship versus caretaking (Sobsey and Doe 1991). Although the location of occurrence for such abuse can be in community or work settings, research suggests that it is most likely to occur in personal residences such as family settings or group homes (Furey 1994; Sobsey 1994). Compared with abuse of women without mental retardation, abuse of persons with mental retardation tends to be more severe and of longer duration and involves repeated episodes and multiple perpetrators (Schaller and Fieberg 1998; Sobsey and Doe 1991). It is also important to note that there may be ‘‘disability-specific’’ forms of abuse unique to individuals with specific disabilities: for example, preventing someone from accessing a telephone or transportation, threatening to abandon them, or saying that no one will want them because of their retardation.
A wide variety of factors may help to explain the greater vulnerability to intimate partner abuse among persons with mental retardation, including the nature of their mental retardation, childhood history, factors pertaining to how mentally retarded persons are socialized in society, and current living circumstances. Individuals with mental retardation have a variety of cognitive, language, and communication limitations that interfere with their development of good social skills and recognition of abuse (Protection and Advocacy, Inc. 2003). Professionals who worked with mentally retarded individuals in one study noted deficits in reading and understanding social cues (Carlson 1998). A history of childhood abuse is known to predispose women in general to subsequent victimization, and research has documented that childhood abuse occurs more frequently among children with disabilities, including mental retardation (Sobsey, Randall, and Parilla 1997).
Mental retardation is a stigmatizing condition, and these individuals have been segregated historically from ‘‘normal’’ society and subject to a host of discrediting cultural stereotypes that portray them as ‘‘dangerous, diseased, or worthless,’’ leading to ‘‘internalized devaluation’’ (Sobsey and Doe 1991, p. 253). Such dehumanizing stereotypes reduce the inhibition against violence and allow perpetrators to abuse them without guilt, while at the same time raising questions about the credibility of abuse allegations. These societal views have permitted individuals with mental retardation to be socialized in dysfunctional ways that train them to be overly compliant and disempowered (Protection and Advocacy, Inc. 2003). Thus, people with mental retardation tend to have more limited self-advocacy skills (Protection and Advocacy, Inc. 2003). From childhood, they become accustomed to high levels of dependency on others for assistance with tasks of daily living (Groce 1988; Strickler 2001). This can lead to learned helplessness and the belief that they lack control over their lives, as well as overly compliant behaviors, all of which increase vulnerability for abuse (Sobsey 1994; Strickler 2001). Low self-esteem, resulting from social devaluation and traditional ways of treating individuals with mental retardation, is also said to be common among people with developmental disabilities (Carlson 1998; Groce 1988), further contributing to vulnerability for abuse.
Another myth is that people with developmental disabilities are asexual or lack the need or desire for intimate or sexual relationships (Strickler 2001). This in turn has resulted in a lack of education provided to them on these topics (Lumley and Miltenberger 1997; Tharinger, Horton, and Millea 1990), which became increasingly problematic once deinstitutionalization occurred on a large scale. For example, many individuals with mental retardation may be unaware that they have the right to refuse unwanted sexual overtures (Protection and Advocacy, Inc. 2003). Social isolation (Strickler 2001) and limited opportunities and skills for social interaction are associated with an elevated desire to please and be accepted by others, as well as misplaced trust. Women with mental retardation have been said to value romantic relationships so highly that they are willing to place themselves in high-risk situations: ‘‘Thus they will compromise themselves rather than risk the loss of a lover, even if that lover exploits and abuses them’’ (Stromsness 1993, p. 147).
Sequelae and Consequences of Intimate Partner Violence
Little is known about the consequences of intimate partner violence among individuals with mental retardation. One obvious consequence is injury. In her qualitative study, Carlson (1998) found the full range of injuries reported, including the need for hospitalization. Other reported consequences include reduced self-esteem (Carlson 1998; Schaller and Fieberg 1998); shame and guilt (Schaller and Fieberg 1998); impaired sense of safety and trust in others (Carlson 1998; Schaller and Fieberg 1998); social isolation (Schaller and Fieberg 1998); reduced levels of functioning, including ‘‘extreme regression’’ (Carlson 1998); and impaired ability to self-regulate anger (Schaller and Fieberg 1998), which may lead to violence or aggression against others. A sizable body of research has documented the wide-ranging consequences of intimate partner violence among women in general, including depression, anxiety, posttraumatic stress disorder, and various medical complaints and illnesses such as migraine headaches. There is every reason to assume that women with mental retardation suffer similar effects. In fact, professionals in the developmental disabilities field have speculated that women with such disabilities have even more exaggerated effects than women without them. One professional noted that mentally retarded individuals ‘‘get into the cycle [of victimization] earlier, stay longer, and have more trouble getting out’’ (Carlson 1998, p. 109).
Terminating the Abuse: Reporting and Disclosure Issues
Cognitive impairments and deficits in communication skills may interfere with the ability to recognize, label, and report or disclose abuse (Tharinger et al. 1990). ‘‘[D]isabled adults, particularly those whose conditions make them dependent on others for support, may be unwilling or unable to report abuse or neglect. Many fear, with justification, that they will not be believed or that retaliation will occur’’ (Groce 1988, p. 236; Tharinger et al. 1990). Even if an individual experiencing abuse wants the abuse to stop and wishes to report it, he or she may not be able to develop and implement a plan to do so (Protection and Advocacy, Inc. 2003). Related fears include retribution or loss of services, employment, housing, or important relationships due to disclosure (Strickler 2001; Stromsness 1993). Another barrier to disclosure is the fear that one’s children may be removed (Groce 1988), a fear shared by abused women without mental retardation. As a result of these barriers to disclosure, when individuals with developmental disabilities are abused, the abuse may last longer and get worse, because it is more likely to go undisclosed and unreported (Protection and Advocacy, Inc. 2003).
When agencies learn of abuse, there are many barriers to reporting it to appropriate authorities, even when mandated by law, including fear of reprisals, bad publicity for the agency, accusations of professional incompetence, fear of licensing implications, and so forth (Protection and Advocacy, Inc. 2003). Abuse cases among individuals with mental retardation are more difficult to investigate and prosecute due to victims’ cognitive deficits that create communication problems, as well as investigators’ (e.g., police) lack of knowledge about and expertise in working with developmentally disabled people: ‘‘[T]he presence of an array of communication difficulties frequently leads to frustration when officers taking a report cannot understand the victim’’ (Protection and Advocacy, Inc. 2003, p. 4). Furthermore, ‘‘encounters with the criminal justice system can be baffling and intimidating to people with cognitive impairments’’ (Protection and Advocacy, Inc. 2003, p. 34), as they are to abused women who are not disabled in any way.
Implications for Prevention
Preventing physical, sexual, and emotional abuse among individuals with mental retardation will require a multifaceted effort. The movement toward greater inclusion into society of people with all types of disabilities has initiated many positive changes that will help to prevent intimate partner abuse among and against them by addressing several of the risk factors or sources of vulnerability discussed above. These changes include better integration of people with mental retardation into the community and systematic efforts to empower people with all types of developmental disabilities. In fact, it has been said that the cornerstone of abuse prevention is empowerment in that abuse tends to occur in a context of power differentials between abuser and victim (Sobsey 1994). Also sorely needed are social skills training and sexuality education (Strickler 2001), as well as assertiveness training and self-protection skills. Several studies are reported in the literature evaluating sexual abuse prevention programs (e.g., Lumley and Miltenberger 1997). In addition, one intervention program to prevent domestic violence and sexual abuse has been developed and evaluated, with promising initial results. The intervention employs the Effective Strategy-Based Curriculum for Abuse Prevention and Empowerment (ESCAPE) curriculum, a combination of twelve didactic sessions covering knowledge of abuse, empowerment, and decision making, as well as six support group sessions to review and reinforce the presented material (Khemka, Hickson, and Reynolds 2005).
Implications for Intervention
At this time, there is no research on empirically based interventions for intimate partner violence in victims with mental retardation, nor are there guidelines on best practices. Given the seemingly high prevalence of intimate partner violence, a strong case can be made for universal screening for abuse of women with mental retardation by professional staff with expertise in both domestic violence and developmental disabilities. Such screening should occur in all organizational settings where such individuals predominate, such as residential and group homes, shelter workshop programs, abuse and rape crisis centers (ARCs), and so forth. Abuse screening tools exist that have been adapted by clinicians for women with disabilities, such as the Abuse Assessment Screen– Disability, available from the Center for Research on Women and Disabilities (CROWD). It is important for professionals working with the mentally retarded population to be knowledgeable about whether reporting of adult abuse is mandated by law in their state, and if so, whether they are a mandated reporter. Those in doubt should contact the state’s Adult Protective Services agency. Professionals required by law to report suspected maltreatment should become familiar with details of such reporting, which can be very complex (Protection and Advocacy, Inc. 2003).
Although some in the mental retardation field and many counselors outside the field question the extent to which individuals with developmental disabilities can benefit from counseling (e.g., Strickler 2001), there is ample evidence that therapeutic intervention can be successful with people with mental retardation (e.g., Tharinger et al. 1990). However, accommodations need to be made (e.g., repetition, greater structure and directiveness, a more educational stance). It is important that treatment goals be attainable, taking into account the client’s limitations as well as strengths. Interventions can occur on an individual level or in group settings. Groups are a widely utilized intervention modality with domestic violence generally, for both victims and offenders, and are a good format for victims to share their stories and obtain support as well as to acquire safety skills (Tharinger et al. 1990). Use of videos to stimulate discussion and role playing are other widely used techniques (Sobsey 1994).
As of 2006, few if any communities have service programs specifically for mentally retarded victims of intimate partner abuse. Referral to an existing domestic violence program should be considered for such victims; however, few such programs have staff or expertise in working with women with developmental disabilities. Therefore, before making a referral to a domestic violence program, one should check to determine if the program can accommodate the needs of a client with mental retardation. Primary considerations in working therapeutically with a mentally retarded victim of intimate partner abuse are gaining his or her trust and maintaining confidentiality. Empowerment and self-determination should be the foremost guiding principles in such work (Sobsey 1994). The first step is to establish a victim’s safety, which may be difficult if he or she resides in the same setting as the abuser. Much has been written about safety planning in work with abused women (see, for example, Davies, Lyon, and Monti- Catania 1998). An important intervention is to impart personal safety skills, defined as ‘‘patterns of behavior that are intended to reduce an individual’s risk for abuse, exploitation, and violence’’ (Sobsey 1994, p. 195).
One common source of help for abused women is support and practical assistance from family and extended family members, but many women with mental retardation and developmental disabilities have limited or nonexistent relationships with family members. In these cases professional staff will need to provide such support (Groce 1988).
Interventions by the criminal justice system are a critical component of the comprehensive package of needed interventions for victims of intimate partner violence, including arrest and prosecution of abusers. For example, protective orders are commonly issued for victims that instruct the abuser to stay away and impose serious sanctions if the orders are violated. The ability of victims with mental retardation to take advantage of this form of assistance can be compromised by several factors. The complexity of the justice system can present a daunting challenge for any victim, which is only compounded by cognitive limitations. Such limitations can make people with mental retardation poor witnesses (Protection and Advocacy, Inc. 2003). Lack of familiarity with mental retardation on the part of criminal justice agents can also serve as a barrier to mentally retarded victims being able to avail themselves of the protections of the justice system.
Implications for Social Policy
To address the pervasive problem of intimate partner violence among people with mental retardation, a number of policy changes can be made with the goal of enhancing detection and amelioration of such abuse. First, reporting systems need to be improved. Some states already have mandatory reporting of abuse of all adults, or of vulnerable adults such as those who are elderly or dependent, and this requirement should be expanded to all states. For states that do have such reporting requirements, changes may need to be made in how the requirements are implemented and/or processed. California found that law enforcement and Adult Protective Services workers lacked sufficient information and training to work effectively with people with cognitive limitations; prosecutors and judges may similarly lack necessary expertise (Protection and Advocacy, Inc. 2003).
A related change pertains to increasing the expertise in identifying abuse and facilitating its reporting among those who regularly come in contact with people with mental retardation, such as those who staff group homes, shelter workshop settings, and developmental centers, as well as professionals who might be the recipients of such reports, such as law enforcement. The prevalence of abuse against individuals with mental retardation is sufficiently high to warrant designation of a specific staff person or persons who are trained in intimate partner abuse and sexual abuse in agencies that regularly provide services to the developmentally disabled population. This person should be alert to the presence of abuse and familiar with its investigation and reporting to outside authorities. Increased education might best be accomplished by developing collaborations with local domestic violence and rape crisis programs which are knowledgeable about interpersonal violence and accustomed to providing education on these topics (Hassouneh- Phillips and Curry 2002). Such collaborations would be an ideal way to begin to educate those who staff these programs regarding how to increase their accessibility to clients who present a range of disabilities, including cognitive impairment (Groce 1988).
Another important innovation would be increased education and training of professionals who regularly encounter intimate partner abuse regarding how to work effectively with clients who present with mental retardation. This would include, at a minimum, those who staff domestic violence programs, including shelters, as well as agents of the criminal justice system, including law enforcement, prosecutors, and judges. It is strongly advised that criminal justice professions develop collaborations with disability and victim advocacy organizations in their communities in order to promote greater professional understanding of these issues and to better meet the needs of abused victims with mental retardation. Wisconsin has been in the forefront of efforts to develop statewide coalitions on behalf of abused women with developmental disabilities. In the wake of an outpouring of stories during the 1990s of women with mental retardation being abused, a unique partnership was forged between the Wisconsin Council on Developmental Disabilities and the Wisconsin Coalition Against Domestic Violence, with goals of ‘‘cross-training,’’ public education, system change, and improved advocacy on behalf of abused women with developmental disabilities. California has also undertaken innovations such as multidisciplinary statewide conferences to promote better understanding of the issues facing crime victims with developmental disabilities and funding pilot programs to address the needs of such victims (Protection and Advocacy, Inc. 2003).
A variety of resources on the Internet are available regarding abuse of people with mental retardation, e.g., Oregon Health Science University’s Center for Self-Determination and the Wisconsin Coalition for Advocacy. In addition, state coalitions against domestic violence and state disabilities advocacy organizations have increasingly posted information on this topic, e.g., Wisconsin Council on Developmental Disabilities (http://www.wcdd.org/). Most states have Developmental Disabilities Councils, which may be another source of information. An excellent website for information on intimate partner violence in general that also includes information on abuse of people with disabilities is maintained by the Minnesota Center Against Violence and Abuse (MINCAVA) (http://www.mincava.umn.edu/). Finally, the Center for Research on Women with Disabilities at Baylor College of Medicine in Houston (https://www.bcm.edu/research/centers/research-on-women-with-disabilities/) has an excellent website with a section on violence against women with disabilities that features an extensive discussion of research on prevalence and risk factors as well as intervention and recommendations, including specific guidelines for professionals.
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