Trauma Impact

Mental Illness and Marriage

I was interviewed on how mental illness affects marriage and how to cope. Listen to the podcast.

What kind of impact does mental illness have on a marriage?

In today’s society, it’s becoming more and more common for individuals to be living with some sort of mental health condition or illness like anxiety or depression. And while there are many issues and conditions that present themselves in different, unique ways, oftentimes the effects on a marriage are very similar.

In addition to anxiety and depression, some people suffer from more extreme conditions like post-traumatic stress disorder and substance abuse problems. When these issues creep in without the proper treatment, their impact on a marriage and the individual can be fundamentally problematic. In some situations, the partner without the condition will have to pick up the slack for the other. And in many cases, couples will begin to suffer from tension and exhaustion within their marriage.

Our guest today is Dr. Nerina Garcia, a clinical psychologist with Williamsburg Therapy and Wellness in Brooklyn, NY. Nerina is here to give us some advice about how couples and individuals can learn to cope with mental illnesses within marriages while building a network of support.

To find out more about Nerina and her practice, visit her website or call (917) 816-4449.

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Preventing Posttraumatic Stress Disorder by Facing Trauma Memories

This article discusses the benefits of facing our painful memories, challenging our beliefs about the traumatic experience, self care and breathing exercises.

Nov. 27, 2012— Posttraumatic stress disorder (PTSD) is a form of learning that begins at the moment of the exposure to extremely stressful situations and that grows in impact as trauma-related memories are rehearsed and strengthened repeatedly. This somewhat oversimplified view of PTSD yields a powerful prediction: if one could disrupt the rehearsal and strengthening of traumatic memories, a process called reconsolidation of memories, then one might reduce PTSD risk or PTSD severity after potentially traumatic events.

To be certain, it is tricky to attempt to alter traumatic memory reconsolidation. In fact, some early strategies for "trauma debriefing" turned out to strengthen rather than diminish posttraumatic learning.

Despite these challenges, a new study by Dr. Barbara Rothbaum and colleagues reports that a behavioral intervention delivered to patients immediately post-trauma is effective at reducing posttraumatic stress reactions.

"PTSD is a major public health concern," said Rothbaum, professor in Emory's Department of Psychiatry and Behavioral Sciences. "In so many people, what happens immediately after a traumatic event can make things worse or better. Right now, there are no accepted interventions delivered in the immediate aftermath of trauma."

To conduct the study, the researchers approached patients who presented to the local emergency room due to a traumatic event, including rape, car accident, or physical assault. Half of those who agreed to participate received the behavioral intervention, which was started immediately, while the other half did not. All patients were repeatedly assessed for symptoms of depression and stress over a twelve-week period.

The intervention is a modified form of exposure therapy in which a survivor confronts anxiety about a traumatic event by recounting it. Administered over the course of 3 1-hour sessions, the goal is to alter the person's thoughts and feelings about the traumatic event. Trained therapists asked the participants to describe the trauma they just experienced and recorded the description. The patients were instructed to listen to their recordings every day. The therapists also helped the patients look at obtrusive thoughts of guilt or responsibility, and taught them a brief breathing relaxation technique and self care.

They found that the intervention was safe, feasible, and successful at reducing posttraumatic stress reactions, compared to those who were assigned to the assessment-only condition, at 4 and 12 weeks post-injury.

"This study provides an elegant and clinically important test of the trauma reconsolidation hypothesis," commented Dr. John Krystal, editor of Biological Psychiatry.

The implications of this study are immense, Rothbaum explained. "If we know what to do, then we can train emergency workers to intervene with patients on a large scale. In addition to being implemented in the emergency room, it can help on the battlefield, in natural disasters, or after criminal assaults."

She concluded, "More research is needed, but this prevention model could have significant public health implications. A long-standing hope of mental health research is to prevent the development of psychopathology in those at risk instead of being limited to symptom treatment after disease onset."

Elsevier (2012, November 27). Preventing posttraumatic stress disorder by facing trauma memories. ScienceDaily. Retrieved December 10, 2012, from­ /releases/2012/11/121127094102.htm

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Childhood Trauma Leaves Mark On DNA of Some Victims: Gene-Environment Interaction Causes Lifelong Dysregulation of Stress Hormones

How we live and what happens to us changes our genes. Trauma in early childhood can change DNA and lead to PTSD, anxiety and depression.

Dec. 2, 2012 from— Abused children are at high risk of anxiety and mood disorders, as traumatic experience induces lasting changes to their gene regulation. Scientists from the Max Planck Institute of Psychiatry in Munich have now documented for the first time that genetic variants of the FKBP5 gene can influence epigenetic alterations in this gene induced by early trauma.

In individuals with a genetic predisposition, trauma causes long-term changes in DNA methylation leading to a lasting dysregulation of the stress hormone system. As a result, those affected find themselves less able to cope with stressful situations throughout their lives, frequently leading to depression, post-traumatic stress disorder or anxiety disorders in adulthood. Doctors and scientists hope these discoveries will yield new treatment strategies tailored to individual patients, as well as increased public awareness of the importance of protecting children from trauma and its consequences.

Many human illnesses arise from the interaction of individual genes and environmental influences. Traumatic events, especially in childhood, constitute high risk factors for the emergence of psychiatric illnesses in later life. However, whether early stress actually leads to a psychiatric disorder depends largely on his or her genetic predisposition.

Research Group Leader Elisabeth Binder of the Max Planck Institute of Psychiatry examined the DNA of almost 2000 Afro-Americans who had been repeatedly and severely traumatised as adults or in childhood. One-third of trauma victims had become ill and was now suffering from post-traumatic stress disorder. The risk of developing post-traumatic stress disorder rose with increasing severity of abuse only in the carriers of a specific genetic variant in the FKBP5 gene. FKPB5 determines how effectively the organism can react to stress, and by this regulates the entire stress hormone system. The scientists hoped to cast light on the mechanisms of this gene-environment interaction by comparing modifications of the DNA sequence of victims who had not become ill with that of those who had.

The Munich-based Max Planck scientists were then able to demonstrate that the genetic FKBP5 variant does make a physiological difference to those affected, also in nerve cells. Extreme stress and the associated high concentrations of stress hormones bring about what is called an epigenetic change. A methyl group is broken off the DNA at this point, causing a marked increase in FKBP5 activity. This lasting epigenetic change is generated primarily through childhood traumatisation. Consequently, no disease-related demethylation of the FKBP5 gene was detected in participants who were traumatised in adulthood only.

Torsten Klengel, a scientist at the Max Planck Institute of Psychiatry, explains the findings of the study as follows: "Depending on genetic predisposition, childhood trauma can leave permanent epigenetic marks on the DNA, further de-repressing FKBP5 transcription. The consequence is a permanent dysregulation of the victim's stress hormone system, which can ultimately lead to psychiatric illness. Decisive for victims of childhood abuse, however, is that the stress-induced epigenetic changes can only occur if their DNA has a specific sequence."

This recent study improves our understanding of psychiatric illnesses which arise from the interaction of environmental and genetic factors. The results will help tailor treatment particularly for patients who were exposed to trauma in early childhood, thereby greatly increasing their risk of illness.

Story Source:

The above story is reprinted from materials provided by Max-Planck-Gesellschaft (2012, December 2). Childhood trauma leaves mark on DNA of some victims: Gene-environment interaction causes lifelong dysregulation of stress hormones. ScienceDaily. Retrieved December 10, 2012, from­ /releases/2012/12/121202164057.htm

Link to article

El Huracán Sandy: Como Lidiar con las Secuelas Emocionales

Por Nerina Garcia,-Arcement Ph.D. Traducción por Carla Saad, B.A.

Los desastres naturales, como el Huracán Sandy, nos recuerdan que tan vulnerables somos.  Entre más cercano haya sido la experiencia de uno con el huracán, la reacción que uno sentirá después podrá ser más intensa.  Al sobrevivir un desastre natural como el Huracán Sandy, uno puede sentir estrés, ansiedad, depresión y síntomas del trastorno de estrés postraumático.  Si usted ha sufrido de problemas emocionales en el pasado, el enfrentarse con un evento estresante, como el Huracán Sandy, puede exacerbar éstas condiciones pre-existentes.

Algunas de las reacciones emocionales típicas que uno puede sentir tras vivir un desastre natural incluyen sentimientos de incredulidad, sentirse confundido o indefenso, irritabilidad, tristeza, miedo, dificultad para concentrarse y para tomar decisiones, sentirse preocupado y pensar constantemente acerca de lo que paso durante/después de la tormenta, sentir preocupación por consecuencias negativas que puedan llegar a ocurrir, y sentir que uno está volviendo a vivir los eventos del desastre.  Algunas de las reacciones físicas comunes que uno puede tener incluyen: dificultad para dormir, tener pesadillas, sentirse nervioso y sobresaltarse con facilidad, latidos rápidos del corazón, problemas para respirar, dolor de cabeza y sentirse tembloroso.

Hay varias cosas que usted puede hacer para sentirse mejor si ha notado que está teniendo éstos problemas:

  1. No se aísle: Busque apoyo de gente querida, amigos y vecinos que entiendan lo que usted está viviendo. Esto le ayudará a darse cuenta que no está solo, y no es el único que siente éste dolor.
  2. Hable con amigos y gente querida acerca de como se siente: El expresar sus preocupaciones, miedos, ansiedades, tristeza, sentimientos de incredulidad y confusión puede ser un proceso curativo y catártico.
  3. Limite ver noticieros: Ver las imágenes de destrucción únicamente recuerdan la experiencia traumática y reafirman los sentimientos de miedo y vulnerabilidad.
  4. Participe en actividades de recursos de socorro: El ser voluntario y donar su tiempo en esfuerzos de ayuda humanitaria le ayudará a sentir mayor control y sentir que puede causar un impacto positivo. Ayudar a otras personas a sentir menos dolor, le puede ayudar a aliviar su propio dolor.
  5. Participe en pasatiempos o en actividades positivas: El participar en actividades que uno disfruta le ayuda a distraerse y en no pensar en su aflicción, y le recordará que aún existe belleza y creatividad en el mundo, y no solamente destrucción.
  6. 6.      Manténgase activo: Haga ejercicio, o salga a dar caminatas. Estas actividades le ayudarán a no pensar en sus problemas. El mantener el cuerpo activo le ayuda a liberar hormonas que reducen el estrés.

Si después de intentar éstos consejos usted todavía se siento afligido, considere hablar con un experto en problemas de salud mental o con un consejero espiritual.  El sobrevivir un desastre natural puede tener impactos negativos y duraderos en la manera en que nos sentimos y en la que vemos el mundo.  El enfrentar el dolor emocional lo antes posible reduce las probabilidades de que los síntomas de estrés, ansiedad, depresión y del trastorno de estrés postraumático sean duraderos, y persistan en los años por venir.

Trauma and Disaster: Helping Teens Manage the Impact of Hurricane Sandy

Listen to my interview on The Mary Waldon Show on the emotional impact and how to cope with Hurricane Sandy. Hurricane Sandy has had a tremendous impact on countless families up and down the east coast of the United States. Such an event can leave even the most well-informed parent with questions and concerns.What is the potential impact of natural disasters and other traumas on teenagers? What can parents do to help mitigate the impact of Hurricane Sandy? What is an expected reaction to such extreme events, and what kinds of reactions indicate a need for professional intervention? For answers to these and other related questions, please tune in to The Mary Waldon Show to hear the insight and expertise of Dr. Nerina Garcia-Arcement, an expert in the treatment of Post Traumatic Stress Disorder.

Link to radio show

Hurricane Sandy: Coping with the Emotional Aftermath

By Nerina Garcia-Arcement, Ph.D. Natural disasters, such as Hurricane Sandy, remind us of our vulnerability. The closer the impact of the hurricane to you the more intense your reaction can be. Surviving a natural disaster such as Hurricane Sandy can bring about stress, anxiety, depression and post traumatic stress symptoms. If you have experienced emotional distress in the past, then a major stressor such as Hurricane Sandy is likely to exacerbate a pre-existing condition.

Typical emotional reactions include disbelief, feeling confused or helpless, irritability, sadness, fear, difficulty focusing and making decisions, feeling preoccupied and ruminating about what happened during/after the storm, worrying about what future negative things could occur, and re-experiencing events from the disaster. Common physical reactions are sleep problems, nightmares, feeling jumpy and being easily startled, racing heart, trouble breathing, headaches and trembling.

If you notice you are experiencing these problems there are actions you can take to feel better:

  1. Do not isolate yourself: Seek out support from loved ones, friends and neighbors that know what you are going through.  This will help you realize you are not alone in your pain.
  2. Talk to friends and loved ones about how you are feeling: Expressing your worries, fears, anxieties, sadness, disbelief and confusion can be healing and cathartic.
  3. Limit your news watching: Seeing the images of destruction simply reminds you of your traumatic experience and reinforces your feelings of fear and vulnerability.
  4. Donate or volunteer your time through relief efforts: This will help you feel more in control and that you can make a difference. Aiding others through their pain helps reduce your own.
  5. Engage in hobbies or life affirming activities: Doing things you enjoy will help distract you from your distress and remind you that there is beauty and creativity in the world, not just destruction.
  6. Stay Active: Exercise or go outside for walks. These activities will get your mind off of your problems.  Getting your body moving will help release hormones that relieve stress.

If you find you are still distressed after trying these suggestions, consider talking to a mental health professional or a faith based adviser. Surviving a natural disaster can have a lasting negative impact on how you see the world and how you feel. Addressing your emotional pain now can reduce the chances of your stress, anxiety, depression or PTSD symptoms lasting for years into the future.


Naming the Shame that Can Cripple

I was quoted on the causes of shame, how to cope and treatment options. By Marcia G. Yerman

When Amy Ferris asked me to contribute an essay to Dancing at the Shame Prom: Sharing the Stories That Kept Us Small, I wasn't sure that I had any shame. Then, when I thought about it, I realized that I did. I just hadn't framed it that way. I agreed to participate. After I handed in my essay, I heard back from co-editor Hollye Dexter. "I think you are holding back," she said. "Can you go a little deeper?" So I did. Along with twenty-six other women, I wrote openly about issues that had impacted my life.

Now that the book is out, I have taken off my memoirist hat and am writing as health journalist. Reading the stories that encompassed familial alcoholism, sexual abuse, parental suicide, distorted body images, hoarding, alienation, and racial identity anxiety - I wanted to get to the psychological root of how shame shapes who we are and how we live our lives.

I interviewed four practitioners who shared insights that were both clinical and revelatory. We focused on how shame specifically impacts girls and women. Many of their observations and verbiage overlapped. To a person, they all began the conversation by drawing a distinction between shame and guilt.

Shame is a feeling or belief that screams, "I am bad." Guilt is evidenced as, "I did something bad." Shame is feeling worthless. Guilt is external; you can fix it. Specifically, shame is, "I am damaged."

Amber Lewter, EdS., LAPC, whose background includes working as a survivor advocate at a rape crisis center, told me, "When women define themselves as being bad, it creates low self-esteem and a poor sense of self-worth." Treating those who have experienced childhood sexual trauma, Lewter sees women coming in for counseling with a lot of "shoulds" ("I should have told someone.").

She conducts an exploration of shame through expanding awareness of external factors, pointing out that what happened "was beyond the control" of the patient. She believes that shame is more of an issue for women because they are "relationship-centric" and therefore bring childhood shame and a "less than" mindset into their adult relationships.

Ph.D. and Licensed Clinical Psychologist, Nerina Garcia-Arcement, qualifies shame as "an insidious emotion, often at the root of mental health problems like depression and anxiety." She sees shame as creating "a sense of isolation which poisons an individual's self-esteem."

She told me, "My patients feel silenced due to their shame. Often, they can't even speak out loud what they feel ashamed about." Garcia-Arcement defines shame as a reflection of a "core value." Therefore, what results is a need to cover up what we feel ashamed about.

She related, "The power of shame is that it silences us and creates internal negative dialogue, such as, 'I wasn't good enough. I deserved it.' So we want to stay invisible. We don't want to feel vulnerable. This stunts our ability to grow." Garcia-Arcement explained how the fallout of shame translates into a "fear of takings risks."

"A silent killer," is how Lori Freson, Licensed Marriage and Family Therapist, describes shame. Her practice specializes in women's issues and self-esteem.

"Women don't always acknowledge shame as a presenting problem," she said. "Women can have body image problems and not realize it is shame."

She spelled out, "Shame about our bodies can lead to isolation, depression, and eating disorders." Shame about sexual abuse can lead to "avoidance of intimacy, relationships, sexual problems, and self-harm." Shame about an addiction "can delay or sabotage" efforts to recover.

Finally, she added the key observation, "Shame is connected to self-perception and how you think people perceive you."

Founder of the Critical Therapy Center, Silvia M. Dutchevici, spoke at length about how our culture "plays into our perceptions." Her philosophy embraces a holistic approach. "Psychology is not in a vacuum," she emphasized. She referenced the issue of race, class, gender, ideology, and economic status. Her point of view is that "society has issues as well," forcing people to "adapt to a false criteria rather than challenging that criteria."

Dutchevici was crystal clear in her assessment. "For women in particular, depending on the trauma, feelings of shame may arise from our culture's imposition of gender roles and the way women have been socially conditioned regarding their view of themselves. The more a society demands perfectionism," Dutchevici continued, "the more we have shame."

Both Freson and Garcia-Arcement addressed this element as well.

"A lot of shame comes from external societal factors," Freson said. "People want to be accepted. People are afraid of being different. Shame among women and girls is more prevalent because of cultural standards."

Freson pointed to celebrity media and fashion magazines. "People shut shame down because they want to have the perfect image." Her message about shame to young girls is, "You don't have to be perfect. Be your best self."

"The core expectation for women," said Garcia-Arcement, "is that we can do it all. Be beautiful and be everything to everybody." When girls and women buy into cultural norms they "learn to hate their bodies and themselves." It all comes back to not being "good enough." Garcia-Arcement illustrated shame from the ground level of family dynamics, up and outward toward group identification.

"Our family is a reflection of who we are," she said. "So if there is a family behavior [alcoholism, suicide, sexual abuse, domestic violence], it's still a part of us." Treatment by Garcia-Arcement entails the challenges faced by people of color. She identified that if a person from a minority community does something that the rest of the group is not proud of - it is seen as a "personal reflection on who they are."

In tandem, Dutchevici - a political refugee from Romania - touched on the use of shame as a tool of control in promoting a specific ideology. Shame also operates by keeping group memberships and affiliations intact.

So what can be done? All four women I spoke with communicated the need to explore an individual's experience through expanding consciousness.

Lewter articulated about introducing an awareness of "external factors." Freson, who maintains that if "shame is not exposed and dealt with it can destroy your relationships and your life," believes the more exposure the topic gets the more taboos are broken down.

Applauding the premise of the book, Freson sees it functioning as a tool for dialogue while enabling readers to discover, "Oh. It's not just me. I'm not the only one."

Dutchevici agreed. "The more people come out and talk about shame, the less power it has." She reiterated that it was important to "name the emotion."

"The first step is to realize that you are not alone," Garcia-Arcement reiterated. She uses a combination of talk therapy, cognitive behavior therapy, and insight-oriented work. She suggested mindfulness exercises, trying to connect the mind and body, sitting with your feelings, and being in the moment. Garcia-Arcement stressed the power of stories, advising the importance of sharing one's story.

"Empathy is essential to healing. If you can't say it out loud yet, write it down. Excise it from yourself. Writing is a useful tool, as there is no witness to the shame." An important element of eventually sharing the narrative is that it helps individuals "normalize their experience," through a realization that they are not alone and not to blame.

(The Shame Prom has a Tumblr blog where anyone can post a shame narrative, either with her name or anonymously).

Garcia-Arcement said definitively, "Everyone has shame. We just don't want to look at it."

In her essay, Elizabeth Geitz wrote, "I've learned letting go of shame is one of the most freeing things I've ever done. I've learned that I don't have to dance at the Shame Prom forever. The dress, the shoes, the long-wilted corsage are now gone.

"The music has finally stopped."

Link to article

How Are You Coping With the Recent Mass Shootings?

I was quoted on the important topic of PTSD and typical reactions to mass shootings and trauma. In this I share tips on how to cope after a trauma.

By Rheyanne Weaver  |

The two mass shootings in the last couple of months have been on the minds of many Americans, especially because they took place in seemingly safe places -- a movie theater and a temple. Experts have suggestions for how the general public and victims can cope with such saddening and scary events.

Nerina Garcia-Arcement, a licensed clinical psychologist, said in an email that she previously worked with 9/11 survivors. “Unfortunately many people do not seek help for mental health problems following a trauma and most people wait an average of 10 years to seek mental help,” Garcia-Arcement said.

“A majority of my 9/11 clients sought help six to 10 years after 9/11. By this point many were isolated from all social support, had difficulties working as they avoided public transportation and public spaces, and suffered from chronic stress due to fear of the ‘next terrorist attack.’"

She hopes that victims of recent shootings get help from mental health professionals sooner in order to cope with trauma. There are a plethora of mental health issues that could result from being a victim of a shooting.

“The closer the person was to the event, the more emotionally impacted they are likely to be,” Garcia-Arcement said.

“For people directly affected by the recent shootings, it is common to experience Post Traumatic Stress Disorder (PTSD), anxiety (including panic attacks, generalized anxiety and phobias related to the attack, such as social phobias or fear of the dark) and depression symptoms.”

“It is a normal reaction for people to re-experience or remember the event, have nightmares, feel sad and scared, be hypervigilant, avoid reminders of their trauma and isolate from people,” she added. “This is the mind trying to process and make sense of what happened.”

“Survivors of the [Colorado] shooting will find that things like the smell of popcorn, popping sounds, the dark, being in crowded spaces or watching a movies might trigger reminders of their experience,” Garcia-Arcement said.

“These are normal reactions that can be managed with deep breathing, relaxation exercises and positive self talk (i.e., ‘this is just a reminder, it is not happening again. I am okay. I am safe.’). For many survivors, those in the theaters and injured, survivor's guilt is common.”

People who were not directly involved in the shooting can still suffer from slight mental health issues as well, such as “sadness, horror and anxiety,” and avoidance of reminders of the shootings.

Here are some tips from Garcia-Arcement to help people cope with the recent shootings:

1) “Offer each other social support, as individuals and as a community.”

2) “Remind yourselves that this was an isolated horrible event that happened to good people. It was not their fault.”

3) “My strongest recommendation is that survivors and the general public do not avoid reminders of the trauma and do not isolate. It is instinctive for people to avoid things that remind them of their trauma. Unfortunately once they begin avoiding going to movies or spending time in crowded spaces, it often escalates to avoiding more and more things. They begin to misinterpret the fact that they are safe simply because they avoided going to the movies, instead of forcing themselves to go to the movie and realizing they are safe.”

4) “A person should seek mental health support if they are feeling overwhelmed by their reactions to the shooting. If after a few months they find they are still experiencing PTSD, anxiety or depression symptoms, they ought to seek a therapist that could help them process their normal reactions.”

Robin Zagurski, a licensed clinical social worker, works with adults and teens who have gone though traumatic experiences. She said in an email that a major indicator that professional mental health is needed after a mass shooting is if people are unable to function in their daily lives.

She suggested keeping the same daily routine in order to distract from thinking about the recent shooting, and taking care of one’s overall health and well being.

She said that it’s difficult to plan for rare shooting situations, but to be aware of any “leakage” statements, where a future shooter may tell someone or post on the Internet what their plans are.

Don’t assume these statements are merely threats. Reporting this to authorities could potentially save lives.

“Think ... of maintaining your safety in all environments, especially for hazards that have a higher likelihood,” Zagurski said.

“For example, always know where the exits are in any building in case of fire. Practice evacuations so that you know how to get out safely. If someone talks to you about hurting themselves or others, report it to authorities immediately.”


Link to article

Domestic violence and mental health: How are they intertwined?

Domestic violence leads to complicated emotional reactions. In this article I share information that sheds light on typical reactions to trauma and why it is difficult for the abused to leave.

By Rheyanne Weaver |

The United States still has a lot of work to do in regard to addressing the prevalence of domestic violence.

In fact, an in-depth story from the Arizona Republic has pointed to the fact that in the last several years, the number of deaths from domestic violence has stayed fairly consistent in Arizona.

While this means there hasn’t really been an increase in deaths, there certainly hasn’t been a decrease either.

Fortunately, researchers are seeking more information about domestic violence and specifically about domestic violence that ends in death. Not surprisingly, much of the research has a mental health aspect.

For example, the article mentioned how substance abuse, depression and estrangement are just some of many risk factors that could increase a battered woman’s chance of eventually being killed by her partner.

Later, the article explained that generally before a battered woman’s life ends at the hands of her partner, there are warning signs. For example, the partner usually engages in a specific kind of abusive behavior called “intimate partner terrorism” or “coercive control.”

“Coercive control is almost exclusively the domain of men,” according to the article. “It is long-term and tyrannical abuse that includes, often in addition to physical violence, attacks on a woman's self-worth, degrading remarks and obsessive monitoring of her whereabouts and her contact with other people.”

The abuser often has mental health issues like depression or substance abuse, and struggles with obsessive and possessive behavior. In some cases, abusers cope with massive self-shame by severely abusing or killing their partners.

Mental health experts have more insight into how domestic violence can impact mental health, and what issues sometimes predispose people to being in relationships that involve domestic violence.

Nerina Garcia-Arcement, a licensed clinical psychology and a clinical assistant professor at the NYU School of Medicine, said in an email that there is a gradual process that leads from “normal” relationships to relationships involving domestic violence.

“Women don't enter violent relationships where they are being hit from day one,” Garcia-Arcement said. “They date men that pay attention to them, are possessive and slowly begin to limit their behavior and social interactions (i.e., the woman can't talk to friends or family as much or at all, or she can't wear certain things). Often this controlling behavior is couched as ‘loving them.’"

Then comes the act of lowering the victim's self-esteem.

“Once they are socially isolated, they (abusers) begin to erode their self-esteem by insulting them or calling them names, telling them that no one else would want them, etc.,” Garcia-Arcement said. “Once the (victim’s) self esteem is fragile, they often begin the physical abuse.”

“This is why women don't just leave,” she added. “By the time they are being hit, they are socially isolated, feel stupid and undesirable, doubt their self-worth and fear the consequences of leaving. If they are not staying out of fear, they are staying because they have come to believe they deserve this treatment, that they are at fault for being hit, for ‘being stupid/saying the wrong thing,’ etc."

Women in abusive relationships tend to suffer from mental health issues like anxiety, depression and post-traumatic stress disorder as a result, she said.

“Many women who are in abusive relationships grew up in households where they witnessed abuse,” Garcia-Arcement said. “This normalizes it. Confuses love and violence. This is a pattern that is familiar. For other women (who) don't grow up in abusive households, the typical cycle of abuse prepares them. Their self-esteem gets eroded until the abuse makes sense.”

David M. Reiss, a psychiatrist and previous interim medical director for Providence Behavioral Health Hospital, just spoke at the 35th annual convention of the International Psychohistorical Association about child abuse and trauma, and their impact on individuals, communities and society. He said in an email that relationships with domestic violence are characterized by dysfunction and pathology.

“No relationship can maintain appropriate intimacy and trust if there is violence occurring,” Reiss said.

Some women also try to rationalize that it’s better for the children if they stay with their abusive partner.

“Staying ‘for the children’ is misguided, as children need role models who do not let themselves be abused,” Reiss added.

Freda Emmons, the author of “Flame of Healing: A Daily Journey of Healing From Abuse and Trauma,” said in an email that she grew up with abuse throughout her childhood.

Her mother was a victim of abuse by her father, and the mother also contributed to some child abuse along with the father.

“I asked her once why she stayed and she said it was because of us kids; she didn't believe that she could provide for us,” Emmons said. “I told her it would have been better to get assistance or whatever she could do to spare us the horrible years of pain.”

However, Emmons’ mother couldn’t take care of herself and was suffering from issues that are associated with abuse victims, so she was unable to protect her children from their father or herself.

“I think some women have been so battered, physically and emotionally, that they have lost their sense of personal value,” Emmons said. “They think that they are the cause of the problem, that if they would just be a better wife, mother, spouse, cook, cleaner, etc. that the abuse would stop. It never does.”

She hopes her book can help others find a way out of the despair she experienced.