This study demonstrates that there are major commonalities among women's experiences of turning points, although varied for individual women. In all five themes, the turning point was when prior views or beliefs about the violence, the relationship, their partner, or their ability to change their situation was challenged or altered by either an external event or internal realization. When women discussed protecting others or being aware of the increased severity of violence, they recognized that the effects of violence were greater than they had previously thought or been willing to accept. Partner betrayal or recognition that the abuser was not going to change caused women to lose a concept of the relationship—i.e., exclusivity, promises of better treatment—that had allowed them to tolerate the violence. Recognizing the availability of external support and resources shifted the women's view of their situation from one of feeling trapped and isolated to one of feeling hopeful for change and relief from abuse.
Our findings correlate with those of other studies. Patzel,52
studies also described escalation or increased severity of violence, protecting others, and infidelity as turning points. Zink and colleagues also noted in their study of mothers who had experienced IPV that when women noted effects of the IPV on their children (i.e., the child was hurt, commented on abuse, or mimicked the abuser's behavior), they found greater motivation to actively seek change in their situations.55
In her study focusing on abused African American women, Laughon described her study participants as reaching a turning point when they were “tired” of enduring the violence,61
which is similar to our theme of fatigue.
In their study of turning points among Israeli women experiencing IPV, Eisikovits and colleagues described turning points as six types of personal or interpersonal loss that then generated change when “the women could no longer explain violence in terms of existing categories of meaning.”62
Our themes of protecting others and increased severity of violence fit with their description of “loss of security” when the women recognized that they could not control or limit the scope or severity of the violence. Our theme of partner betrayal can be included in Eisikovits' descriptions of “loss of love” in which the woman confronts a challenge to her idealized version of a special partnership or bond with her abusive partner. In the case of betrayal, when the illusion of exclusive love and commitment is shattered, the women then lose the justification for tolerating the violence. Additionally, our theme of fatigue correlates with both Eisikovits' descriptions of “loss of faith in the possibility of change” and “loss of meaning in coping.”62
Turning points described by other authors but that were not mentioned by our participants included women's achieving independent financial security, allowing them to admit to the IPV and label themselves as abused,60
and women becoming concerned about their own personality changes or adoption of violent behavior.60,62
This study underlines the importance of understanding women's own perceptions of their turning points. In looking at the similarities to and differences from the populations involved in other studies, it may be possible to build a framework of interviewing questions and interventions that will be effective for a greater number of women. The agreement of results from our study with those among widely different populations underscores the similarity of specific factors that can trigger a turning point in a woman's motivation to seek change in IPV. Healthcare providers' efforts to help women experiencing IPV then need to incorporate an understanding of each woman's perception of her situation and her turning point. The themes from the study can be used as discussion points in talking with women experiencing IPV. The realization of individual differences among women can help inform healthcare providers and counselors in these discussions.
Our study does have several limitations. This is a descriptive qualitative study using a purposive sample population. Qualitative studies are not designed to be generalizable; rather, they are designed to identify rich themes.64,65,70,71
In this regard then, we cannot presume that the findings from this study are applicable to all women experiencing IPV. Potentially, a broader range of turning points could emerge in additional interviews and focus groups. However, only one new turning point emerged during the individual interviews after the focus group—that of partner betrayal—and redundancy of themes was noted by the fourth individual interview. We thus feel comfortable that we had achieved thematic saturation—i.e., we were no longer hearing new themes—at the completion of this study.71,72
Additionally, our research design did not allow us to perform comparisons among women in various types of relationships—i.e., same-sex couples, biracial couples, immigrant couples—nor explore differences among women who were childless compared to those with children. We also lacked the ability to perform any comparisons based on race, culture, or economic status. Different findings would potentially emerge in different cultural or social groups. Additional research is needed to explore the process of change and turning points among different populations of women, including those in more isolated situations (e.g., immigrant women, women in rural settings).
While further research is needed to develop and test IPV interventions that incorporate the concept of turning points, we can begin to imagine how we might utilize these themes in helping women experiencing IPV move toward change and safety. For example, health providers and counselors can assess which turning point themes, if any, are relevant for a particular woman. Providers can assist women experiencing IPV to more fully consider their options by brainstorming potential scenarios and responses. For example, one possible thematically relevant question might be: “What will you do if the violence gets worse?” Indeed, such a question prompting women to voice their concerns within the Increased Severity theme may be a way to introduce the concept of safety planning, a key component of best practices IPV intervention.
Providers and counselors may also ask women about concerns they may have about their children's exposure to violence in the home, and build awareness about the deleterious effects that witnessing IPV has on children.73–75
Women may not be aware of how much their children see, hear, and sense regarding the IPV, nor how this exposure can be associated with adverse health, mental health, and behavioral and academic outcomes in children.73–77
This counseling strategy can help women explore their own personal perspectives on the Protecting Others theme that women in our and other studies have shown to be a powerful influencer of change. Understanding what the woman already knows about or is concerned about in this regard may open the opportunity for awareness building in the form of education about child witnessing and support for the woman's own concerns. It is important that such counseling be performed in a nondirective and nonjudgmental fashion to avoid conveying a sense of blame to the woman. The focus should be on providing additional information regarding the less well-known effects of IPV on children to help her in her own efforts to better protect them.
Health providers and counselors also can be aware of the themes of loss and grief that women experience as they move within the themes of Fatigue and Betrayal toward their turning points. The loss of their perception of the relationship, of their partner, of the reality that he is not likely to change—all can be addressed as they surface in discussions. The cognitive shift described by our participants within these themes has often been noted to occur prior to women's decisions to leave their abusers.44,45,52,69,78
While it then may be tempting to counsel a women to leave her abuser, providers must recognize that not all women experiencing IPV wish to or are ready to leave. Additionally, it is crucial for providers to understand that the act of leaving often increases instead of decreases danger to victims, so that leaving may not be the safest action for a given victim at a given time. In Morocco's study of femicide in North Carolina, half of the women killed by their partners had some form of separation event (e.g., divorce, breakup, separation) immediately prior to the murder.79
For women who do indicate an intention to leave, providers should encourage women to work closely with community IPV victims' advocacy services and develop a clear safety plan to increase the safety of the leaving process. Other studies also caution against being too directive and not recognizing the women's stage in the process of dealing with IPV. Zink and colleagues warned that providers should be careful not to overwhelm or alienate victims.39
Studies have shown that increased familiarity and knowledge regarding IPV obtained through educational and training programs correlate with increased health provider confidence and competence in addressing IPV.80–84
Understanding the process of change in IPV and potential turning points, healthcare providers will have greater knowledge and ability to respond more appropriately to women who disclose IPV and better tailor their IPV counseling to the particular circumstances and needs of each woman. This practice change, in combination with other recommended IPV interventions such as the provision of accurate information, referral to community advocacy services, recognition of the individuality of each woman's situation, affirmation that she deserves to be safe, and reassurance that she will not have to face these challenges alone,40,85–88
can then help foster a woman's sense of awareness, self-empowerment, and support—all three key factors in the Psychosocial Readiness Model.43
In this way, then, health providers can become catalysts in helping women experiencing IPV move along the path to their own turning points.