Effects of religious and spiritual variables on outcomes in violent relationships

Abstract

Objective

Religious and spiritual factors in intimate partner violence have received increasing attention. But are such factors related to outcomes in violent relationships? The purpose of this study was to assess the relative impact of spiritual symptoms and religious coping on attitudinal/behavioral and clinical outcomes among women in violent relationships.

Methods

Adult women with a recent history of husband-to-wife physical abuse were recruited from six primary care clinics. Once enrolled, 200 subjects completed a baseline interview and daily assessment of level of violence, using the Interactive Verbal Response for 12 weeks. At the completion of the study, contact with each participant was attempted to determine whether she had either sought professional help or left the relationship. Three religious/spiritual variables were assessed at baseline—number of visits to a religious/spiritual counselor, religious coping, and severity of spiritual symptoms. Stepped multiple linear regression was used to explain factor-analyzed outcomes (coping and appraisals, hope and support, symptomatology, functional status, readiness for change, and medical utilization), adjusting for demographic, marital, childhood, mental health, and violence variables.

Results

After controlling for duration, severity and dynamics of violence, the use of spiritual resources, and the level of spiritual symptoms were associated with most attitudinal/behavioral and clinical outcomes, while religious coping was only associated with staying in the relationship.

Conclusions

Religious and spiritual factors were associated with most outcomes. Spiritual symptoms had a consistently negative effect on outcomes while use of spiritual resources had variable effects. Religious coping was only associated with refraining from leaving the relationship.

Keywords

Religion spirituality battered women domestic violence symptomatology functional status coping

Introduction

The role of religious and spiritual factors in intimate partner violence (IPV) has received increasing attention in recent years. In terms of predictors of violence, a consistent correlate of husband-to-wife abuse is religious incompatibility between spouses.^1,2 Generally, interfaith marriage and more religious involvement by the wife than the husband have been associated with abuse. In addition, the couples’ involvement in more conservative, “fundamentalist” faith traditions was also associated with IPV,^3–7 although IPV can be linked to a lack of religious practice as well.^8,9 However, Brinkerhoff et al.¹⁰ found no association with religious denomination and a weak curvilinear relationship with church attendance. Such findings of violence and church attendance correlation may reflect different attitudes about the sanctification or importance of marriage.¹¹ Discordance in religious denomination, church attendance, and religious beliefs and practices may be symptomatic of a larger disparity in values between spouses.¹²

Are religious or spiritual factors related to outcomes in violence? Religiousness has been linked to a variety of outcomes in family violence, including dysfunctional thoughts and behaviors,^13,14 perceived strength,¹⁵ self-esteem,¹⁶ and depression and suicidality.^17,18 Religious coping is a common approach to stressful life events,^19,20 but a history of abuse correlates with reliance upon self rather than collaboration with God.²¹ Abusive experiences in childhood have been linked to seeking spiritual support as an adult.²² Does religious coping or use of religious resources help victims of abuse? Webb and Whitmer²¹ found that self-worth was inversely related to the use of self-reliance, but positively associated with collaboration with God. In addition, Ryan²³ found that seeking personal spirituality helped in the recovery from childhood sexual abuse.

The purpose of this study was to assess the relative impact of spiritual symptoms and religious coping on attitudinal/behavioral and clinical outcomes among women in violent relationships while controlling for demographics, and violence characteristics and dynamics.

Methods

Sample

The methods used have been reported previously;²⁴ this study was approved by the Institutional Review Board at the University of Texas Health Science Center at San Antonio. In this study, women with a recent history of husband-to-wife abuse were recruited from six primary care clinics in San Antonio, TX. Adult (18–64 years old), nonpregnant women seen without their husbands present at the time of the visit were asked to complete a six-item brief Conflict Tactics Scale²⁵ in the examination room while they waited to see their physician. If they had experienced violence from their partner in the past 30 days, they next responded to a Danger Assessment Screen. Women in severely dangerous relationships were excluded from the study. All women with a positive screen for partner violence, whether they participated in the study or not, were referred to the Family Justice Center, a city-supported victim assistance program located in one of our downtown clinical buildings.

Procedure

Once enrolled, the 200 subjects completed a baseline interview eliciting data on demographics, relationship and violence history, and mental disorders as well as both attitudinal/behavioral and clinical outcomes. Subjects were instructed to complete a daily assessment of husband and wife violence for 12 weeks using the Interactive Verbal Response via telephone. At the completion of the study, researchers contacted each participant to determine whether she had sought professional help concerning the violence or left the relationship.

Measurement

The baseline assessment included basic information about the relationship (duration of the relationship, duration of the marriage, duration of abuse) and three religious/spiritual variables. (1) The number of visits to a religious/spiritual counselor (i.e. clergy, folk-healer, or spiritualist) during the prior two months was assessed using the Health Care Utilization form.²⁶ (2) Religious coping was measured using the COPE instrument.²⁷ (3) The severity of spiritual symptoms (i.e., lack of reason for living, lack of sense of purpose, lack of harmony and peace, lack of feelings of productivity, and lack of self-comfort) was assessed using the Biopsychosociospiritual Inventory (BioPSSI) with higher scores indicating more spiritual problems.²⁸

Previous work showed that IPV could impact subjects’ health, attitudes, and/or behaviors. Hence, we assessed both attitudes and behaviors (hope, coping strategies, appraisal, and support) as well as clinical outcomes (health care utilization, functional status, symptom levels, and readiness for change) at the beginning and end of the study period. Hope was assessed using the 12-item Herth Hope Scale.²⁹ Coping strategies were assessed with the 53-item COPE, which has 12 subscales measuring active versus avoidant coping mechanisms. Five scales measure problem-focused coping, four scales measure emotion-focused coping, and three scales measure maladaptive coping. Because the COPE can assess situational and dispositional coping, it could be sensitive to change.²⁷ Appraisal was assessed using the Appraisal Dimension Scales. This 24-item instrument assesses six dimensions of appraisal (control, salience, novelty, duration, causality, and predictability). Appraisals were directed at the primary stressor (violence).³⁰ Finally, family support and stress were assessed using the 22-item Duke Social Support & Stress Scale.³¹

Clinical outcomes included the following: Health care utilization was assessed using a 10-item health care utilization instrument which documents the number of visits to general medical (emergency departments, minor emergency rooms, clinics, and medical physician offices) and mental health (psychiatrists, psychologists, social workers, and therapists) settings in the previous two months;²⁶ previous studies suggest that depressed patients accurately recall two-month utilization.³² Functional status was measured using the Medical Outcomes Study Short Form-36 (MOS SF-36). The SF-36 consists of 36 items forming eight subscales and was used to assess functional status and quality of life.³³ Symptomatology was evaluated using the BioPSSI. This 29-item instrument assesses physical, psychological, social, and spiritual symptoms.²⁸ Finally, readiness for change was assessed using questions based on the Transtheoretical Model of Change. This model states that behavior change moves through five stages: precontemplation, contemplation, preparation, action, and maintenance.³⁴ Subjects were asked to report their plans to (1) seek help for their domestic violence and (2) leave the relationship using a 5-point scale from I am not interested to I am trying to leave (get help) now.³⁵

Analysis

Three measures of violence severity were computed. First, the frequency of husband-perpetrated violence was used. Second, the mean level of episode severity for husbands was calculated across all days in which any violence occurred. Finally, the overall level of violence burden for husbands was calculated as the mean daily violence across all days reported.

Assessment of violence dynamics

To quantitatively assess violence dynamics, time series data must be complete. Daily reports were made on a mean of 63.2 (±15.9 SD) days with 50% of subjects reporting on 80% of days or more; missing data were imputed using the n-step procedure in the TISEAN software package³⁶ to maintain any nonlinear characteristics. The n-step approach to imputation has been shown to least distort nonlinear characteristics of time series when compared to traditional methods.³⁷ Unlike other approaches to handling missing data, n-step successfully corrected for 25–60% missing data if such data were missing at random and 15–40% if missing data followed a power distribution in chaotic time series, and 40% and 25%, respectively, in periodic time series.³⁸ When the initial data points in the time series were insufficient to apply n-step (generally n ≤ 4), the mode of the time series was inserted until the time series was long enough to use n-step.

Three types of complexity measurements are available, and we used one example of each type.³⁹ Nonlinearity suggests either chaotic or random dynamics. Algorithmic complexity (a measure of the amount of information needed to describe the data) was measured by LZ complexity.⁴⁰ Regularity (or the lack of it) was measured by approximate entropy (ApEn).⁴¹ Finally, sensitivity to initial conditions (speed with which two adjacent points diverge over time) was measured with the largest Lyapunov’s exponent.⁴² Using the time series of the daily assessments of level of husband-to-wife violence, we calculated LZ complexity and Lyapunov exponents using the Chaos Data Analyzer software for each subject’s time series. We calculated ApEn using the ApEn module in OCTAVE. Stable estimates require as few as 50 data points for ApEn^43–45 and 30 data points for LZ complexity;⁴⁶ Lyapunov exponents are resistant to the effects of missing data if nonlinearly imputed data (≤15%) were used in datasets with underlying periodic or chaotic dynamics.³⁸

Relationship between violence, religion/spirituality, and outcomes

To reduce the number of outcomes for regression analyses, we conducted principal components factor analysis with varimax rotation for end-of-study attitudinal/behavioral and clinical health outcomes. Factor loadings ≥ 0.3 were considered significant based on corresponding statistical significance of correlation coefficients. Factor analysis resulted in five attitudinal factors and four clinical outcome factors using scree plots (see Table 1). A staged regression analysis was conducted with each outcome factor using stepwise methods to minimize collinearity effects. In the first stage, demographic variables (age, Hispanic ethnicity, and socioeconomic status score⁴⁷) were entered. In the second stage, violence characteristics (duration in years, age-of-onset, violence frequency, mean episode severity, overall burden, and the three nonlinearity measures) were entered. Finally, the three religious/spiritual variables were entered. A similar procedure was used with staged logistic regression to determine the effect of these religious/spiritual variables on whether women actually sought help and/or left the relationship. P values ≤ .05 were considered significant with .05 < P ≤ .1 deemed as tending toward significance.

Table 1.

Outcome factors.

Attitudinal/behavioral outcomes, Variable (factor loading)	Clinical outcomes, Variable (factor loading)
Positive coping (COPE)	Symptoms & functioning
Planning (.842)	Psychological symptoms [BIOPSSI] (.837)
Active coping (.723)	Poor mental health [SF-36] (.819)
Reinterpretation (.599)	Physical symptoms [BIOPSSI] (.795)
Negative coping (COPE)	Social functioning [SF-36] (−.757)
Denial (.811)	Emotional role functioning [SF-36] −.705)
Behavioral disengagement (.796)	Physical functioning [SF-36] (−.588)
Mental disengagement (.655)	Medical utilization
Acceptance (.598)	Primary care settings (.736)
Positive appraisal (ADS)	Emergency settings (.688)
Importance (−.750)	Readiness for change
Not temporary (−.748)	To leave relationship (.840)
Control (.630)	To seek help (.720)
Negative appraisal (ADS)	Social symptoms & mental health care
Novelty (.790)	Mental health utilization (−.764)
Predictable (−.537)	Social symptoms [BIOPSSI] (.648)
Not self-caused (.510)
Hope & support
Seeks support [COPE]
Emotional reasons (.814)
Instrumental reasons (.538)
Total social support [DUSOCS] (.635)
Hope [HHI] (.319)

Note. [] = Instrument used to measure.

Results

As seen in Table 2, the sample was predominantly a low-income, Hispanic population. Eighty-five (43%) women were in common law relationships of almost 10 years duration (mean = 9.6 ± 8.9 (SD) years). On average, the duration of abuse was 5.5 ( ± 6.5 SD) years with an age-of-abuse-onset of 32.6 (±11.3 SD) years. Although 24 (12%) of the women reported having a church wedding, 47 (23.5%) reported at least one use of a spiritual counselor or resource for health reasons during the prior two months. Overall, the average COPE score of turning to religion was 8.86 (±3.73 SD) out of a possible 12-point maximum. Similarly, the average level of spiritual symptoms was 18.82 (±9.06 SD) of a possible 35 points.

Table 2.

Demographic information (n = 200).

Descriptor	Frequency, n (%)
Race/ethnicity
White	34 (17)
Hispanic	152 (76)
Age (mean ± SD years)	38.2 ± 11.7
Employment
Part time	30 (15)
Full time	49 (25)
Education^a
<High school graduate	64 (32)
High school graduate	41 (21)
Some college	90 (45)
Income^a (<$20,000)	105 (53)
Socioeconomic class^47,a
I	2 (1)
II	10 (6)
III	28 (16)
IV	18 (10)
V	117 (67)

Missing data account for total ≠ 100%.

Having a church wedding was not associated with any differences in outcomes at the P ≤ .05 level. However, spiritual variables (particularly the level of spiritual symptoms) contributed to the variance of four out of five attitudinal/behavioral outcomes (Table 3). Spiritual symptoms were correlated with the use of negative coping strategies and were inversely related to positive coping, appraisal, hope, and support. The use of spiritual counselors or resources was inversely related to positive appraisals and positively correlated with symptoms/dysfunction and readiness for change. Spiritual symptoms were associated with more symptoms/dysfunction and social symptoms/lack of mental health care (Table 4). Finally, the use of religious coping was inversely related to leaving the relationship (Table 5).

Table 3.

Predicting attitudinal/behavioral outcomes [beta (p)].

Predictors	Coping		Appraisal		Hope/support
Predictors	Positive	Negative	Positive	Negative
Violence variable
Timing
Age-of-violence onset				0.43 (.020)
Violence duration
Severity
Violence frequency
Episode severity	−0.19 (.085)
Violence burden
Dynamics
LZ complexity					−0.32 (.019)
Approximate entropy
Lyapunov exponent				−0.22 (.060)
Spiritual variables
Utilization of spiritual resource			−0.22 (.020)
Religious coping
Spiritual symptoms	−0.33 (.004)	0.28 (.012)	−0.39 (.000)		−0.50 (.000)
F-statistic	5.79	1.92	7.19	2.22	3.92
Significance (P)	.000	.116	.000	.061	.005
Adjusted R²	.261	.042	.348	.070	.233

Note. Adjusted for age, Hispanic, socioeconomic status.

Table 4.

Predicting clinical outcomes [beta (p)].

Predictors	Symptoms & dysfunction	Social symptoms & mental health care	Medical utilization	Readiness to change
Violence variable
Timing
Age-of-violence onset
Violence duration
Severity
Violence frequency
Episode severity	0.17 (.068)		0.38 (.000)	0.27 (.010)
Violence burden
Dynamics
LZ complexity
Approximate entropy				0.17 (.100)
Lyapunov exponent
Spiritual variables
Utilization of spiritual Resource	0.25 (.009)			0.25 (.016)
Religious coping
Spiritual symptoms	0.39 (.000)	0.51 (.000)
F-statistic	8.16	6.90	8.18	5.28
Significance (P)	.000	.000	.000	.000
Adjusted R²	.394	.228	.264	.240

Note. Adjusted for age, Hispanic, socioeconomic status.

Table 5.

Predicting action taken [beta (p)].

Predictors	Sought help	Left relationship
Violence variable
Timing
Age-of-violence onset
Violence duration
Severity
Violence frequency	2.25 (.020)
Episode severity
Violence burden		0.66 (.045)
Dynamics
LZ complexity
Approximate entropy
Lyapunov exponent
Spiritual variables
Utilization of spiritual Resource
Religious coping
Spiritual symptoms		−0.16 (.082)
Chi square-statistic	11.04	11.96
Significance (P)	.026	.035
Nagelkerke R²	.164	.236

Note. Adjusted for age, Hispanic, socioeconomic status.

Discussion

After controlling for duration, severity and dynamics of the violence, the use of spiritual resources, and the level of spiritual symptoms were associated with most of the attitudinal/behavioral and clinical outcomes, while low religious coping was only associated with leaving the relationship. Unlike our prior study,⁴⁸ a history of a church wedding was unrelated to leaving in the current study.

The level of spiritual symptoms and concerns had a significant effect on all of the attitudinal/behavioral outcomes except negative coping, even when controlling for violence severity and relationship characteristics. As spiritual symptoms worsened, positive coping, appraisal, and hope/support decreased, and symptoms/dysfunction and social symptoms worsened. Few studies have looked at spiritual symptoms. Katerndahl⁴⁹ reported an impact of spiritual symptoms on increased utilization of general and mental health settings as well as poorer quality-of-life measures in a general primary care population. In a prior analysis of these data,⁵⁰ women in violent relationships decreased rather than increased their mental health care utilization in response to spiritual symptoms, possibly due to the inverse relationship between hope and mental health utilization previously observed in IPV. However, women in that analysis also noted similar associations between spiritual symptoms and dysfunction as those in the current analysis.

Previous research suggests potential contradictory effects of spiritual resource use. Religious communities can provide support, improve quality of life, and assist healing,^2,51 and church attendance and religious involvement are linked to increased self-efficacy,⁵² improved social support, and decreased psychiatric symptoms.⁵³ However, religious resources can have negative effects as well, perpetuating silence about the abuse⁵⁴ and alienating victims.⁵⁵ In fact, involvement of church leaders and clergy can also be problematic. While clergy can promote self-esteem⁵² and safety,⁵⁶ use of these social resources can also serve to maintain the violence^56–59 and inhibit healing.⁶⁰ This may explain why women are often dissatisfied with the faith-based IPV resources they use.⁶¹ However, in this study, associations with the use of spiritual resources were not contradictory; such use was inversely related to positive appraisal, but positively to both symptoms/dysfunction and readiness to change. Thus, women in violent relationships seek spiritual resources when experiencing high levels of symptomatology and dysfunction, lacking positive appraisals, and considering taking action.

Actually taking action (leaving the relationship) was uniquely and inversely related to religious coping. Religion, in general, is used as a coping strategy in IPV and can be transformative, empowering them to change.^62,63 Prior studies in primary care populations suggest that religious coping is associated with social support and health status² and, among victims of violence, religious coping can diminish psychiatric symptoms^64–66 and promote well being.^64,67 However, it can also serve as a barrier to safety.^68,69 In this study, religious coping was inversely related to leaving the relationship only, possibly confirming its role as a motivation to stay in the relationship.

This study has several implications. First, independent of the duration, severity and dynamics of the violence, religious and spiritual factors are important to our understanding of outcomes; we need to attend to them when we are dealing with victims of IPV. Second, the level of spiritual symptoms (i.e. lack of purpose or peace) is consistently and inversely related to positive outcomes. Perhaps interventions targeting these symptoms need to be developed for victims of violence.

This study also has limitations. First, the associations found in this study are only associations and cannot be used to determine causality. In addition, the population in this study was predominantly low income and Hispanic; previous studies found that the effect of religious involvement on IPV varied with ethnicity.⁷⁰ African Americans, for example, use religious coping more than other groups after sexual assault⁶⁴ and partner violence,⁷¹ and prefer spiritual sources over medical ones for IPV.⁷² In these samples, church attendance led to reduced IPV frequency.⁷⁰ Thus, the results of this study may not apply to other populations.

In conclusion, even after adjusting for violence severity, duration and dynamics, religious and spiritual factors were associated with most outcomes. Spiritual symptoms had a consistently negative effect on outcomes while use of spiritual resources had variable effects. Religious coping was only associated with remaining in the relationship.

Footnotes

Acknowledgments

We wish to thank Stephanie Mitchell, Kelli Giacomini, Robert Mesec, and Wilson Pace for their invaluable assistance.

Conflict of interest

None declared.

Funding

This study was funded through a grant from the National Science Foundation (#0826812). Automated data collection was provided by the University of Colorado, Department of Family Medicine Information Services group.

References

Hotaling

Sugarman

. Analysis of risk markers in husband to wife violence: the current state of knowledge. Violence Vict 1986; 1: 101–123.

Katerndahl

Obregon

. Exploration of the spiritual and psychosocial variables associated with husband-to-wife abuse and its effect on women in abusive relationships. Int J Psychiatry Med 2007; 37: 113–128.

Vakili

Nadrian

Fathipoor

. Prevalence and determinants of intimate partner violence against women in Kazeroon, Islamic Republic of Iran. Violence Vict 2010; 25: 116–127.

Heinrich

. Relationship of religion to beliefs about physical punishment and physical abuse. Dissert Abstr Intl: Section B: Sci Eng 2009; 70: 7210.

Pournaghash-Tehrani

Ehsan

Gholami

. Assessment of the role of religious tendency in domestic violence. Psychol Rep 2009; 105: 675–684.

Antai

. Attitudes of women toward intimate partner violence. Rural Remote Health 2008; 8: 996.

Rodriguez

Henderson

. Who spares the rod? Child Abuse Negl 2010; 34: 84–94.

Jackson

. Examination of social risk factors for wife abuse in the Dominican Republic. Fam Ther 2008; 35: 1–22.

Dunn

Oths

. Prenatal predictors of intimate partner abuse. J Obstet Gynecol Neonatal Nurs 2004; 33: 54–63.

10.

Brinkerhoff

Grandin

Lupri

. Religious involvement and spousal violence. J Sci Study Relig 1992; 31: 15–31.

11.

Ellison

Anderson

. Religious involvement and domestic violence among U.S. couples. J Sci Study Relig 2001; 40: 269–286.

12.

Ellison

Bartkowski

Anderson

. Are there religious variations in domestic violence? J Fam Issues 1999; 20: 87–113.

13.

Seballo

. Religion as a protective factor in resilience. Dissert Abstr Intl: Section B: Sci Eng 2012; 73: 654.

14.

Berkel

Vandiver

Bahner

. Gender role attitudes, religion, and spirituality as predictors of domestic violence attitudes in white college students. J College Student Dev 2004; 45: 119–133.

15.

Fowler

Rountree

. Exploring the meaning and role of spirituality for women survivors of intimate partner abuse. J Pastoral Care Counsel 2010; 64: 1–13.

16.

Reiland

Lauterbach

. Effects of trauma and religiosity on self-esteem. Psychol Rep 2008; 102: 779–790.

17.

Jesse

Swanson

. Risks and resources associated with antepartum risk for depression among rural southern women. Nurs Res 2007; 56: 378–386.

18.

Dervic

Grunebaum

Burke

. Protective factors against suicidal behavior in depressed adults reporting childhood abuse. J Nerv Ment Dis 2006; 194: 971–974.

19.

Conway

. Coping with the stress of medical problems among black and white elderly. Int J Aging Hum Dev 1985; 21: 39–48.

20.

Koenig

George

Siegler

. Use of religion and other emotion-regulating coping strategies among older adults. Gerontologist 1998; 28: 303–310.

21.

Webb

Whitmer

. Abuse history, world assumptions and religious problem solving. J Sci Study Relig 2001; 40: 445–453.

22.

Reinert

Smith

. Childhood sexual abuse and female spiritual development. Couns Values 1997; 41: 235–245.

23.

Ryan

. An exploration of the spirituality of fifty women who survived childhood violence. J Transpersonal Psychol 1998; 30: 87–102.

24.

Burge

Becho

Ferrer

. Safely examining complex dynamics of intimate partner violence. Fam Syst Health 2014; 32: 259–270.

25.

Straus

Gelles

Steinmetz

. Behind closed doors, New York, NY: Anchor Books, 1980.

26.

Katerndahl

Realini

. Use of health care services by persons with panic symptoms. Psychiatr Serv 1997; 48: 1027–1032.

27.

Carver

Scheier

Weintraub

. Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol 1989; 56: 267–283.

28.

Katerndahl

Oyiriaru

. Assessing the biopsychosociospiritual model in primary care. Int J Psychiatry Med 2007; 37: 393–414.

29.

Herth

. An abbreviated instrument to measure hope. J Adv Nurs 1992; 17: 1251–1259.

30.

Vitaliano

. Manual for appraisal dimension scale and revised ways of coping checklist, Seattle: Department of Psychiatry, University of Washington, 1985.

31.

Duke University. Duke social support and stress scale, Durham: Duke University, 1986.

32.

Brown

Adams

. Patients as reliable reporters of medical care process. Med Care 1992; 30: 400–411.

33.

Ware

Jr Sherbourne

. The MOS 36-item short form health survey (SF-36), I. Conceptual framework and item selection. Med Care 1992; 30: 473–483.

34.

Prochaska

DiClemente

Toward a comprehensive model of change. In: Miller

Heather

(eds). Treating addictive behaviors, New York, NY: Plenum Press, 1986.

35.

Glasgow

Ory

Klesges

. Practical and relevant self-report measures of patient health behaviors for primary care research. Ann Fam Med 2005; 3: 73–81.

36.

Heggler

Kantz

Schreiber

. Practical implementation of nonlinear time series methods: the TISEAN package. Chaos 1999; 9: 413.

37.

Kreindler

Lumsden

. Effects of the irregular sample and missing data in time series analysis. Nonlinear Dyn Psychol Life Sci 2006; 10: 187–214.

38.

Kreindler

Lumsden

. Effects of irregular sampling and missing data on largest Lyapunov exponents. Nonlinear Dyn Psychol Life Sci 2007; 11: 401–412.

39.

Land B and Elias D. Measuring the “complexity” of a time series, http://www.nbb.cornell.edu/neurobio/land/PROJECTS/Complexity/index.html (2005, accessed 21 May 2015).

40.

Ziv

Lempel

. Compression of individual sequences via variable-rate coding. IEEE Trans Inf Theory 1978; 24: 75.

41.

Pincus

. Approximate entropy as a measure of irregularity for psychiatric serial metrics. Bipolar Disord 2006; 8: 430–440.

42.

Wolf

Swift

Swinney

. Determining Lyapunov exponents from a time series. Physica 1985; 16D: 285–317.

43.

Yeragani

Pohl

Mallavarapu

. Approximate entropy of symptoms of mood. Bipolar Disord 2003; 5: 279–286.

44.

Gevers

Pincus

Robinson

ICAF

. Differential orderliness of the GH release process in castrate male and female rats. Am J Physiol 1998; 274: R437–R444.

45.

Pincus

Hartman

Roelfsema

. Hormone pulsatility discrimination via coarse and short-time sampling. Am J Physiol 1999; 277: E948–E957.

46.

Zhang

Zhu

Thakor

. Detecting ventricular tachycardia and fibrillation by complexity measure. IEEE Trans Biomed Eng 1999; 46: 548–555.

47.

Hollingshead

Redlich

. Social class and mental illness, New York, NY: John Wiley & Sons, 1958.

48.

Becho

Burge

Katerndahl

. Serendipitous intervention: qualitative findings from the study of dynamic patterns of husband-to-wife abuse. J Fam Violence 2013; 28: 243–251.

49.

Katerndahl

. Impact of spiritual symptoms and their interactions on health services and life satisfaction. Ann Fam Med 2008; 6: 412–420.

50.

Katerndahl

Burge

Ferrer

. Do violence dynamics matter? J Eval Clin Pract 2014; 20: 719–727.

51.

Taylor

. Relationship between religion, spirituality and intimate partner violence. Dissert Abstr Intl: Section B: Sci Eng 2012; 72: 7114.

52.

Neergaard

. Intimate partner violence. Dissert Abstr Intl: Section B: Sci Eng 2009; 69: 4124.

53.

Watlington

Murphy

. Roles of religion and spirituality among African American survivors of domestic violence. J Clin Psychol 2006; 62: 837–857.

54.

Pyles

. Complexities of the religious response to domestic violence. Affilia: J Women Soc Work 2007; 22: 281–291.

55.

Valin

. Do you hear their cries? Dissert Abstr Intl: Section B: Sci Eng 2007; 67: 3854.

56.

Richardson

. Christian clergy response to intimate partner violence. Dissert Abstr Intl: Section B: Sci Eng 2008; 69: 1404.

57.

Levitt

Ware

. Anything with two heads is a monster. Violence Against Women 2006; 12: 1169–1190.

58.

Behnke

Ames

Hancock

. What would you do? J Interpers Violence 2012; 27: 1259–1275.

59.

Copel

. Lived experience of women in abusive relationships who sought spiritual guidance. Issues Ment Health Nurs 2008; 29: 115–130.

60.

Bowland

. Process theology’s relevance for older survivors of domestic violence. J Pastoral Care Counsel 2011; 65: 1–9.

61.

Fowler

Faulkner

Learman

. Influence of spirituality on service utilization and satisfaction for women residing in a domestic violence shelter. Violence Against Women 2011; 17: 1244–1259.

62.

Ting

. Out of Africa. Health Care Women Int 2010; 31: 345–364.

63.

Gatobu

. Towards an interpretive understanding of survivors of domestic violence. Dissert Abstr Intl: Section B: Sci Eng 2007; 67: 4706.

64.

Ahrens

Abeling

Ahmad

. Spirituality and well-being. J Interpers Violence 2010; 25: 1242–1263.

65.

Bradley

Schwartz

Kaslow

. Posttraumatic stress disorder symptoms among low-income, African American women with a history of intimate partner violence and suicidal behaviors. J Trauma Stress 2005; 18: 685–696.

66.

Gall

. Spirituality and coping with life stress among adult survivors of childhood sexual abuse. Child Abuse Negl 2006; 30: 829–844.

67.

Arnette

Mascaro

Santana

. Enhancing spiritual well-being among suicidal African American female survivors of intimate partner violence. J Clin Psychol 2007; 63: 909–924.

68.

Hassouneh-Phillips

. Strength and vulnerability. Issues Ment Health Nurs 2003; 24: 681–694.

69.

Nash

Hesterberg

. Biblical framings of and responses to spousal violence in the narratives of abused Christian women. Violence Against Women 2009; 15: 340–361.

70.

Ellison

Trinitapoli

Anderson

. Race/ethnicity, religious involvement, and domestic violence. Violence Against Women 2007; 13: 1094–1112.

71.

El-Khoury

Dutton

Goodman

. Ethnic differences in battered women’s formal help-seeking strategies. Cultur Divers Ethnic Minor Psychol 2004; 10: 383–393.

72.

Paranjape

Tucker

McKenzie-Mack

. Family violence and associated help-seeking among older African American women. Patient Educ Couns 2007; 68: 167–172.