Abstract
Women with disabilities face a heightened risk of intimate partner violence (IPV) compared with those without disabilities (Breiding & Armour, 2015). IPV includes physical, sexual, and psychological harm perpetrated by a current or former intimate partner (Breiding et al., 2015). IPV degrades the health of women with disabilities (Barrett et al., 2009) and presents occupational challenges that result in financial difficulty (Smith & Strauser, 2008) as well as physical and social isolation (Plummer & Findley, 2012). Occupational deprivation is “a state in which people are precluded from opportunities to engage in occupations of meaning due to factors outside their control” (Whiteford, 2000, p. 200). Survivors of IPV with disabilities may be subject to occupational deprivation because abusive living environments prevent them from engaging in desired—and, in some cases, necessary—occupations (American Occupational Therapy Association [AOTA], 2017).
AOTA (2017) recognizes the damaging impact of IPV on survivors’ ability to competently and independently engage in daily occupations and acknowledges the role occupational therapy practitioners can fulfill in working with survivors to mitigate IPV-related occupational deprivation. However, scant research has examined the impact of occupational deprivation on survivors of IPV with disabilities. In this brief report, we outline findings from a larger qualitative study of women with physical disabilities receiving services from an IPV agency that specializes in serving people with disabilities. The findings reported here focus on instances of occupational deprivation faced by survivors of IPV who have physical disabilities. An exploration of how occupational therapy practitioners can help survivors with disabilities escape IPV through occupational engagement follows.
Background
Women with disabilities are more often subject to severe forms of physical abuse, including being kicked, punched, or bitten, yet they also experience subtle forms of abuse that exploit aspects of disability, such as withholding medication or denying needed supports (Brownridge, 2006). Life circumstances of women with disabilities, including reduced community inclusion, social isolation, and a deeper dependence on intimate partners for assistance with daily needs, may heighten their potential for victimization (Plummer & Findley, 2012). The physical and mental health of women with disabilities is further degraded by IPV. The World Health Organization (2011) cited higher rates of violence against women with disabilities as a major factor in their diminished health status, linking violence to “immediate and long-term” health outcomes, including “injuries, physical and mental health problems, substance abuse, and death” (p. 59). These negative health effects contribute to occupational deprivation. Women who have experienced IPV are more likely than those without a history of IPV to report that they are unable to work, possibly because of the physical and mental distress that results from abuse (Bosch et al., 2017).
Role of Occupational Therapy
In the context of IPV, occupational therapists possess specialized skills and expertise to mitigate the negative impact of abuse on survivors’ ability to engage in daily life occupations independently and competently (AOTA, 2017) and work through IPV-related barriers. Although research on the occupational needs of IPV survivors is limited, several studies indicate the importance of addressing this issue. Javaherian-Dysinger et al. (2016) found that women residing in a domestic violence shelter prioritized occupational goals related to education, work, and instrumental activities of daily living, and occupational therapy groups and individual sessions at the shelter improved survivors’ self-rated satisfaction and goal attainment. Another study of women receiving services from a domestic violence agency determined that before permanently ending their abusive relationships, they had made an average of six attempts to leave their abusers but were unable to because of financial dependence or an inability to perform life skills such as maintaining a job or household (Gorde et al., 2004).
The combination of IPV and disability may exacerbate challenges to occupational engagement, in turn entrapping women in abusive relationships because they lack the means to independently support themselves and their children. Previous research has indicated that women with disabilities who experience IPV are more likely to be unemployed than (1) women experiencing IPV who do not have a disability and (2) women with disabilities who have not experienced IPV (Smith & Strauser, 2008). Women with work limitations are far more likely to live in poverty than those without (VonSchrader & Lee, 2017). Moreover, an inability to work may exacerbate chronic health conditions among survivors of IPV: For example, Bosch et al. (2017) found that women who were unable to work and had a history of IPV were more likely to have high blood pressure, have high cholesterol, and be obese than women who were employed (Bosch et al., 2017).
Occupational justice centers on the notion that occupations are the means through which people exert empowerment, choice, and control. When people are deprived of opportunities to participate in meaningful occupations, they experience occupational injustice and deprivation (Wilcock & Townsend, 2000). Women with disabilities may face compounded occupational deprivation because of health-related challenges along with the power and control exerted by abusive intimate partners. In this study, we examined the impact of occupational deprivation on survivors of IPV with physical disabilities and explored the role occupational therapy practitioners can play in helping survivors regain optimal occupational functioning.
Method
Setting and Participants
Participants (n = 25; all women) were recruited from a nonresidential domestic violence agency located in New York City that serves people with disabilities. It is one of only a few domestic violence agencies nationwide that works specifically with this population. The study protocol was approved by Columbia University’s institutional review board. Purposive sampling was used to seek participants, who were recruited through flyers and word of mouth within the agency.
To be eligible for the study, participants were required to be older than age 18, have been diagnosed with a physical disability, have previously experienced domestic violence perpetrated by an intimate partner, and be a current or former client of the agency. Physical disabilities encompass conditions affecting physical mobility and chronic illnesses that affect one’s physical functioning, such as a heart condition or asthma. Women with pain conditions were included in the study because pain conditions are considered a subset of physical disabilities; these conditions included chronic pain experienced in any part of the body. Participants were all living independently in New York City at the time of the study. Women who were currently in relationships with an abusive partner were to be excluded from the study out of concern for participants’ safety; however, none were ultimately excluded for this reason. Additional participant information is provided in Table 1.
Participant Demographic Characteristics (N = 25)
Data Collection
The women were interviewed over the course of 18 mo. Interviews were conducted by the second author (Freyer), a social worker experienced in working with survivors of IPV with disabilities. The semistructured, in-depth interviews focused primarily on questions related to four areas: (1) abuse experience and risk assessment, (2) use and nonuse of self-protective strategies, (3) necessary support services, and (4) the impact of disability in relation to these phenomena. Five interviews were conducted via telephone; all women were interviewed face to face. Women were asked the same questions using a standard interview script regardless of interview location. Given the sensitive nature of these data, strict procedures were followed to protect participant confidentiality.
Data Analysis
We used grounded theory methods for analysis (Charmaz, 2014). Coding was conducted using ATLAS.ti (Version 8; Scientific Software Development, Berlin, Germany). The second author, who is trained in qualitative methods, led the coding process under the supervision of the first author. Data analysis began with the open coding of verbatim transcripts and notes. The next step involved using code mapping (Saldaña, 2013) to consider how these codes related to one another and were indicative of patterns. While conducting the analyses, we returned to the data repeatedly as categories, concepts, and themes developed. Once the properties of each category had been filled and no new ideas emerged from this iterative process (Charmaz, 2014), we determined that the categories were saturated, and analysis ceased. The study’s original goal was not to explore occupational deprivation among survivors with disabilities; however, this theme emerged in analysis through the inductive nature of qualitative research.
Ensuring rigor in qualitative research involves demonstrating that findings are well grounded in the data. To allow readers to critically evaluate the interpretations made, ample detail is provided regarding participants, setting, and how the raw data support the study’s findings (Creswell, 2013). In addition, the strategy of code mapping helps organize observations as one progresses toward second-cycle coding, and it enhances credibility and trustworthiness by providing a data display that illustrates how coding progresses from phase to phase (see Freyer, 2018, for more details regarding the study’s method).
Results
The findings reported here focus on themes related to instances of occupational deprivation experienced by the participants. Participants identified a number of occupational barriers preventing them from escaping IPV. The themes elaborated on here are educational barriers, vocational barriers, financial barriers, and physical barriers.
Educational Barriers
Although many women expressed a desire to work or attend college, few were employed at a steady job at the time of the study or had attended college. Education was noted as an important step toward obtaining a job and financial independence, but the effects of IPV and disability had sometimes derailed participants’ attempts at seeking education. One woman lamented the chronic health condition that kept her from pursuing the education she desired, in turn preventing her from obtaining the resources needed to separate from an abusive partner: “They said find a job. I’m sick, I have a fever, I’m not doing it because I want to. I wanted to go further, eventually getting a doctorate. And I mean, it’s not because I don’t want to work.” Another could not finish college because of the abuse she experienced: “I would like to finish college. [My partner kept] putting me in the hospital every time I came close to graduating.”
When educational attainment was possible, it gave many women a sense of safety and fulfillment. One woman had recently graduated from college at the time of her interview. Of this accomplishment, she said,
Everything they said I couldn’t do when I started losing my vision, I said you know what I want to do with my life? I want to go to school. That’s what saved me . . . I feel like I have a purpose, and it’s not to be abused, you know?
Multiple disabilities compounded this woman’s situation, but occupational engagement provided her with purpose and the possibility of a life free of abuse.
Vocational Barriers
Disability and IPV made it difficult for the women to acquire and maintain employment. One woman’s partner forbade her to work: “I had no bank account for like 4 years. . . . I kept saying, I need to work, I need to feel like I’m helping people.” Another woman stated a desire to feel productive and feel safe. Both were essential to her independence:
I want to go back to school . . . I want to do something productive. I have to get my GED, I have to find a school, I have to get hooked up with VESID [a vocational rehabilitation program] and . . . I am trying to do all I can . . . and still be safe, you know?
Another woman looked forward to getting back to work after going on leave because of a back injury:
I haven’t given up on working. I had a good job. I was a construction worker. I like things where I’m moving around, and I was in pretty good shape then. You know, so I really want to go back to doing it. And I made a nice salary.
Work was central to both her sense of well-being and her financial independence; however, her disability prevented her from working, which in turn limited her options for escaping IPV.
Financial Barriers
For some women, occupational engagement provided a route out of poverty, yet others struggled to find occupations that would provide a livable wage. The pursuit of work, education, or both was particularly meaningful because these occupations provide a gateway to financial independence and, often, an alternative to abusive relationships. One woman identified occupational and financial independence as crucial to her safety, explaining,
I want to do something that can help me to stay independent. I want to work, even [go to school] for something I want to do . . . economically I’m not safe. [I’d feel safe] if I had a job, and then I can pay my rent.
Another woman saw financial independence as essential to safety:
If you cannot financially stand on your own, or . . . your spouse or whoever is abusing you is not permitting you to become independent, you will never find safety. Mentally or physically . . . People need financial literacy.
To maintain a sense of safety, survivors of IPV need the tools to remain financially independent. Study participants who were able to become financially independent of abusive partners generally had more options at their disposal when attempting to escape IPV.
Physical Barriers
Some women needed to become functionally independent to separate from abusive partners; that is, they needed to be able to take care of themselves physically to live independently. One woman made note of the elements put into place to help her live apart from her husband: “[The domestic violence agency] helped me get an ambulette. . . . I was getting a leg made, and I had a wheelchair . . . so at that time I really didn’t have to depend on him.” Another woman outlined the functional supports she would need to have in place to escape an abusive situation, including how to continue having her disability-related personal care needs met in the event that she separated from her partner and found herself living alone. She explained, “I need someone to come help me at least 4 hours a day with shopping, to make meals, clean, pay bills.” Assistance in completing these tasks was necessary to functional independence, which ultimately would provide her greater confidence to separate from her abusive partner.
Discussion
Women were subject to occupational deprivation when their partners prevented access to educational, vocational, and health-promoting activities. Occupational deprivation was described by a number of the women as a tactic used by abusive partners to isolate them. In some cases, however, women’s disabilities and chronic health conditions presented barriers to occupational engagement independent of IPV. The combination of IPV and disability may exacerbate challenges to occupational engagement, entrapping women in abusive relationships because they lack means to independently support themselves and their children.
The immediate safety-related needs of IPV survivors are understandably the predominant focus of many domestic violence organizations (Javaherian et al., 2007); however, occupational therapy practitioners can enhance these safety-promoting services by providing education and interventions that increase the ability of survivors with disabilities to live independently. Occupationally minded interventions for survivors of IPV focus on self-determination and promote the learning of assertiveness skills as components of active participation in healthy occupations (AOTA, 2017). Occupational engagement is a crucial aspect of empowerment for women with disabilities who experience abuse (Smith & Hilton, 2008).
Several study participants described feeling physically fit and healthy as empowering, yet interventions involving physical activity may be viewed as off-limits for women with physical disabilities by clinicians who are focused on the perceived constraints of impairment and thus unfamiliar with adaptive strategies. Occupational therapy practitioners can help domestic violence agencies modify their practices to be accessible to the widest range of survivors possible, regardless of disability type. At the study site, occupational therapy interns help survivors with goals in six distinct areas: work, volunteer, and education skills; cognitive skills; life skills; improving physical function; and leisure exploration and social skills, along with referrals to additional programs if needed. Although providing occupational therapy interventions on site at domestic violence agencies is ideal, it is not always financially feasible. Alternatively, occupational therapy practitioners can provide consultation to domestic violence agencies, either for referrals or for in-house assistance, to help survivors with disabilities pursue their occupational goals. Examples of such collaboration include working with domestic violence program staff to identify areas of overlap between needs reported by survivors and occupational therapy interventions, such as helping the agency implement programming on developing life skills or recommending clients’ participation in vocational and educational programs (Javaherian-Dysinger et al., 2016).
Limitations
Limitations should be considered when interpreting this study’s results. First, to address the lack of disaggregated research data on survivors of IPV with disabilities, we limited the sample to women with physical disabilities. Although all participants had a physical disability, many had co-occurring disabilities of other kinds. However, the range of disabilities and health conditions described by the participants is perhaps a more realistic reflection of disability: It is a fluid condition that can shift with time and circumstance, and certain aspects of disability will have more of an effect than others, depending on the personal and social context. A second limitation is the former employment of one of the authors at the study site. However, steps were taken to minimize researcher and respondent bias by openly documenting possible biases through the use of memos and journaling and integrating these documents into the analytic process.
Implications for Occupational Therapy Practice
The findings of this study have the following implications for occupational therapy practice:
This study illuminates how occupational deprivation compounds the negative impacts of IPV, particularly among women with disabilities. Occupational therapy practitioners can play an important role in helping IPV survivors overcome these barriers.
Occupational therapy practitioners should familiarize themselves with the signs and symptoms of IPV among people with disabilities to heighten awareness of its occurrence among their clients.
Occupational therapy practitioners can assist individual clients and domestic violence agencies alike to help IPV survivors with disabilities heighten occupational engagement and independent functioning to the extent possible.
Conclusion
The benefit of occupational therapy services for survivors of IPV with disabilities has been largely unexplored, but this study underscores the utility of addressing the occupational needs of this population. Working with survivors with disabilities to optimize occupational functioning and enhance independence may be among the most important interventions to provide women with the tools to escape abuse. Further research on this topic and exploration of effective occupational therapy interventions for IPV survivors with disabilities are recommended.