J Fam Viol (2015) 30:795–802 DOI 10.1007/s10896-015-9740-8

ORIGINAL ARTICLE

Stress Management and Intimate Partner Violence: A Randomized Controlled Trial Eleni Michalopoulou 1 & Georgia Tzamalouka 2 & George P. Chrousos 1 & Christina Darviri 1

Published online: 31 May 2015 # Springer Science+Business Media New York 2015

Abstract Intimate partner violence is a major health problem for women; some of the most common symptoms of violence are depression, psychological distress, and sleep disturbances. In this parallel randomized controlled trial, which took place in Athens-Greece, abused women were randomly assigned to undergo either an 8-week stress management program (n=16; relaxation breathing and progressive muscle relaxation, twice a day counseling) or standard shelter services (n=18). Selfreported validated measures were used to evaluate perceived stress, health locus of control, depression, and ways of coping. In participants in the intervention group, perceived stress was significantly decreased after 8 weeks of relaxation, showing a medium effect of 0.45, but no significant results were noted for sleeping hours, health locus of control, depression, and ways of coping. These results reveal the need to develop interventions for this vulnerable population and future studies should incorporate more objective laboratory outcomes. Keywords Domestic abuse . Anxiety . Depression . Coping . Intervention Intimate partner violence (IPV) is a major health problem for women regardless of race, education, religion, or economic status (Farrell 1996). The term ‘intimate partner violence’ George P. Chrousos and Christina Darviri contributed equally to this work. * Eleni Michalopoulou [email protected] 1

School of Medicine, University of Athens, Soranou Ephessiou Str., 4, GR-115-27 Athens, Greece

2

Technological Educational Institute of Athens, Agiou Spiridonos 28, Egaleo 122 43, Greece

refers to any behavior within an intimate relationship that causes physical, psychological, emotional, or sexual harm to those in that relationship. It includes acts of physical aggression (slapping, hitting, kicking, or beating), psychological abuse (intimidation, constant belittling, or humiliation), moral abuse (neglect and poor care which can influence victim’s growth), forced sexual intercourse (Domestic Violence Advisory Council 1998) or any other controlling behavior (isolating a person from family and friends, monitoring their movements, and restricting access to information or assistance) (Dahlberg et al. 2002). The lifetime prevalence of physical, psychological, or sexual violence in women who have ever had a partner ranges from 15 to 71 %, though prevalence varies significantly between and within countries (large cities versus less populated areas) (Ferris 2007). According to General Secretariat for Gender Equality in Greece, 3955 domestic violence allegations were reported during the year 2012 (General Secretariat for Gender Equality 2012). Moreover, this long-term violence is a situation which affects the emotional and mental equilibrium of women and their general activity, as battering is a leading cause of morbidity and mortality for women of all reproductive ages, especially among younger women, and during pregnancy (Gunter 2007). Intimate partner violence has negative health consequences for survivors, even after the abuse has ended and can cause poor health status, poor quality of life, and high use of health services (Campbell 2002). Physical abuse is the most important risk factor which can lead women to alcohol and drug abuse (Caetano et al. 2000) and/ or to commit suicide (Bergman and Brismar 1991) and the most common somatic complaints include chronic headaches (Coker et al. 2000) insomnia; hyperventilation (Caetano et al. 2000); gastrointestinal symptoms; chest and back pain (Dutton et al. 2006); somatic disorders (American Psychiatric Association 1994); pelvic pain; hearing, vision, and concentration problems;

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and other neurological problems (Campbell and Lewandowski 1997). Women who have been physically abused by a spouse or live-in partner are significantly more likely than other women to have been diagnosed with sexually transmitted diseases (Dutton et al. 1992) and reproductive health problems (World Health Organization, 2011). Abuse during pregnancy may also result in detrimental health outcomes such as low birth weight or fetal death by placenta abruption (McFarlane et al. 2002a; Schei and Bakketeig 1989). Moreover, several studies suggest that it is the daily stress associated with surviving an intimate partner’s physical and verbal assaults that jeopardizes women’s health, as it can seriously compromise physical and psychological well-being (Campbell and Lewandowski 1997; Dutton et al. 1992). Depression and Post-Traumatic Stress Disorder are the most commonly identified disorders among abused women. Other psychological symptoms include sleep difficulties (World Health Organization, 2011), anxiety symptoms (Pico-Alfonso et al. 2006), emotional distress, low self-esteem and self-efficacy (McKinney and Wang 1997), feelings of uselessness, and guilt (Taylor et al. 2001). More specifically, the prevalence of depression among abused women is twice that of the general population (Caetano and Cunradi 2003). Depressive symptoms are chronic and continue to exist over time for some battered women, even in the absence of recent revictimization. Finally, greater depression is associated with greater severity of traumatic experiences (Campbell et al. 1997; Cascardi & O’Leary 1992; Golding 1999). Furthermore, partner abuse, as a traumatic stressor, can lead to the development of Posttraumatic Stress Disorder (PTSD), which involves distressing memories, nightmares, insomnia, and loss of concentration (American Psychiatric Association 1994). At the moment, the rates of PTSD among battered women range from 31 to 84 %, as compared to the rates found among general community samples of women, which range from 1 to 12 % (Mechanic et al. 2008). Abused women also experience more negative life events and daily hassles than do non-battered women (Campbell and Lewandowski 1997; Eby et al. 1995). These findings indicate that there is a substantial link between abuse, stress, and women’s health (Sutherland et al. 2002) and it is thus evident that stress reduction in battered women could merit benefits, such as a reduction in depressive symptoms, feelings of uselessness and guilt, better coping and adjustment to difficult situations, and an improvement in well-being. Stress management may be accomplished by several methods, of which the simplest and most easily administered are relaxation techniques, such as yogic breathing (pranayama) (Franzblau et al. 2006), music therapy (Hernández-Ruiz 2005), and biofeedback (Leroi et al. 1996). Other studies have examined the impact of different interventional programs of social support and life skills (Trimpey 1989; Constantino et al. 2005), counseling and selfempowerment techniques (Sullivan et al. 2002; Hyman 2001), psychotherapy (Crespo & Arinero 2010; Kubany

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et al. 2003), and safety-promoting behaviors (Tiwari et al. 2012; McFarlane et al. 2002b, 2006) on women’s stress and mood. Results have shown an improvement in self-efficacy and a decrease of posttraumatic stress disorder, depressive, and anxiety symptoms. Moreover, these relaxation techniques have helped women to avoid revictimization, to develop selfadvocacy strategies, and to manage psychological distress. This Study Examined an Intervention Based on two Relaxation Techniques Relaxation Breathing (RB) and Progressive Muscle Relaxation (PMR). The RB technique is performed by taking deep diaphragmatic inspirations followed by slow prolonged expirations and the general aim is to shift from upper chest breathing to abdominal breathing. On the other hand, PMR is a technique for learning to monitor and control the state of muscular tension. In this phase of relaxation, patients were guided through successive contractions for several seconds and relaxations of different large muscle groups in a down-top orientation. The muscle group includes toes, feet, thighs, hips, stomach, back, chest, shoulders, hands, forearms, upper arms, neck, and facial muscles. In each step, the patients were encouraged to focus on the difference between tension and relaxation, thus gradually sharpening the perception of the relaxation response (Jacobson 1938). Both techniques have many advantages. Studies have shown that RB allows the person to substitute negative thoughts with the simple act of breathing (Williams et al. 2000). Moreover, deep abdominal breathing encourages the beneficial trade of incoming oxygen for outgoing carbon dioxide and can slow the heartbeat and lower or stabilize blood pressure (Harvard Health Publications 2006). Relaxation breathing can improve fatigue (Kim & Kim 2005a), anxiety, and depression levels in patients (Kim & Kim 2005b) and increase parasympathetic activity eliciting the experience of alertness and re-invigoration (Jerath et al. 2006). Although the exact mechanism of action is unclear, it is thought that PMR induces a relaxation response, including alterations in sympathetic nervous system activity. Progressive Muscle Relaxation decreases pulse rate, blood pressure, musculoskeletal tone, and altered neuroendocrine function (Cooke 2013). Also, PMR decreases pain, reduces tension headaches and fatigue, increases energy, and improves emotional well-being (McCallie et al. 2008). This deep somatic restfulness has been found to reduce perceived stress and salivary cortisol soon after the end of training (Pawlow and Jones 2005; Carlson and Hoyle 1993), reduces anxiety and physical arousal (Molassiotis et al. 2002), and improves sleep. Moreover, RB and PMR are two simple relaxation techniques; everyone can learn how to practice them, initially with the help of a professional. Furthermore, both of them are easy, efficient, and have immediate results. Although there are a number of studies which have focused on the benefits of these

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techniques, only few trials have tested their effectiveness on health and abuse outcomes in women who experience domestic violence. The reasons stated above highlight the need to evaluate RB and PMR techniques on abused women’s behavior and well being, in order to improve their physical and psychological state of health. In conclusion, the aim of this study is to determine the most significant psychological symptoms of intimate partner abuse and subsequently, when the intervention program is completed, to measure the resulting improvements. More specifically, the hypotheses refer to the decrease of perceived stress and depressive symptoms of abused women, the coping behaviors they use against stressful situations, and finally, the impact of the intervention program on women’s locus of control and on sleep quality and quantity.

Method Participants The study was conducted at a non-government organization called BFrontida,^ a family violence unit of Athens and also with the referral of a church located in Loutraki, Korinthos, between September 2012 and May 2013. Recruitment was performed once per week and on the same day each week. During this recruitment period, a research assistant liaised with clinical staff and approached eligible women. The research assistant offered them participation in a Bstudy about intimate partner violence^ and asked to speak with them in private. Then, the study procedure was explained and all participants were asked to provide a fully informative written consent to participate in the 8-week study. After obtaining written consent, the research assistant administered the baseline survey. Each potential participant initiated contact with one of the researchers, who then conducted a brief screening interview to ensure that they met all the inclusion criteria. All participants who self-identified themselves as verbally, emotionally, physically, and/or sexually abused by a man were invited to participate. Other inclusion criteria included being over 18 years of age, being able to converse and write in Greek, and had been out of an abusive relationship for at least 30 days with no intention of reconciling. Potential participants were excluded if they were using psychotropic drugs (e.g., antidepressants, benzodiazepines, antipsychotics, cannabis, or other stimulants) or if they were practicing other relaxation techniques (e.g., yoga, pilates, meditation, psychotherapy).

Materials Self-reported validated measures were used to evaluate the eventual improvements:

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Socio-demographic Variables These variables included age, marital status, children in the household, educational level, employment status, and smoking status. Perceived Stress Scale The Perceived Stress Scale (PSS) is a self-reported 14-item measure of the degree to which situations in an individual’s life are appraised as stressful (Cohen et al. 1983). For this purpose, respondents rated the frequency of their feelings and thoughts over the previous month in a 5point Likert-type scale (from 0=never to 4=very often). There are seven positive and seven negative items and the total score was calculated by summing up each score after reversing all the positive items (minimum total score =0, maximum total score=56). Higher scores indicate the higher level of perceived stress by the individual during the last month. The PSS measurement was performed at the beginning of the trial and at the end of the 8 weeks of follow-up. Good psychometric properties of this measure within the Greek population have been recorded (Andreou et al. 2011). In addition, the internal consistency of the 14-item scale for this study was good for both the initial and final measurements (Cronbach’s alpha 0.82 and 0.81, respectively). Health Locus of Control Scale Health Locus of Control was measured using the 18-item Health Locus of Control Scale (HLC) (Wallston et al. 1978). The respondents expressed their level of agreement to 18 statements in a 6-point Likert-type scale (from 1=strongly disagree to 6=strongly agree). The scale is built upon three 6-item subscales, namely Binternal HLC^ (HLC1), Bexternal HLC^ (HLC2), and Bchance^ (HLC3). The internal HLC (HLC1) measures the degree to which the individual believes that he/she is responsible for his/ her health status. The external HLC (HLC2) and chance (HLC3) represent the extent to which other people (such as medical doctors) or chance, respectively, are perceived by individuals as the main health determinants. After summing up answers for each subscale, higher scores indicate higher strength of each type of health belief (total score range 6–36 for each subscale). Health Locus of Control measurements were made at baseline and at the end of 8 weeks. The instrument was standardized for Greek populations (Karademas 2009). The internal consistency for each subscale was found to be acceptable for both the initial and final measurements (Cronbach’s alpha: initial HLC1 0.65, HLC2 0.60, HLC3 0.80 and final HLC1 0.69, HLC2 0.60, HLC3 0.79). Beck Depression Inventory The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression over the last week, such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex (Beck et al. 1961). Items are rated from 0 to 3, with higher

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scores indicating a larger number of symptoms (minimum total score =0, maximum total score=63). BDI measurements were performed at the beginning of the trial period to determine baseline and at the end of the 8-week study. The instrument was standardized for Greek populations (Donias and Demertzis 1983). The internal consistency was found to be very good for both the initial and final measurements (Cronbach’s alpha 0.92 and 0.93, respectively). Ways of Coping Checklist The Ways of Coping Checklist (WCCL) is a 38-item self-report questionnaire designed to assess coping thoughts and behaviors in response to a specific stressor (Lazarus and Folkman 1984). It consists of five coping strategies people use in response to stressful events. These include the cognitive restructuring-WCCL1 (items refer to cognitive strategies that alter the meaning of the stressful transaction as it is less threatening, it is also examined for its positive aspects and is viewed from a new perspective, etc.), the social support-WCCL2 (items refer to seeking emotional support from people, family or/and friends), the wishful thinking-WCCL3 (the items involve hoping and wishing that things could be better), the problem avoidance- WCCL4 (items refer to the denial of problems and the avoidance of thoughts or action about the stressful event) and the problem solving-WCCL5 (items refer to both behavioral and cognitive strategies designed to eliminate the source of stress by changing the stressful situation). Subjects respond on a 4-point Likert scale and items are rated from 0=never to 3=often. After summing up answers for each subscale, higher scores indicate higher use of each type of coping strategies. Ways of Coping measurements were made at baseline and at the end of 8 weeks. Moreover, the instrument was standardized for Greek populations (Karademas 1998). The internal consistency for each subscale was found to be acceptable for both the initial and final measurements (Cronbach’s alpha: initial WCCL1 0.72, WCCL2 0.7, WCCL3 0.62, WCCL4 0.71, WCCL5 0.72 and final WCCL1 0.69, WCCL2 0.68, WCCL3 0.61, WCCL4 0.67, WCCL5 0.74).

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group were provided with identical verbal and written information concerning stress and its effects on health during the first session. During sessions 2–7, women who were randomly assigned into the intervention group were trained in RB and PMR. Both RB and PMR were administered in the form of an audio CD, consisting of 10 min of RB and 15 min of PMR. Abused women were instructed to practice the guided RBPMR CD twice a day for 8 weeks at home (for a maximum of 112 times). Training and explanation of the concept of stress management took place during the first session. Moreover, counseling in the intervention group was provided as soon as a problem occurred. Counseling interventions were brief and often problem-specific, mainly aimed to prevent women from intimate partner violence. Each woman consulted in a private room with the researcher for a freeflowing chat session with no structure, in order to talk about their worriesNo one was present except the researcher and the women, since women reported that staff inhibited their ability to be themselves and to speak and behave freely. Compliance to daily recommended sessions was encouraged by telephone communication at the end of each week and recorded by a self-reported checklist. Finally, the purpose of session 8 was to measure the eventual improvements, as the interventional program was completed. On the other hand, the women in the control group continued to receive the standard shelter services, including meals, shelter, job searching, legal issues surrounding divorce, and social services appointments. To provide consistency between the experimental and control groups, experienced health professionals also telephoned the control patients at the end of each week. During telephone communications with both groups, participants were asked, using the standard open questions, to report on their mood and their principal sources of stress during the last week, in order to increase compliance and/or reduce drop-outs. At the end of eight weeks, women in the control group were rewarded for their participation in the study with a relaxation CD.

Results Procedure The study used a randomized controlled, parallel-group design. Participants were randomized to the intervention or control group according to a list of random permutations prepared by computer-generated blocked randomization (www.random. org). Randomization, baseline, and final measurements were not blinded. Moreover, after trial commencement, no change of the initial protocol (e.g., eligibility criteria) took place. The purpose of session 1 was to establish a relationship of mutual trust between researcher and participants, to obtain a partner abuse history, and provide women with an overview of the study. Moreover, both the intervention and the control

The study flowchart is shown in Fig. 1. In total, 36 abused women were assessed during the recruitment period (September 2012–May 2013). Of 36 women, one was not eligible to participate as she was taking psychotropic drugs (antidepressants and anxiolytics). From the remaining 35 eligible women, 17 were randomly assigned into the intervention group and 18 were randomly assigned into the control group. Of the 17 women in the intervention group, one had droppedout as she changed family violence units. The last measurement assessment after the 8-week follow-up period took place in July 2013 (recruitment stopped in May 2013 after reaching a total of 34 eligible patients).

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799 Table 1

Women assessed (n=36) Not eligible for study entry (n=1) Randomized (n=35)

Allocated to intervention (n=17)

Main baseline data

Intervention group

Control group

(N=16)

(N=1 8)

41 (19–55) 9 (56.3) 13 (81.3)

38 (24–66) 6 (33.3) 12 (66.7)

1 (6.3) 13 (81.2) 2 (12.5)

2 (11.1) 9 (50) 7 (38.9)

6 (37.5) 9 (56.3)

12 (66.7) 10 (55.6)

p- valuea

Psychotropic drugs

Allocated to control (n=18)

Excluded during follow-up (n=1) Change family violence unit

Analyzed (n=16)

Baseline characteristics of the 34 abused women in the study

Analyzed (n=18)

Fig. 1 Flowchart of participants

Baseline group characteristics are presented as median, minimum-maximum, and absolute and proportion values. For group comparisons, Pearson’s chi-square, Student’s t-test, or the Mann–Whitney U-test were used according to normality. Changes in PSS, HLC1, HLC2, HLC3, BDI, and WCCL scores (after 8 weeks minus baseline) were used as outcomes. Finally, the effect size was calculated for each variable using the following formula: r=Z/N0.5, where Z is the value of the Mann–Whitney U-test and N is the total sample. In general, the effect sizes 0.5, 0.3, and 0.1 are considered as large, medium, and small, respectively. The p-value of significance was set at 0.05 for all analyses. Statistical calculations were performed using the IBM SPSS Statistics for Windows (version 21.0) statistical software (SPSS Inc., Chicago, IL). Baseline characteristics are described in Table 1. Most of the participants were middle-aged and married with children. Furthermore, most of them completed secondary education, were employed, and were smokers. The mean baseline measurements of sleeping hours, perceived stress, health locus of control, depression, and coping strategies are also presented. According to the theoretical ranges of scores described in the method section, midline scores were recorded for PSS (mean 33.15±5.80), internal (mean 25.80±4.80), external (mean 21.20±5.20) and chance (mean 17±5.90) HLC, BDI (mean 20.50±14.20), cognitive restructuring (mean 21.20±5.30), social support (mean 12.50±3.50), wishful thinking (mean 17.80±3.40), problem avoidance (mean 18.02±4.80), and problem solving (mean 6.20±2.40) WCCL. There were no significant baseline differences between the two study groups (p>.05).

Discussion The purpose of this pilot randomized controlled study was to assess the efficacy of a brief stress management treatment in women victims of violence by their intimate partner. According to the observed median changes and the p-values,

Age (median, min-max) Married (n [%]) Children (n [%]) Education (n [%]) primary secondary tertiary Work status (n [%]) employed Current smoking (n [%]) Outcomes (median, min-max) Sleeping hours PSS score HLC1 score HLC2 score HLC3 score BDI score WCCL1 score WCCL2 score WCCL3 score WCCL4 score WCCL5 score

.66 .53 .34 .18

.09 .98

6 (3–8) 6.50 (5–10) .12 29.50 (21–42) 25 (17–40) .37 25 (17–3) 26.50 (13–33) .49 21 (12–28) 18 (6–23) 20 (0–49) 22.50 (6–28) 14.50 (6–18) 18 (10–24) 19 (9–25) 7.50 (2–11)

21 (12–32) 16.50 (6–28) 25.50 (0–35) 22 (13–32) 13 (8–17) 19 (12–24) 18 (11–26) 6 (3–10)

.98 .84 .89 .84 .83 .67 .87 .21

PSS Perceived Stress Scale, HLC Health Locus of Control (1=internal, 2=external, 3=chance), BDI Beck Depression Inventory, WCCL Ways of Coping Checklist (1=cognitive restructuring, 2=social support, 3=wishful thinking, 4=problem avoidance, 5=problem solving) Frequencies tested by the Pearson’s χ2 , medians by the Student’s t-test and non-parametric Mann–Whitney U-test a

as shown in Table 2, no significant results were noted for sleeping hours, health locus of control, depression, and ways of coping. However, this stress management program resulted in a significant improvement of perceived stress, showing a medium effect of .45, indicating there was something more beneficial taking place in the intervention group than in the control group. Despite the fact that our study supports the possible beneficial role of stress management for improving abused women’s well-being, this intervention should be considered as an adjunctive program. Our results are indicative of the need for more comprehensive programs, incorporating not only stress management but also additional support for women. This support should examine maladaptive cognitions and behavior, convert traumatic into adaptive memories, and replace cognitive distortions with constructive thinking. Moreover, numerous studies indicate that social support is essential for maintaining physical and psychological health. As a result, a complete program should provide social support

800

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Table 2 Adjusted median changes of primary outcomes by study group and effect sizes during the studyPSS Perceived Stress Scale, HLC Health Locus of Control (1 = internal, 2 = external, 3 = chance), BDI Beck Depression Inventory, WCCL Ways of Coping Checklist (1=cognitive restructuring, 2 = social support, 3 = wishful thinking, 4 = problem avoidance, 5=problem solving) Outcomes Intervention group Control (median, min-max) (N=16) group (N=18)

Z

Sig. r

ΔSleeping hours ΔPSS score ΔHLC1 score ΔHLC2 score ΔHLC3 score ΔBDI score ΔWCCL1 score ΔWCCL2 score ΔWCCL3 score ΔWCCL4 score ΔWCCL5 score

−1.78 −2.66 −0.22 −0.89 −0.10 −1.28 −1.72 −0.12 −1.11 −1.43 −0.83

.07 .00 .82 .37 .91 .20 .08 .90 .26 .15 .40

0 (0–1) 3 (0–6) 0 (−2–1) 0 (−1–1) 0 (−2–2) −1 (−18–2) 1 (−1–3) 0 (−5–4) 0 (−2–1) 1 (−2–3) 0 (−1–0)

0 (0–1) 2 (−2–6) 0 (–5–6) 0 (−1–2) 0.50 (−2–2) −1 (−18–3) 0 (−3–2) 0 (−1–3) 0 (−1–2) 0 (−2–5) 0 (−1–2)

.30 .45 .03 .15 .01 .20 .29 .02 .19 .24 .14

treatment, nourish a sense of belonging, and foster a sense of self-worth. Finally, the intervention program should provide psychoeducation on different aspects of maladaptation to daily life and help women develop coping strategies and problem-solving skills. It is acknowledged that this study has a number of limitations. First of all, the entire primary outcome measures were based on self-administered self-reports as opposed to objective clinical assessments (e.g., cortisol) and as a result the reliance on these data may be distorted by recall bias and/or social desirability. Furthermore, the intervention lasted for only 8 weeks, a relatively short period of follow-up compared to other studies, suggesting that it would be interesting to determine whether longer intervention programs create more psychological benefits. Finally, we have to admit that differences with regards to the main study’s outcomes, especially for stress, were more likely to be found between the groups due to the lack of any supportive/therapeutic intervention in the control group. The generalization of these findings is also restricted to battered women over 18 years of age. Also, it refers to women who have been out of abusive relationships for at least 30 days, with no intention of reconciliation. Moreover, these findings broadly concur with the findings of Hernández-Ruiz’s study, where a music therapy procedure (music listening paired with progressive muscle relaxation) resulted in the reduction of anxiety and improvement of sleep patterns in abused women in shelters (Hernández-Ruiz 2005). In Constantino et al.’s study, a social support intervention decreased psychological distress symptoms in abused women and help them to address or overwhelm different perceptions of stress (Constantino et al. 2005). On the other hand,

psychotherapeutic cognitive-behavioral programs and forgiveness therapy were efficacious as therapeutic strategies for the amelioration of long-term negative psychological outcomes of spousal psychological abuse, such as depression, trait anxiety, posttraumatic stress symptoms, and self-esteem (Crespo and Arinero 2010; Reed and Enright 2006). In conclusion, this intervention program for intimate partner violence resulted in a significant improvement of perceived stress but did not reduce other psychological symptoms. Despite this, RB-PMR is a simple relaxation technique for abused women. It should be deemed as highly costeffective with practice feasibility and no harm or adverse effects. Future studies should extend these preliminary findings using greater sample sizes, examining other similar techniques, and measuring more objective laboratory outcomes, such as biomarkers.

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