Insomnia,Posttraumatic Stress Disorder Symptoms,and Danger: Their Impact on Victims’ Return to Court for Orders of Protection

Abstract

The linkages between intimate partner violence (IPV), posttraumatic stress disorder (PTSD), and insomnia have been the subject of inquiry. This study is the first to explore the associations between clinical-level insomnia, PTSD symptoms, danger, and victim socio-demographics, and whether IPV victims pursue permanent orders of protection (OPs). Data for this secondary analysis were collected through surveys, interviews, and reviews of court records on 112 women who resided in upstate New York. Women initiated actions to obtain OPs from the Domestic Violence Intensive Intervention Court (DVIIC), from 2007 to 2008. The following factors were analyzed to determine their impact on whether a woman returned to court: (a) age, (b) race, (c) employment status, (d) perceived danger, (e) PTSD symptoms, and (f) clinical-level insomnia. This study finds that the following factors significantly relate to return to court: race, clinical-level insomnia and perceived danger, clinical-level insomnia and PTSD symptoms, and severe danger level. However, in the final multivariate logistic regression, only race emerged as a predictor of whether a woman returned to court. Specifically, women of color were a third less likely to return to court than White women. These results have significant implications for future research and clinical intervention.

Keywords

intimate partner violence orders of protection PTSD insomnia

For women, being in an intimate relationship can be dangerous. Intimate partners perpetrate the vast majority of violent acts against women (Black et al., 2011; Saltzman, Fanslow, McMahon, & Shelley, 2002; Tjaden & Thoennes, 2000). In the United States, an estimated 7 million women each year will experience physical violence, rape, and/or stalking by an intimate partner. An estimated 16.6 million women each year will experience psychological violence by an intimate partner (Black et al., 2011). As a result, the presence of fear and danger in victims’ lives as a consequence of their abusers’ threats and actions poses a significant threat to women’s overall safety and health (Jones, Hughes, & Unterstaller, 2001; Stover, 2005). The judicial system has emerged as a source of safety and support for victims. Research verifies that victims turn to the courts for assistance more than any other possible support system (Hollenshead, Dai, Ragsdale, Massey, & Scott, 2006). The present study explores unique barriers to intimate partner violence (IPV) victims’ use of the courts. Namely, it is focused on sleep disruption, perceived danger, and symptoms of posttraumatic stress disorder (PTSD).

It is well documented that IPV victims suffer a vast array of physical and mental health problems. Adverse physical consequences of IPV include physical injuries, death due to homicide, miscarriages, and exposure to HIV and other sexually transmitted diseases (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Detrimental mental health consequences of IPV include PTSD symptoms, depression, and substance abuse (Cerulli et al., 2011; Dutton et al., 2006; Hedtke et al., 2008; C. Humphreys & Thiara, 2003; Jones et al., 2001). More recently, a limited number of studies published have investigated the connection between sleep disruption and IPV. These studies have found that IPV victims commonly experience significant sleep disturbances that include truncated sleep, nightmares, and less restful sleep (Hernández-Ruiz, 2005; J. Humphreys, Lee, Neylan, & Marmar, 1999; J. Humphreys & Lee, 2005; Lowe, Humphreys, & Williams, 2007; Newton, Burns, Miller, & Fernandez-Botran, 2016; Pigeon et al., 2011; Rasmussen, 2007; Walker, Shannon, & Logan, 2011; Woods, Kozachik, & Hall, 2010). Furthermore, studies of IPV victims have found associations between sleep disruption and PTSD symptoms, and associations between sleep disruption and depression, suicidality, nightmares, and insomnia (Belleville, Guay & Marchand, 2009; Pigeon et al., 2011; Walker et al., 2011; Woods et al., 2010).

Although sleep disruption has been identified as a secondary symptom of PTSD, there is growing evidence that sleep disruption (particularly insomnia and nightmares) may be a core component of PTSD. Moreover, nighttime symptoms of PTSD may be linked to the development and maintenance of sleep disturbance (Nappi, Drummond, & Hall, 2012). Seventy percent of those who have been diagnosed with PTSD describe insomnia as a significant problem (Ohayon & Shapiro, 2000).

Pigeon et al. (2011) examined the associations between mental health, insomnia, nightmares, and IPV in a specialized court setting. Pigeon et al. (2011) found, in their study of 121 female IPV victims seeking orders of protection (OPs), that insomnia and nightmares were prevalent. In addition, nightmares and insomnia were strongly associated with the presence of depression and suicidality (Pigeon et al., 2011). Research confirms significant associations between PTSD and insomnia and between PTSD and IPV. Given these associations, it is reasonable to explore opportunities to address these three public health concerns. Courts offers such opportunities.

OPs issued by the courts have been repeatedly found to be an effective tool to enhance victim safety (Cattaneo, Stuewig, Goodman, Kaltman, & Dutton, 2007; Holt, Kernic, Lumley, Wolf & Rivara, 2002; Holt, Kernic, Wolf, & Rivara, 2003; Logan & Walker, 2009; McFarlane, Malecha, & Gist, 2004; Postmus, 2007; Roberts, Wolfer, & Mele, 2008). Depending on a victim’s state, OPs are often available through civil and criminal courts. Judges issue orders to perpetrators after examining alleged facts. Protection orders can be a complete “stay away,” which means the perpetrator must stay away from the victims in all circumstances, or “refrain from,” which includes behaviors the perpetrator must refrain from—such as annoying, harming, or harassing the victim. Orders can be issued which also limit the contract a perpetrator has with a victim, such as removing a perpetrator from a shared residence (Klein & Orloff, 1993; Labriola, Bradley, O’Sullivan, Rempel, & Moore, 2010). While the above literature discusses how OPs work to protect victims, they are not foolproof.

OPs do not stop all violence against all victims of IPV. Nonetheless, there is growing evidence that the existence of an OP is associated with positive outcomes for IPV victims. Studies have indicated that anywhere from 65% to 80% of the women who had OPs in place for at least 12 months experienced significant decreased risk of further abuse (Carlson, Harris, & Holden, 1999; Holt et al., 2002; Holt et al., 2003; Logan & Walker, 2009; McFarlane et al., 2004; Postmus, 2007). Kothari et al. (2012), in their longitudinal study of 993 IPV victims who obtained a civil OP, showed that participants experienced a decrease in the number of police contacts and hospital emergency department visits. Studies have also found that IPV victims who obtained OPs experienced reduced violence, decreased symptoms of depression, decreased symptoms of PTSD, and enhanced quality of life (Holt et al., 2003; Kothari et al., 2012; Wright & Johnson, 2012).

Research that has examined barriers to IPV victims’ use of the courts has focused on victim-identified external factors. These external barriers include deficient police response, unsatisfactory court response, lack of transportation, lack of money, and perpetrators’ adverse reactions to victims’ attempts to obtain court assistance (Fugate, Landis, Riordan, Naureckas, & Engel, 2005; Postmus, 2007). The current study examined barriers not typically addressed. Specifically, this study hypothesized that higher levels of sleep disruption, PTSD, and perceived danger would reduce the odds of a victim completing the OP process.

The theoretical underpinnings for this study recognizes the dynamic nature of help seeking on the part of IPV victims (Liang, Goodman, Tummala-Narra, & Weintraub, 2005). Liang et al. (2005) proposed a theoretical framework that provides insight into the complex help-seeking process of IPV victims. Figure 1 provides a schematic of the Liang et al. (2005) model for an IPV informed help-seeking framework.

Figure 1.

Theoretical model of help seeking by IPV victims (Liang, Goodman, Tummala-Narra, & Weintraub, 2005).

The model presented by Liang et al. (2005) highlights the dynamic nature of how and from where an IPV victim decides to pursue help, in this study the courts pursuing an OP, and provides a conceptual framework for the three primary themes focused on here.

Method

The participants in the primary study, from which data for the current study were obtained, were women victims of IPV who filed petitions for judicial civil OPs in the Domestic Violence Intensive Intervention Court (DVIIC). Monroe County, New York, was the setting for the primary study. The DVIIC is a specialized civil court that is designed to address the safety needs of IPV victims. The DVIIC, like other specialized IPV courts, includes judges and staff who have received training about the dynamics of IPV and relevant law (Labriola et al., 2010; Tsai, 2000). The DVIIC offers on-site resources utilizing a multidisciplinary approach.

Recruitment Procedure

The primary study’s staff approached 380 women who self-identified as victims of IPV for recruitment in the study. The women were approached in the DVIIC’s secured waiting area while they waited to be called into court to petition for a temporary OP. Of the 380 women approached, 190 women agreed to participate in the study. Participants were recruited from May 2007 through January 2008. All participants had children in common with the alleged abuser.

To be eligible, participants needed to be female, 18 years of age or older, English speaking, and eligible to petition the DVIIC for a permanent OP against an abuser pursuant to the New York Family Court Act. At the time of recruitment for the primary study, eligibility to request an OP from the DVIIC required a petitioner to be formerly or currently married to, or to have biological children in common with, the respondent. Participants were excluded if they were male, non-English speaking, seemingly intoxicated or critically ill, unable to complete a brief computerized survey, unable to read, and previously enrolled in the study (i.e., they returned to court on a violation of an OP).

Study sample

Of the 190 women who agreed to participate in the primary study, 24 participants denied their petitions for a temporary OP, and one participant left the courthouse before data could be collected. Of the remaining 165 women, 122 women completed the surveys required for this study. The final study sample used for the current study analysis was 112 women. Eight of the removed participants completed the surveys but did not receive a temporary OP. Without the receipt of a temporary OP, these eight participants had no further scheduled court dates. An additional two participants were removed because age and race data for them were absent.

Measures

During the initial meeting, a study staff person interviewed the participant, completed the demographic intake form for the participant, and administered the Danger Assessment (DA; Campbell, Webster, & Glass, 2009) and Modified PTSD Symptom Scale–Self-Report (PSS-SR; Falsetti, Resnick, Resick, & Kilpatrick, 1993) to the participant. During the second session, 2 weeks or more from time a participant entered the study, the participant responded to a structured interview, either face-to-face or by phone, and was given the Insomnia Severity Index (ISI; Bastien, Vallières, & Morin, 2001). For all women who participated in the study, study personnel conducted manual and electronic chart reviews of the DVIIC docket 1 year from the start of the study.

Clinical-level insomnia

Clinical-level insomnia was measured using the ISI (Bastien et al., 2001). The ISI is a brief self-report survey of an individual’s perception of her insomnia. The instrument is composed of seven items with a 5-point Likert-type scale (0-4), with 0 indicating “not at all” and 4 indicating “very severe.” The seven-question scale assesses the following: (a) difficulty falling asleep, (b) difficulty staying asleep, (c) problems waking up too early, (d) satisfaction with current sleep pattern, (e) interference with daily functioning, (f) noticeability of impairment attributed to the sleep problem, and (g) level of distress related to sleep problems. Examples of the questions include “How satisfied/dissatisfied are you with your current sleep pattern?” and “How worried/distressed are you about your current sleep problem?” The measure is reliable and valid with a Cronbach’s alpha = .78 (Bastien et al., 2001; Smith & Wegener, 2003). A total score was calculated for each participant. Clinical-level insomnia was indicated with an ISI score greater than 10. Insomnia was coded into a dichotomous variable. Subjects who scored greater than 10 were coded 1 = yes clinical-level insomnia, and those who scored 10 or less were coded 0 = no clinical-level insomnia.

Perceived danger

For perceived danger, a weighted perceived danger total score (continuous) and four dichotomous danger level variables were used. Perceived level of danger was measured by the DA (Campbell, 2004). The DA is a 20-item scale with weighted scoring that identifies four levels of danger: (a) variable danger (score of 0-7), (b) increased danger (score of 8-13), (c) severe danger (score of 14-17), and (d) extreme danger (score of 18 and above). The DA’s weighting system recognizes that the type of danger identified by a victim is as important as the number of types that are selected. The measure is reliable and valid with a full-scale Cronbach’s alpha = .91 (Campbell, 1995). The DA was administered initially in person when the participant consented to enter the primary study, and again, either in person or by phone, at least 2 weeks following her entry into the primary study.

PTSD symptoms

The presence of PTSD symptoms was measured using the PSS-SR. In the primary study, the two sleep items were removed from the Modified PSS-SR due to the investigators’ concern with multicollinearity with the insomnia measure, ISI. The two items that were removed were “Have you been having recurrent bad dreams or nightmares about the event(s)?” and “Have you been having persistent difficulty falling or staying asleep?” The Modified PSS-SR is a 17-item scale that assesses the frequency and severity of PTSD symptoms as reflected by Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R; American Psychiatric Association, 1987). A total score is determined that can range from 0 to 119 symptoms. The measure is reliable and valid with a full-scale Cronbach’s alpha = .91 (Foa, Riggs, Dancu, & Rothbaum, 1993). The Modified PSS-SR is a self-report measure that depends upon participant’s own assessment of the presence and severity of their PTSD symptoms. Examples of the questions include “Have you had recurrent or intrusive distressing thoughts or recollections about the events(s)?” and “Have you markedly lost interest in free time activities since the events(s)?”

The total score for PTSD symptoms was recoded into a dichotomous variable. The cutoff score of 46 was used for the PSS-SR to indicate the presence of significant PTSD symptoms (Falsetti et al., 1993). Subjects who scored 46 or higher were coded 1 = yes for significant PTSD symptoms, and those who scored less than 46 were coded 0 = no significant PTSD symptoms. The PSS-SR was administered initially when the participant consented to enter the primary study.

Dependent variable return to court

The variable return to court was created by reviewing data collected from the court’s docket and files. The variable return to court incorporated the following data with respect to each time a woman was scheduled to return to court: (a) whether the proceeding concluded at that time or whether the proceeding was scheduled for a successive date, and (b) whether the proceeding was scheduled for a successive date or whether the woman returned to court. The variable return to court was coded 0 = no did not return, 1 = yes returned.

Data Analytic Plan

The study used SPSS version 20 to conduct all statistical analyses. Univariate analyses were conducted to determine sample characteristics with respect to age, race, employment status, perceived danger, clinical-level insomnia, PTSD symptoms, and return to court. Bivariate analyses using t tests for continuous and chi-square tests for dichotomous variables were conducted for clinical level of insomnia and return to court across all variables and co-variables.

Logistic regression

Logistic regression was used to test the hypotheses related to the associations between the covariates (age, employment status, race, perceived danger, and PTSD symptoms) and clinical-level insomnia with respect to return to court.

Power

A power analysis for the logistic regression was conducted. The parameters recommended by Agresti (A. Agresti, 1996; A Agresti, 2002) were utilized. Stata statistical software (StataCorp, 2007) was used for this analysis. This analysis indicated that a sample size of 112 was sufficient to detect an effect (.78; Cohen, 1992).

Institutional review board

The Research Subject Review Board of the University of Rochester, School of Medicine and Dentistry, approved the primary study (RSRB00012523) and secondary study (RSRB00045023). The University at Buffalo Internal Review Board approved the secondary study (388640).

Results

Sample Equivalence

An analysis of sample equivalence between those who completed the study surveys and those who did not complete the study surveys found the sample to be equivalent for all variables with the exception of race. There was group difference with respect to race, χ²(2, N = 189) = 9.23, p = .01. Specifically, more women of color than White women completed the surveys.

Univariate Analyses

Univariate analyses were conducted to determine sample characteristics of the 112 study participants. The study sample’s characteristics are summarized in Table 1. The women in this study ranged in age from 19 to 82 years old, with a mean age of 34.6 (SD = 10.9). The majority of the study participants were women of color and were employed. Forty-six (41%) were White women and 66 (59%) were women of color. Seventy (63%) of the women were employed. All of the women in the sample reported a perceived level of danger with the mean danger score of 16.9 (SD = 7.6). Seventy-four (66%) of the women reported severe or extreme levels of danger. Of these women, 51 (46%) perceived their danger level as extreme. PTSD symptoms and clinical-level insomnia were present in this sample of women. Fifty-two (46%) of the women identified clinical-level insomnia. Fifty-two (46%) of the women identified PTSD symptoms. The mean score for PTSD symptoms was 43.6 (SD = 27.9). Similarly, 52 (46%) of the women identified clinical-level insomnia.

Table 1.

Summary of Sample Characteristics (N = 112).

Variable	n	%	M	SD
Age			34.6	10.9
Race
White	46	41
Women of color	66	59
Employment status
No	42	37
Yes	70	63
Perceived danger (Total weighted score)			16.9	7.6
Variable level	13	12
Increased level	25	22
Severe level	23	20
Extreme level	51	46
Clinical-level insomnia
Yes	52	46
No	60	54
PTSD symptoms: Total score			43.6	27.9
Yes	52	46
No	60	54
Return to Court
Yes	84	75
No	28	25

Note. PTSD = posttraumatic stress disorder.

Finally, 84 (75%) of the women returned to court to pursue their permanent OP. Eighty-two (73%) of these women were required to return to court more than 2 times. Of the women who did not return to court, nine (32%) did not return for their first scheduled return court date. The mean number of times women returned to court was 2.7 times (SD = 1.86).

Bivariate Analyses

There were no significant differences between women who reported clinical-level insomnia and those who did not with respect to race, age, or employment.

Perceived danger

There was a significant positive association between clinical-level insomnia and level of danger. Women with clinical-level insomnia reported higher levels of perceived danger (M = 18.8, SD = 7.4), while women with no clinical-level insomnia reported lower levels of perceived danger (M = 15.4, SD = 7.4), t(110) = 2.43, p = .02.

Women who reported clinical-level insomnia were more likely to perceive themselves in extreme danger, the highest level of danger, χ²(1, N = 112) = 4.10, p = .04. Phi measure of effect was small at .2. Moreover, a significant inverse relationship existed for women who reported that their danger level was increasing but who reported no clinical-level insomnia, χ²(1, N = 112) = 4.39, p = .04. Phi measure of effect was small at .2.

PTSD symptoms

There was a significant positive relationship between clinical-level insomnia and PTSD symptoms. Women who had PTSD symptoms were more likely to have clinical-level insomnia than women who did not have PTSD symptoms, t(110) = 5.21, p = .0001. Table 2 displays the results of the bivariate analyses of covariates on insomnia.

Table 2.

Bivariate Analyses on Insomnia.

Characteristics (n = 112)	Insomnian = 52 (46%)	No Insomnian = 60 (54%)	Test	p value
Demographics
Age (M, SD)	35.2 (12.0)	34.2 (9.9)	t test	.61
Race (n, %)			χ²	.16
White	25 (54)	21 (46)
Women of color	27 (41)	39 (59)
Employment status (n, %)			χ²	.17
Employed	29 (41)	41 (59)
Not employed	23 (55)	19 (45)
Perceived danger
Total weighted score (M, SD)	18.8 (7.4)	15.4 (7.4)	t test	.02*
Perceived danger level
Variable danger (<8)			χ²	.54
Yes	5 (38%)	8 (62%)
No	47 (48%)	52 (52%)
Increasing danger (8-13)			χ²	.04*
Yes	7 (28%)	18 (72%)
No	45 (52%)	42 (48%)
Severe danger (14-17)			χ²	.88
Yes	11 (48%)	12 (52%)
No	41 (46%)	48 (54%)
Extreme danger (≥18)			χ²	.04*
Yes	29 (57%)	22 (43%)
No	23 (38%)	38 (62%)
Trauma
PTSD total score (M, SD)	56.8 (27.5)	32.5 (22.9)	t test	.0001***
PTSD symptoms (n, %)			χ²	.001** *
Yes	33 (64%)	19 (36%)
No	19 (32%)	41 (68%)

Note. PTSD = posttraumatic stress disorder.

*p ≤ .05. ***p ≤ .001. ****p ≤ .0001.

There were no significant differences between women who returned to court and women who did not based on their age or employment status.

There was a significant relationship between women who returned to court and their race, χ²(1, N = 112) = 3.98, p = .05. Twenty-one (32%) of the 66 women of color did not return to court. Phi measure of effect was small at .2.

Perceived danger

There were no significant differences between women who returned to court (M = 17.07, SD = 7.32) and women who did not (M = 16.58, SD = 8.36) with respect to perceived level of danger, t(110) = 0.30, p = .77, using the total weighted score. However, when an association was tested between return to court and the four levels of danger, there was a significant positive relationship between the women who perceived a severe level of danger and return to court. Twenty-one (91%) of the 23 women who experienced a severe level of danger returned to court, χ²(1, N = 112) = 4.1, p = .04. Phi measure of effect was small at .2.

PTSD symptoms

There were no significant differences between women who returned to court (M = 44.00, SD = 26.93) and women who did not (M = 42.29, SD = 31.29) with respect to the presence of PTSD symptoms, t(110) = 0.280, p = .78. Table 3 displays the results of the bivariate analyses of covariates on return to court.

Table 3.

Bivariate Analyses on Return to Court.

Characteristics (n = 112)	Returnedn = 84 (75%)	Did Not Returnn = 28 (25%)	Test	p value
Demographics
Age (M, SD)	35.6 (11.6)	31.8 (8.2)	t test	.12
Race (n, %)			χ²	.05*
White	39 (85)	7 (15)
Women of color	45 (68)	21 (32)
Employment status (n, %)			χ²	.82
Employed	52 (74)	18 (26)
Not employed	32 (76)	10 (24)
Danger
Perceived danger (M, SD)	17.1 (7.3)	16.6 (8.4)	t test	.77
Perceived danger levels
Variable danger (<8)			ªFET	.73
Yes	9 (69%)	4 (31%)
No	75 (76%)	24 (24%)
Increasing danger (8-13)			χ²	.15
Yes	16 (19%)	9 (29%)
No	68 (81%)	19 (71%)
Severe danger (14-17)			χ²	.04*
Yes	21 (91%)	2 (9%)
No	63 (71%)	26 (29%)
Extreme danger (≥18)			χ²	.91
Yes	38 (74%)	13 (26%)
No	46 (75%)	15 (25%)
Trauma
PTSD total score (M, SD)	44.0 (26.9)	42.3 (31.3)	t test	.78
PTSD symptoms (n, %)			χ²	.38
Yes	37 (71)	15 (29)
No	47 (78)	13 (22)

Note. PTSD = posttraumatic stress disorder.

ªFTE = Fisher’s exact test, used when cells have expected count <5.

*p = .05. **p = .01. ***p = .001. ****p = .0001.

Logistic regression

The logistic regression analysis was conducted using total perceived danger score (continuous) for perceived danger. There were no significant results for demographics, with the exception of race odds ratio (OR) = .34, 95% confidence interval (CI) = [0.123, 0.917]. This result indicates that women of color were a third less likely to return to court than White women. Danger, clinical-level insomnia, and PTSD symptoms were not significant. Table 4 presents the results of the analyses using Logistic Regression Model 1.

Table 4.

Logistic Regression Model 1: Factors Predicting Return to Court.

	SE	df	Exp(B)OR	95% CI for EXP(B)
	SE	df	Exp(B)OR	Lower	Upper
Age	.025	1	1.039	0.989	1.090
Employed (no)	.500	1	0.681	0.255	1.815
Race (White)*	.512	1	0.336	0.123	0.917
Perceived danger	.033	1	1.017	0.953	1.086
Insomnia (no)	.759	1	1.674	0.378	7.414
PTSD symptoms (no)	.686	1	0.879	0.229	3.370

Note. Reference category in parentheses. Dichotomous variables: employment status, PTSD symptoms, and clinical-level insomnia were coded 0 = no, 1 = yes. Race was coded 1 = White women, 2 = women of color. OR = odds ratio; CI = confidence interval; PTSD = posttraumatic stress disorder.

p ≤ .05.

The goodness-of-fit test evaluated Logistic Regression Model 1 against the actual outcomes. Hosmer–Lemeshow (H-L) produced a nonsignificant χ²—χ²(8, N = 112) = 10.95, p = .20—that indicated that the proposed logistic regression model was tenable. The Logistic Regression Model 1’s corrective probability for predicting which women will return to court was 76.8% (sensitivity 10.7%, specificity 98.8%). This corrective probability is a slight improvement over the constant model’s corrective probability of 75%.

Discussion

This study found significant associations between clinical-level insomnia, PTSD symptoms, and danger perceived by IPV victims. Study participants reported clinical-level insomnia at a higher rate than the 10% to 30% prevalence rate for the general population (Léger, Partinen, Hirshkowitz, Chokroverty, & Hedner, 2010; Roth, 2007; Sivertsen, Krokstad, Øverland, & Mykletun, 2009). In addition, of the women who had clinical-level insomnia, 63% also reported PTSD symptoms. This study found a positive association between perceived level of danger and clinical-level insomnia with women who experienced extreme danger reported higher levels of clinical-level insomnia.

One of this study’s most compelling findings is that 75% of the participants who received a temporary OP returned to court to pursue a permanent OP. Although many of the women in this study were burdened by danger, clinical insomnia, and PTSD symptoms and had multiple scheduled return-to-court dates, their return-to-court rate exceeded the less than 50% return-to-court rate found by Zoellner et al. (2000). Contrary to the common perception that victims of IPV do not take steps to alter their situation, this finding suggests that they act and strive to do so despite multiple challenges. The results of this study revealed the perseverance of IPV victims. For this reason, further research of the factors that foster resilience and perseverance is warranted. Understanding the factors that support and motivate IPV victims to navigate challenging situations and systems despite the burdens of insomnia, PTSD symptoms, and danger would provide useful information to develop effective interventions to help IPV victims.

Notably, this study identified race as the single predictor for non-return to court. Specifically, women of color were significantly less likely to return to court than White women. This finding conflicts with Zoellner et al.’s (2000) finding that race was not related to a woman’s completion of the OP process even though the samples in both studies had similar racial demographics. The participants in the Zoellner et al. (2000) study were 69% women of color and 31% White women, while the participants in this study were 59% women of color and 41% White women.

It is unknown whether women of color did not return due to institutional racism, distrust of the court or the criminal justice system, or burden of proof issues. It may be the lack of diversity reflected by the DVIIC. To date, the DVIIC have no judges of color on the bench. However, this finding is important because the court system is a frequently used source of assistance, and offers a unique opportunity for intervention with IPV victims.

The results of this study underscore that women seeking OPs experience danger, clinical-level insomnia, and PTSD symptoms. Although it is common practice to discuss safety planning with IPV victims in court-based programs, it is not common practice to assess danger level or other associated factors. This study’s findings support the need to screen women for these conditions. Screening for insomnia, PTSD symptoms, and danger in IPV victims in a court-based setting would help social workers provide more effective safety planning and referrals to services. Furthermore, this study’s finding of the positive association between clinical-level insomnia and perceived danger suggests the importance of screening for IPV in other settings not directly associated with IPV, such as sleep clinics, primary care practices, and specialty practices. This study also highlights the resilience of IPV victims. The study’s participants pursued OPs despite the burdens of PTSD symptoms, insomnia, and danger. This finding challenges social workers to confront victim blaming prejudices, and to work to enhance the strengths that IPV victims have to deal with extreme situations.

This study’s findings have significant implications for future research. This study suggests that further research is needed about the intersection of race, ethnicity, and culture with respect to IPV victims’ help-seeking actions. Future research that focuses on racial disparities among IPV victims can inform system and policy development that could reduce disparities for women-of-color IPV victims as they attempt to access support and services. The Liang et al. (2005) model would provide a useful paradigm for this research. The Liang et al. (2005) model is multi-dimensional and interactional, and recognizes the complex interplay of an individual’s unique coping and interactional style, cultural background, and prior experience with seeking help. All of these factors may influence the definition of the problem, the decision to seek help, and the selection of the specific type of support to address the problem. Most importantly, the model provides flexibility in understanding help seeking as a nonlinear process.

In addition, investigation of the behaviors of primary and auxiliary court staff may be useful in identifying disparities in judicial responses to IPV victims of color or other cultural affiliations. Similar research conducted within medical practices and institutions has shown that clinicians respond differently to patients of color (van Ryn et al., 2011; van Ryn & Fu, 2003). Increased knowledge about the impact of race, ethnicity, and culture within the judicial system can serve to develop more effective interventions. In addition, given this study’s robust finding of race as predictor of return to court, investigation of interaction effects between race and insomnia on IPV victims is needed.

Moreover, since the data in this study were collected, all 50 states have adopted an expanded definition of family for their civil courts that enables lesbians and gay men to access civil courts for assistance related to their families and relationships. Research about how lesbians and gay IPV victims use the civil court system for help is nonexistent. Future studies with court-based IPV victims should include lesbian and gay participants.

This study also suggests that additional research is warranted with respect to clinical-level insomnia and IPV victims. To date, only one published study has examined clinical-level insomnia experienced by IPV victims (Pigeon et al., 2011). In the few studies that have examined general sleep disturbance experienced by IPV victims, victims expressed concern that traditional treatments for sleep problems compromise their ability to stay safe because of the sedating effect of medication. Research on how IPV victims experience and address clinical-level insomnia will assist in the development of safe interventions for IPV victims to address this problem.

To expand the understanding of the interplay between IPV, clinical-level insomnia, PTSD symptoms, and return to court, it would be useful to investigate the psychological abuse experienced by victims. Psychological abuse also contributes uniquely to the development of PTSD (Mechanic, Weaver, & Resick, 2008). For these reasons, it would be helpful to research issues such as the role that psychological abuse plays in the development of clinical-level insomnia and PTSD symptoms, the role that psychological abuse plays in a victim’s definition of her problem and choice of support, and the support systems that victims use for help apart from the judicial system.

Furthermore, because psychological abuse often precedes physical abuse, and because insomnia may be a precursor of PTSD symptoms, understanding the relationships between these factors would help in developing screening mechanisms for IPV, insomnia, and PTSD to enhance early intervention with individuals at risk for IPV. Given the high utilization of the courts by IPV victims, further study of court-based IPV populations should be considered.

Further research on insomnia, PTSD symptoms, and danger is needed to better understand the associations between these conditions and their interactions in the lives of IPV victims. The use of qualitative studies would be advised to obtain IPV victims’ perspectives on the impact of these factors in their lives and on their help-seeking choices.

The results of this study must be weighed cautiously due to its limitations. Because this study was a cross-sectional study, no causal inferences can be drawn. In addition, the sample was a convenience sample drawn from women seeking assistance through a specialized IPV civil court. For that reason, the generalizability of the study is limited. Although the data from this study are from 2007 to 2008, the findings support further investigation of these factors in the lives of IPV victims. Despite its limitations, this study contributes to the fledgling, but needed, body of knowledge pertaining to insomnia, PTSD, and the presence of both in the lives of IPV victims.

Conclusion

This study is the first to explore the associations between clinical-level insomnia, PTSD symptoms, danger, and demographics with respect to whether IPV victims return to court to pursue permanent OPs. This study reveals important relationships between clinical-level insomnia and danger, and between clinical-level insomnia and PTSD symptoms. Unanswered questions remain about the factors that may impede or support an IPV victim’s return to court. Although preliminary in nature, this study contributes to this inquiry by suggesting psychological and physical factors that should be considered.

Additional research is necessary to understand insomnia and PTSD within the context of IPV, and the impact that insomnia and PTSD have on the lives of IPV victims. From a social justice perspective, investigation of the disparities created by race, ethnicity, and culture on IPV victims’ access to specialized IPV courts will be essential. Research that examines the resilience of IPV victims and the barriers they confront will provide a more complete understanding of the consequences of IPV on the lives of women, and will more effectively inform practice, policies, and programs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The primary study was funded by the National Institute of Mental Health (NIMH K01 MN75965-01).

Author Biographies

Catherine M. Mazzotta, PhD, MSW, LCSW-R, is an assistant professor in the Department of Social Work at State University of New York (SUNY) at Buffalo. She a licensed clinical social worker with over 25 years of experience working in mental health, substance abuse, and trauma. She has dedicated her career, as a clinician, advocate, and researcher, to intervention and prevention efforts for victims of intimate partner violence.

Hugh F. Crean, PhD, is an assistant professor of clinical nursing at the University of Rochester, School of Nursing. He also serves as a Health Science Specialist, at the Center of Excellence for Suicide Prevention, Canandaigua Veteran’s Administration Medical Center, providing statistical and research methods support. He has over 20 years of program evaluation experience and expertise, working as lead evaluator of intervention projects at both the local and national levels.

Wilfred R. Pigeon, PhD, an associate professor of psychiatry at the University of Rochester Medical Center where he is director of the Sleep & Neurophysiology Research Laboratory and the Insomnia Clinic. In addition, he is the director of the VA Center of Excellence for Suicide Prevention in Canandaigua, NY. He has received funding from NIH, DOD, the VA, and several industry sources.

Catherine Cerulli, PhD, JD, is the founder and director of the Laboratory of Interpersonal Violence and Victimization and director of the Susan B. Anthony Center at the University of Rochester. She has been working with victims of intimate partner violence (IPV) in a variety of capacities since 1983, including as a counselor, advocate, and prosecutor. She has an extensive research portfolio focused on the intersection of IPV and mental health, particularly suicide. She utilizes community-based participatory research practices to bridge medical and legal systems to better address victim-identified needs and concerns.

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