Funding For Domestic Violence Survivors Is A Care Issue That Should Be On Everyone's Radar

In 2020, I had the immense privilege of working with a neuropsychologist in one-on-one cognition counseling. Our work was less like talk therapy—the open-ended style of counseling that allows patients to process big-picture emotions and personal history through dialogue—and more practical. One way I’ve described it to people is, "Regular therapy is about long-term change and getting better; cognition therapy is about concrete strategies to function better despite being a mess." He was aware of my background in psychology research, so sometimes I’d distract him from whatever problem of mine we were supposed to discuss by talking shop. One week, I asked him how he felt about the idea of complex post-traumatic stress disorder (CPTSD) as a diagnosis.

There is a lot of debate in the psychology community about whether or not this diagnosis should exist. At the time of writing, the World Health Organization recognized it in their diagnostic manual, the ICD-11, but the American Psychiatric Association chose not to in the DSM-5-TR, which was published second. Medical records, billing statements, and other documentation must refer to codes attached to the diagnoses in this manual, so exclusion prevents a disorder from formally existing, though clinicians may still talk about it with their clients. The disagreement is primarily around if it’s "too similar" to the existing PTSD diagnosis.

My neuropsychologist told me that he didn’t love the implication that "regular" PTSD is simple. Still, there is a documented difference in symptoms between people whose PTSD is prompted by a single traumatic incident and those who were stuck in consistently traumatic circumstances for long periods of time. 

Fortunately, there are more resources and treatment options than ever and, therefore, more pathways to recovery. Unfortunately, the majority of these options present severe challenges with scheduling, insurance coverage, cultural competency, or all three.

October is Domestic Violence Awareness and Prevention Month. On September 29, the White House published a proclamation declaring this, and in it, President Joe Biden discussed the many resources for survivors supported by federal funding. These include shelters, rape crisis centers, temporary housing, legal aid, and financial assistance. Each of them are essential services that have helped countless people escape abusive relationships.

But government-funded resources are focused on exactly that—escaping crisis situations involving intimate partner violence. A different set of support services is needed for survivors embarking on the long journey to recovery, and government resources often don’t assist with this in the United States.

For most survivors, domestic violence is a complex traumatic experience in which a survivor is exposed to “an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible.”

Survivors are often stuck in abusive relationships where they regularly experience violence for extended periods of time, based on data from countries similar to the U.S. On average, survivors who utilized adult independent domestic violence advisor services from the British advocacy organization SafeLives had been experiencing domestic abuse for 2.5 years before reaching out for help. In an Australian study on long-term recovery from domestic violence, 45 percent of the participants had experienced abuse for ten years or longer. Years of abuse change how the brain works, and many survivors find it challenging to move forward. 

There are two primary schools of thought on treating CPTSD. The first is a three-phase approach that moves more slowly to minimize the risk of clients falling into a severe emotional crisis as they surface and discuss difficult memories. This begins with safety and stabilization, ensuring the client learns essential skills for managing their emotions and relationships before moving to discussing and integrating the trauma in the second phase and reviewing and reflecting on treatment gains in the third. This is the approach I took personally, and it was the right choice for me, but it’s by far the slowest and most time-consuming. I started with Dialectical Behavioral Therapy (DBT), which is designed to help people who feel emotions very intensely learn how to regulate and manage them without vices or other harmful coping mechanisms. The easiest way to access DBT is in higher levels of care, so I did ten hours a week in an evening intensive outpatient program (IOP), along with six hours of commuting there and back, on top of working a full-time job in person, for five months.

But, I did not have any caring responsibilities, and I did have insurance that covered my treatment. When I was in treatment, I left my apartment at 7:30 a.m. on my three program days, and I returned around 9 p.m. Standard childcare centers can’t cover those hours entirely — most are open 8:30 a.m. to 5:30 p.m. — and finding a 24-hour child care option or hiring an individual nanny can be extremely expensive for many families, especially single-parent families. According to Care.com’s 2023 survey of child care costs, the national average cost to hire a nanny for one child is $736 a week, or nearly $3000 each month. For this reason, intensive therapy options are likely only accessible to survivors with extremely solid support networks through family, friends, or other community members willing to help.

There are providers who offer DBT in a standard one-clinician, one-patient, one-hour-a-week context. But there are very few of them, and many of them are at specialty CPTSD centers that don’t take insurance.

Regardless of the format, the three-phase approach to treatment also relies on the client having faith in the process. It’s not uncommon to not reach the "breakthrough" for months, and some studies have found that many people drop out, frustrated by putting time into something that seemingly isn’t having results when they have so many other things on their plates.

The alternative is to begin trauma narrative work in the first few sessions. Recent research challenges the likelihood that this expedited approach will cause severe distress or crisis. For many, the most accessible form of treatment is Cognitive Behavioral Therapy (CBT), which looks to change thinking patterns to shift feelings and behavior. A trauma-specific version of CBT has shown to be very successful for children, but for adults, it’s recommended that CBT is followed by treatment that focuses on exploring the trauma narrative. These interventions often include words like "exposure" and "desensitization" in their names because the whole point is to recount the worst experiences of your life in extreme detail so that you can make sense of them. This is only helpful in the long term if you have a strong relationship with your clinician and, ideally, flexible scheduling that ensures you don’t need to immediately drive home to watch your kids or take the train to work when your session ends.

To guarantee this, some clinicians set these appointments to be 90 minutes—an hour to do the work and 30 minutes for the client to ground themselves and come back to the present. However, quirks in insurance billing encourage clinicians to refuse insurance if they offer 90-minute sessions. Billing that session length to insurance often requires both fudging the rules when submitting the paperwork and asking clients to pay more than usual.

For these reasons, accessing high-quality CPTSD treatment is difficult for anyone—never mind survivors of domestic violence who are at high risk for employment instability, housing instability, difficulties accessing child care, and other systemic challenges. Within our current status quo, recovery is a privilege for those with great health insurance, flexible employment schedules, and strong support networks. There are policy changes within the mental health care system that would improve the situation, such as changes to billing codes to allow clear coverage of 90-minute appointments and funding that would allow community health centers to invest in more intensive and expensive treatment options like DBT. At the same time, housing first, guaranteed paid family leave, and universal child and family care and health care would make it feasible for more people to access existing treatment options.

As we look to advocate for survivors of domestic violence this month, it’s essential that we consider not only funding crisis services but also how we build a more caring and equitable society that makes recovery possible for all people. As one participant in the aforementioned Australian recovery study put it:

There is a false assumption that once the ‘crisis’ phase is ‘over’ and a [no-contact order] has been granted, that the survivor is safe and can get on with her life. Unfortunately, this is not the case … The recovery phase is fraught with many obstacles and challenges and is often ignored by the sector which is more focused on the crisis stage.

It’s essential that we advocate for policies that prioritize the long-term care required for recovery.