3.Dawn Hughes — Direct (Part 1)

DAWN HUGHES: So, forensic psychology is just the application of the science and principles of psychology to a particular issue, a legal issue at hand.

So, the forensic is -- just comes from the Latin "of the forum," where the courts were. So it's really using what we know in psychology to answer a particular legal question.

DAWN HUGHES: Sure. So I received my Bachelor's Degree in psychology at Hamilton College in upstate New York. I received my Master's Degree and PhD in clinical psychology at Nova Southeastern University, which is in South Florida.

I then had to do -- in order to receive the doctoral degree, one has to do a year internship training. I did that year at Yale University, the School of Medicine in the Department of Psychiatry.

And then, in order to get licensed in all 50 states, now you have to do a year post-doctoral fellowship, and I came back to New York where I'm from and I did that at Weill Cornell Medical College, New York Presbyterian Hospital in a trauma-based program there.

DAWN HUGHES: Sure.

So my specialization is interpersonal violence and traumatic stress. Interpersonal violence is when one individual is violent toward another, and that includes rape and sexual assault, childhood abuse, childhood sexual abuse, domestic violence, sexual assault, physical assault and things of that nature, sexual harassment.

And then traumatic stress is the outgrowth of what happens to individuals when they experience those type of traumatic events.

So, my training is somewhat unique that, when I got to graduate school, I started working immediately with very sort of well-regarded esteemed professionals in the area of trauma and violence. So I worked in a domestic violence program, which was a community-based program, that saw both victims and perpetrators of domestic violence. So I had to assess and treat both victims and perpetrators of domestic violence.

And then, after that, we had another program housed within that community mental health center, which was called the Child Sexual Abuse Survivors Program, and that program was also geared for individuals who had childhood abuse histories to come into treatment. So my job was to really do lengthy interviews, look at questionnaires, look at psychological test data to really understand sort of not only what they experienced, but what else did -- what are the psychological outcomes from some of that abuse.

Then, as part of my graduate training, I also had the opportunity and the honor to work in the Veterans Administration Hospital. So being able to see trauma, not only from an interpersonal violence context, but also through our combat veterans and what they have struggled with and suffered with. So I worked in the outpatient Veterans Administration program and learned more, again, about PTSD and trauma there.

And then, when I went on to internship at Yale, I was at a substance abuse facility and was doing groups for women who had childhood abuse and adult victimization histories, but were also heroin abusers. So they were in recovery for opiate addiction, but also had, you know, significant trauma. So we were doing treatment in groups for those individuals to really try to target both of the significant issues that they had.

And then, when I came back to New York for my post doctoral fellowship at the Paine Whitney Clinic, which is the psychiatric facility of New York Hospital, Cornell Medical Center, we have an anxiety and traumatic stress program there. And that program similarly saw individuals who had either suffered an adult assault or a rape as an adult or some sexual assault or violence also has a child, and we also saw individuals who were in violent relationships as well.

DAWN HUGHES: Right. So, I'm on the teaching faculty and the psychology faculty. So one of the things that I do is I help evaluate the interns that come through, that cycle through the program every year, and review those applications. And I also do some ad hoc supervision.

I don't do weekly supervision anymore, but supervision in terms of if an issue of violence, abuse, rape comes up, I'm the one who gets called if the interns have difficulties with that. And then I also have been teaching -- probably for the last four or five years, I've run the ethics seminar for the interns, so I teach the ethics seminars for the interns.

DAWN HUGHES: Sure. So I see individuals in therapy in my private office. I see men and women who -- probably about 75 percent of my practice are individuals who have experienced some type of violent event or abuse in their lives, whether it be, you know, as a child or as an adult.

So part of my job, as a psychologist and a trauma psychologist, is to really sort of help them heal from the traumatic effects of victimization, sort of decrease their symptomatology and increase their functioning, and also increase their quality of life.

The other part I do in my practice is I do forensic psychology, and that might be something like I'm doing here testifying in court. I also evaluate individuals who were involved in court cases, either in civil court or in criminal court. So that's the forensic aspect.

And then I also have a lot of professional activities that I am involved in. I'm on several -- the Governance Board of the American Psychological Association. I was president of a women's mental health consortium program, which is a multidisciplinary organization in New York City; psychiatry, psychology, social work, nursing, that really looks at women's mental health throughout their life span.

So I'm engaged in a lot of professional activities that take me to meetings and boards and things of that nature.

DAWN HUGHES: No. As I said, there's multiple types of interpersonal violence. So some interpersonal violence can be a physical assault, it can be a stranger physical assault; you can get physically assaulted on the street by a stranger. You can get attacked on the street, that would be a physical assault. You can be sexually assaulted, you can be raped. Certain people can be -- I mean, there's certainly some belief that sexual violence is a violent act even though it's not a physical hit, slap. You know, you can have sexual violence in rape without being punched or hit or grabbed or attacked in that way.

But then we have a lot of psychological aggression and coercive control that has been found to be, you know, incredibly damaging to the psychological well-being of individuals, and that can also occur in the absence of physical violence.

DAWN HUGHES: So the board certification is somewhat analogous to what medical doctors have. In psychology, it's the highest level that one can obtain and you have to go through a variety of steps to get there.

You have to have been practicing for, you know, I think five years after getting the doctoral degree, after your post-doctoral fellowship. You have to then basically apply to be board certified and pass certain requirements that you've done enough continuing education hours in the field, that you've seen people working in the field of forensic psychology. You have to pass an ethics clearance. You have to then take a written test, a written board test. Then you have to submit two work samples that get critically reviewed and examined and torn apart, and then you have to have an oral defense of those work samples.

And after you pass all of those pieces, then you are board certified when you pass them all.

DAWN HUGHES: So I belong to the American Psychological Association, which is the largest body of psychologists, professional body of psychologists. And because it's so large, there are -- it's broken up into subdivisions and I was one of the founding members, about I guess it's 12 years ago now, of the Trauma Psychology Division of APA, because recognizing that trauma psychology also is, you know, a very unique field and has, you know, a unique interest in the study of psychology.

So I've been part of that and part of that board since, you know, off and on, twelve years serving on the executive board and program chair and awards chair. And now I am the representative from the Trauma Division to the larger body of APA and on the governance, meaning I have voting powers in the APA representing that trauma division.

There are other divisions I do belong to; I belong to the Psychology and Law Division. I belong to Psychology of Women Division. And I also belong to the Psychologists in Independent Practice Division.

Of organizations that I belong to, I belong to the International Society For Traumatic Stress Studies. As the name connotes, it's an international society, but it's also a multidisciplinary society. So it's with psychiatry, psychology, social work, nursing, medicine. So you really get a good flavor for the different disciplines in the field of psychology in trauma psychology.

I belong to the International Society for Study of Trauma and Disassociation. I belong to the New York State Psychological Association, the Anxiety Disorders Association of America. I'm a fellow of the American Board of Forensic Psychology.

I think that's most of them.

DAWN HUGHES: So my role, as I understand it and that I agreed to undertake, was to offer the knowledge and experience of what we know in the field about coercive control and sexual assault and abuse and violence, and understanding that there is a very distinct body of literature that exists in this field and in that there are also a lot of myths and misconceptions that perhaps lay people have about being in abusive relationship, leaving an abusive relationship, being sexually assaulted, how they tell their story.

So I think it's important for me to be able to impart what we know empirically and clinically in the field about this topic.

DAWN HUGHES: Sure, there are numerous. One of the myths is that a victim is going to be pulled over in the dark, in an alley, and sexually assaulted with a weapon, and that this person is a stranger. That is a myth because most of the perpetrators of rape and sexual assault are someone known to the victim.

A myth is that the individual would have fought back, she would have screamed, she would have yelled, she would have told someone. The majority of victims do not fight back or scream or yell or tell someone.

A myth is that, if you were really raped you would have went to the police, you would have went to law enforcement. The overwhelming majority of women do not report rape and sexual assault.

The fact that you didn't -- you didn't cry or you didn't say anything when this happened, you just looked stoic, so you must not be affected; not true. That is really understood as the psychological coping of dissociation and emotional numbing of responsiveness to an overwhelming traumatic event.

So there are a number of myths that are just not borne out in the data that sometimes lay people have and that they think.

DAWN HUGHES: So, when the perpetrator is known to the victim, those are the least likely types of cases that are going to be reported to law enforcement.

When it is a stranger, when there may be a weapon involved, when there is physical jury, those are the type of cases that are more likely to generate a law enforcement -- for the person to seek out law enforcement for assistance. But when it's someone known, when it's your ex-boyfriend, your teacher, your coach, your boss, much more reluctant to go to the police for assistance.

DAWN HUGHES: Right, and there are a number of obstacles and we sort of sometimes think of them as the internal processing of: Am I going to report this?

When you know the perpetrator, you fear sort of making that public. You fear that it's going to change the dynamic of the relationship. If it's your neighbor, your boss: What's going to happen to me if I report this? Getting that person arrested might not see [sic] a viable option for that individual. They fear stigma and shame that we know still does happen when people report sex crimes and crimes of sexual violence. They fear not being believed. They fear that they will be blamed for their sexual assault. They fear harsh treatment by law enforcement or people questioning them. Sort of, you know, imposing some of the blame on them.

They fear that, in the disclosure, they may disrupt their peer group. They may disrupt sort of the status quo of whether it's the organization, the workplace, the relationship, the family, because when we do report things do get shooken [sic]. I mean, the whole sort of foundation of what the person is involved in, does it get shaken up by that report. So they fear what that is going to look like and how that may either damage them or their family.

They may fear retaliation. Many victims have been threatened to not report, either threatened with physical harm or threatened with disclosure of personal information that someone might have. A lot of threats with, what we see now, we call revenge porn where if you were in an intimate relationship, pictures were taken of you, maybe those pictures were consensual, maybe they weren't, but now they are being held over your head. So, if you report, there's going to be an absolute contingency coming on you that's not going to be positive. That's going to impact an individuals' decision to report.

And then, also, individuals are suffering, as I mentioned before, from the psychological impact of having been assaulted and having been violated in that way, so they have trauma-based symptoms. They may have this shock and dissociation, and what you do when you feel that type of -- of psychological sort of what we say dysregulation, D-Y-S, you know, not being regulated internally, you try to do things to calm yourself and not feel it, not think about it. You avoid. You push it down. You get it out of your mind.

So if I'm going to report it, that means all this stuff has to come up now and I might not feel psychologically capable to cope with it.

DAWN HUGHES: That's correct. I've seen this in the cases that I've worked on with the Boy Scouts of America, where sometimes in telling about the abuse, then sort of the whole group is going to come down. And, of course, the issue of fearing being believed that somebody who's in high esteem, your Scout Master, could do this to you.

I've seen this in the enormous work I've done in the Catholic church and the clergy abuse, that how can I, the victim, be believed and take down a priest? How is that going to work? Now everybody who is involved in my school or my religious instruction or my church and community, that is going to have a ripple effect on that.

We have seen it in college campus rapes where a woman would report. You want to believe that your friends are going to be there with you, your female friends and your male friends, but now you're the one who's put the damper on the party. Now you said something and now we all can't have fun, and that woman becomes ostracized.

So, there's a lot of fears about -- and, regrettably, well-founded fears. These are not fears that are delusional. This stuff happens and people see it in the media and they see it, perhaps, in their own experience. So, those fears of reporting when it's going to effect a larger group can be a significant deterrence to disclosing the abuse.

DAWN HUGHES: Absolutely.

If you're going to report sexual discrimination, sexual harassment, or assault in the workplace and it's your boss, someone who has clearly more power than you do, how is that going to be believed? You don't believe that people are going to believe you. People aren't going to believe that he could do this and now I could lose my job, people aren't going to want to talk to me, people aren't going to keep me on projects, no one is going to want to work with me.

So, all of that starts circling through an individual's brain while they're also, at the same time, dealing with all the psychological consequences of the assault.

DAWN HUGHES: Reporting is hard enough, right? It's hard enough to report when it's a neighbor that lives five blocks away, even though you know who he is. That's hard. But when you have to be in a situation that you have to remain in, right, it is very difficult.

So, if you have to report against somebody who is in high esteem, right, nobody believes that you're going to be believed. You don't believe you're going to be believed. You can't even believe that this happened to you. How can a priest abuse me? How can my Scout leader abuse me? How can my coach abuse me? How do I reconcile that someone who is supposed to care for me, love me, teach me, guide me, sexually abuse me in this way?

So, that psychological confusion with someone who is in such high esteem, there's no belief that you can be the one that's going to expose that. So, for some of the victims and my patients, it wouldn't even occur to them to report it because it just seems to overwhelming.

DAWN HUGHES: So, in the immediate aftermath, it's usually met with a lot of sort of shock and disbelief. There's a lot of sort of internal wrangling about what just happened? What did he do? Was it my fault? Did I have a piece to blame in here? Did I do something to cause this to bring it on myself? Maybe some rationalization; you know, maybe he was drunk, maybe he wasn't thinking right, maybe I misinterpreted. There's a lot of sort of rationalization and minimization of what just happened in the immediate aftermath.

And then there's a lot that sort of moves a little to a lot of just shock of I can't believe this happened and I don't know what to do about it. So, there's powerlessness, there's shock, there's psychological distress, a lot of confusion about how do I now understand this dynamic? How do I understand now my relationship with this person who, because they're known, chances are they have to see again, they have to interact with again. There's a lot of sort of internal cognitive processing.

But then there's a lot of anxiety. This is trauma. PTSD used to be characterized as an anxiety-based disorder. We've moved it to its own category now, but there's a lot of anxiety around this. You know how you feel -- I know how I feel when I come to testify. You get those butterflies. They feel that all over their bodies with such intensity that then interferes with their ability to concentrate, their ability to attend, their ability to focus.

So, what they try to do is what we all do when we feel something that we don't want: We try to avoid it, we try to push it down, not think about it, directed forgetting, try to compartmentalize it, try to suppress it.

And then there are other techniques, which one is called dissociation. Dissociation is mostly an involuntary process where we sort of separate ourselves from the pain. And what we hear victims talk about is during the assault, they will say, I left my body. I wasn't there. I was watching myself from the ceiling. I was just going to leave my body because I couldn't stand the pain, I couldn't stand what was going on. I was just waiting for it to be over.

There's that emotional disconnection from what she's feeling that carries through also in the aftermath of that sexual assault and they may find themselves zoning out, spacing out, not really being in touch with what's going on, sort of having that glossy look to them, a numbing of responsiveness; not really being attached to feelings of anger or sadness, just sort of numb and blah.

DAWN HUGHES: So, we talked about formal reporting. Formal reporting, right, very, very minimal, amount maybe less than 15, 20 percent. That would be to law enforcement or even medical or a rape crisis center. Very small percentage.

But what a lot of victims do do is because it's so psychologically overwhelming, is they will usually tell a friend, they'll tell their roommate, they might tell their ex-partner if they had a good relationship, they might tell their mother. So, they usually try to tell someone really because the overwhelming feelings that they're having are just too much to bear on their own and they need some support.

DAWN HUGHES: Absolutely, I mean, because we're talking about a psychological traumatizing event that overwhelms normal people's capacity to cope. So, if I'm going to talk about the details, that means that trauma is going to come right up centerfold, right here, and that's going to be too overwhelming to talk about.

Even patients who I have in treatment over the long-term spend a lot of efforts trying to talk around it, not wanting to talk about the details, not wanting to sort of address it head-on, because it's too psychologically threatening. So, we see when they tell, they might say some smaller pieces and that sort of disclosure, depending on the response they get, can unfold over time. It's not a dichotomous I-told-I-didn't-tell-and-it's-over, it's a process that unfolds over time.

DAWN HUGHES: Both.

Sometimes they are. We do -- when we talk about avoidance efforts, there are conscious avoidance efforts. Something will come into your mind, it's like, I'm not going to think about that, I'm not going to talk about it, I'm going to do something else and distract me.

But what we know about sort of trauma is we say it's a cue-based disorder, meaning that something in the environment can trigger also us thinking about it. So, you could be walking down the street and see someone wearing the same khakis as your perpetrator, you can smell a perfume, you can smell an alcohol, you can see anything on TV these days.

And when that gets triggered, there can be the voluntary response, conscious, shut off the TV, but there can also the unconscious response, and that's the dissociative response where all of a sudden they find themselves staring in a room, missing time, not aware of what's really going on, feeling kind of disconnected and having no feeling. And that would be an example of an unconscious process that could happen.

DAWN HUGHES: Absolutely.

You know again, the first thing that we do is we avoid, we suppress, we deny, we push it out, we have some dissociative responses. So, the more that we do that, the less likely we are to allow it to come into our sort of conscious awareness and integrate the trauma, right, understand what happened.

And that can be dangerous because if the person is in an ongoing chronic abusive situation, normal response to trauma is to sort of bury it, avoid it, not think about it, and that puts her at risk for further abuse because she's not able to accurately identify what's going on. She's too much in the forest, not able to see the trees, and then she gets abused again and now we have more trauma and she gets abused again.

So, it's this cyclical pattern that keeps happening where the individual never really gets to integrate and understand what's going on. And that leads to more profound helplessness, hopelessness, shame, embarrassment, humiliation, which makes it very difficult for her to extricate herself from that abusive situation or relationship.

DAWN HUGHES: So, we talk about it's the appearance of normalcy. And I talk about that with my patients all the time because sometimes my patients will say, People say to me you look so calm, you're so put together; meanwhile, they're stoic and freaking out inside.

So, one of the things we know about psychology is the outside doesn't always match the inside. And if somebody is traumatized, you're not necessarily going to see them running around screaming and crying and yelling. They're really trying to use everything that they can to feel control because this internal trauma process is making them feel very out of control because it's coming out of control; they're not trying to think about this stuff, but it's coming.

DAWN HUGHES: So, there's two types of denial.

There's psychological denial, where we engage in that denial and minimization and rationalization of the abuse. Like I said before, maybe he didn't mean it, maybe he was drunk and it couldn't have really been that way, maybe I was to blame. So, there's some bits of denial that go in there.

And then denying sort of the factual elements of it happened when somebody is queried about did this happen and the person feels too threatened to say the truth is yes, and they deny and say that it didn't happen.

DAWN HUGHES: In general, we all do when we are incredibly distressed or angry or anxious or upset and we can't sort of in a meaningful way address the person who caused that distress, sometimes we displace that anger on someone else. Maybe we yell at someone on the street who was getting in front of us on the subway or we yell at our mom because she's easier to yell at, but we can't be mad at the person that really the anger should be directed to.

So, displacement of anger is a very common psychological phenomena.

DAWN HUGHES: Yes, it unfolds over time.

And that's part of the readiness of the individual to talk about this stuff. There are times when people have come into my office who have never told anyone. It would be erroneous for me to assume that in that first session I'm going to say, okay, tell me everything. That's not going to happen.

So, when you bury things, things have to come out sort of a little more in a piecemeal fashion, sort of gauging the person's psychological stability to handle it and their willingness to talk about it. So, it's a process that unfolds over time.

DAWN HUGHES: Later on, I mean, that's what we see when we talk about a delayed disclosure, that the individual might not report the rape or sexual assault at the time of occurrence, within the immediate aftermath of the rape. But we do see a lot of reporting, and it may not be to law enforcement; it may be a therapist, a parent, in the media, as just circumstances change.

So, sometimes it's just the passage of time, where some of those trauma-based incidents have had an opportunity to abate and not cause so much havoc in the person's life. Sometimes there's just age and maturity, where the person feels like they have a better sense and handle on what happened and they can report. Sometimes there's a change in their dynamic with the perpetrator; so, if you've moved, if you've gotten a different job, if you're no longer under that coach, if you've left your boyfriend or girlfriend, those are situations that now have changed that dynamic that you may feel sort of strong enough and ready to report.

Certainly, there are external factors that happen. We know that when there are media reports of sexual assault in a variety of communities, that increases individuals going into therapy, calling rape crisis centers, and, also, reports to law enforcement. And that's because what they do is they see themselves in another victim who has come out.

Because this experience is often so isolating, people don't talk about it. So, they stay in their own world with their shame and humiliation, but then they see something in The New York Post or The New York Times and they say, Hey, that kind of looks like me and that story kind of sounds like me. Maybe I can deal with this now. Maybe I can talk about this now.

So, we do see with the media reports people are more likely to come into treatment or report to others.

DAWN HUGHES: Again, those who don't report, we probably couldn't assess them because we wouldn't know because they wouldn't report it either in our studies or to law enforcement.

But there have been countless times where people have come into my office because of some external event that says I have to deal with this now, I've been burying this for 20, 30, 40 years sometimes, and have told me, I was going to go take this to my grave. I was never going to talk about this ever again. I was never going to do this.

And they expend a lot of psychological effort to not talk about it, but that system eventually breaks down. The distress and the difficulties that come from that become too overwhelming so they have to deal with it and they come in the office.

DAWN HUGHES: Well, clearly, they are unique to each specific victim.

We know that there's this host of factors out there, but they're really going to be mediated by the individual victim, her relationship with this perpetrator, the type of abuse that was perpetrated upon her. Was it a single incident? Was it multiple incidents? Was there other elements of psychological aggression and coercive control?

Is this person a person of authority? Does she have sort of tangible resources that she can do this? If she needs to extricate herself, can she do that? Does she have funds? Does she have a job? Does she have money?

And there's also, what we say, preexisting vulnerabilities that people have before the assault, the rape, or sexual assault. They may have had a previous sexual assault. We know that there's a high degree of revictimization, that individuals who suffered childhood abuse will be victimized later in life. That could get activated and now we have a double trauma someone's trying to deal, which could impact her.

They could have mental health issues without victimization. They could be suffering from depression or anxiety or other types of mental health issues, which lead to vulnerability to the abuse which impact her post rape adjustment and ability to disclose.

DAWN HUGHES: Well, the memory for assaults comes in many different ways. We do know that, for the most part, clinicians and researchers alike, that most people remember what happened to them, they remember their assault; however, when we have chronic assault and repeated assault, sometimes the details tend to blend together. And to sort of extricate what happened on what day becomes much more difficult because there have been successive and so many abusive incidents.

And the way that sometimes trauma is remembered, especially if someone is employing dissociation during the event, the way the memories get encoded sort of like flashbulbs, I have something here, I have something here, I have something here, and something here, but they don't feel linear, it's not A then B then C then D. It's not always a coherent narrative.

And over the course of therapy and time, those pieces tend to then eventually come in place. And sometimes they never come in place, but they know that these things have happened to them.

DAWN HUGHES: So, the empirical data is quite clear and quite robust on the psychological outcome of having been raped or sexually assaulted. What we see is anxiety, we see depression, we se post traumatic stress disorder, other trauma-based disorders; we see other associated symptoms of shame, of humiliation, of self-blame, of self-loathing; we see sexual problems; we see trust difficulties, especially if the perpetrator was someone in authority; we see interpersonal difficulties sort of just being able to relate with another person; we sometimes see other sort of health-related problems, like eating disorders, sexual problems, substance abuse problems.

So, it's a whole host of consequences that individuals experience in the aftermath of rape and sexual assault.

DAWN HUGHES: All the time.

Even when they are in treatment -- you know, I had a patient the other day tell me, you know, I know -- he was abused by his Boy Scout leader, and he said, I know it wasn't my fault, but I can never know it wasn't my fault.

He still believe it's his fault. Well-accomplished individual. That stays with him.

There are things that stay with individuals that continue to be difficulties for them to overcome this abuse.

DAWN HUGHES: Sure.

As I said before, for some victims, because when the perpetrator is somebody of high esteem and regard by others -- not just them, but by others -- it never even occurs to them that they would report. It doesn't even enter their awareness that that was a possibility.

For those who think that they might report, if it enters some cognitive process in their brain, they go through this cost-benefit analysis, like how is this going to work? What is going to happen to me if I report?

And, as I said, usually in the cases in a relational dynamic, there are a lot of other elements of psychological aggression, coercive control, and threats that the sexual assault is one piece, but now you have all of this other sort of threatening behavior that, you know, if I tell then something bad is going to befall me or my family or my friends. That cost-benefit analysis seems too high.

So, what victims do is say, well, I'm going to deal with this myself. I'm going to deal with this within the confines of this relationship or this situation.

DAWN HUGHES: Yes, they do.

And that's one of the things we talked about initially, that the majority, overwhelming majority, know their perpetrators. So, if you're in a relational dynamic, if it's a neighbor down the street, a rape victim might say, Hey, Bob. They might still say that.

If it's your boss, you have to go in every day and work and have a relationship. If it's your partner, if you're not able to, for a variety of reasons, extricate yourself from that abusive relationship, you still have to have a relationship with that person. So, that becomes also very psychologically confusing for the individual, and that's why those other defense mechanisms when you have to stay in that relationship, the avoidance, the denial, the minimization, the rationalization, are all of those psychological defense mechanisms that allow you to maintain the status quo until you can get out.

DAWN HUGHES: Sure, there are a number of obstacles.

There are certainly, as I said, tangible resources, finances. Do you have a job? An apartment? Money so that you can live on your own? Do you have housing and food? Do you have sort of the internal resources that you believe that you can do it on your own?

One of the outgrowths of chronic abuse is that belief you've been so diminished, that you've been so degraded, that you don't even have a sense of your only self-worth and your own competencies. If you don't believe that, how are you going to get out?

Women who have children involved feel very big obstacles to get out of that relationship; fear that near the individual will take custody of the children or prevent them from seeing the children. A very big issue of getting out.

There's also love and attachment towards these individuals, towards your partner. People get into these relationships for all the right reasons. They don't get into them and say, oh, that's an abusive relationship, I want to go there. They get in because they want love and hope and companionship, like we all do, but then it turns and the tables start to turn and they turn suddenly and they turn in insidious ways that aren't just readily available and then, before you know it, you're knee-deep in and you can't get out.

So, that's what they want. They want the love and the companionship that -- that's why they got there in the first place, the good things, but they don't know how to get out of it now that they're been so battered and beaten over the course of time.

DAWN HUGHES: So, an abusive relationship. When we talk about coercive control, it's not an incident-specific thing, it's a pattern of behavior that functions to first gain and then maintain power and control over another individual. And the way that it's obtained is through a variety of tactics that the perpetrator will use.

So, there will be physical abuse, there can be sexual violence, there can be psychological aggression, there can be stalking and surveillance behaviors, there can be economic abuse, there can be the shaming and the humiliation, the isolation. It's all of these tactics that function to entrap a woman in this relationship -- typically a woman -- entrap her in this relationship and then prevent her efforts and resistance and escape to get out of the relationship.

DAWN HUGHES: Right, absolutely.

And that has also been studied, that if you have a perpetrator who is able to control, manipulate, entrap you verbally; where you go, who you see, who you talk to, what you watch on TV, who you look on Instagram, who you check on Facebook, who you answer a text to, when you use the bathroom, when you eat. Perpetrators use a lot of these sort of micromanaging, controlling aspects of an individual's own autonomy and liberty. When they do all of that, they don't need to hit them.

DAWN HUGHES: The Gaslighting term originated out of a movie of the same name, Gaslighting. What it is is a behavior that functions to make you think you're crazy by telling you up is down and left is right.

And it is very crazy-making when somebody says, you know, Well, I wouldn't have to do have this if you only did A, B, and C. You know this is your fault.

Or, I told you to move the car. You didn't move the car.

And she says, But I did move the car.

No, you didn't.

That vest is blue.

No, it's not. It's green.

Like, sort of turning everything upside down where when that happens repetitively and over time in conjunction with all these other abusive behaviors, it functions to make the victim not trust her own perceptions, not trust her own judgment, and not really have a sense of what really is going on because she's continually told that she is to blame for what her perceptions are, are not accurate.

DAWN HUGHES: Yes, absolutely.

You know, it comes in variety of forms. And these are -- threats are a very pivotal part of this coercive dynamic because what you want to establish if you're the perpetrator is you want to establish that there's negative consequences for noncompliance with me. There's going to be negative consequences if you don't do this.

So, there has to be a threat contingency in that negative compliance. So, often what we have is threats to call immigration services, threats to call the police or child services on you, threats to tell your mother this deep, dark secret; some of the naked photos, I'm going to send it to your work, I'm going to send an e-mail blast to everyone in your contacts.

So, those are things that obviously the victim does not want to happen, so it becomes a very real threat. Now, especially when that perpetrator has instituted sexual violence, he's demonstrated not only a willingness to talk about these threats and an ability to do it but he does it. So, when that threat has been seen and felt, the verbal threats now take on greater weight and greater salience.

DAWN HUGHES: Isolation functions to keep the abuse a secret and stop the victim from getting help.

So, if you don't allow the victim or you minimize the relationships of the victim that were once important, then they get taken off the table as a potential help-seeking resource.

You can't call your mother because she doesn't really understand what we are doing here, she doesn't really get us.

You can't call your sister because she just doesn't like me, she's going to say bad things about me. Maybe you shouldn't call her.

Now you're diminishing that victim's social network to sort of help her make sense of this dynamic that she finds herself embroiled in, so it functions to not allow the victim to have help-seeking and also to keep this abuse a secret.

DAWN HUGHES: So, in indoctrination we think of -- also, we say psychological manipulation. So, making sure that the perpetrator is establishing dominance, that my views are the views and those are the views that you're going to accept. So, any other view doesn't have value here, there's no respect for your point of view, and there's no reason for you to offer anything independent of yourself.

And what that does is that continues to sort of chop away and diminish an individual's own sense of their independence, own sense of their individual capacity, their sense of their own autonomy and freedom of thought, the ability to have independent thought, comes to -- sort of erodes away at that. And, again, that will interfere with her ability to extricate herself from that relationship.

DAWN HUGHES: Oh, so, surveillance.

So, what we talk about is surveillance techniques that are a very integral part of these coercive control relationships in that they want to know, sort of really micromanage, all aspects of the victim's life: Where you go; who you see; what it says on the odometer; if the store was only five miles away and you went six miles, where did you go; you stopped at the store, you should have been in there five minutes for milk, how come you were ten minutes; where's the receipt; let me see your phone; who were you talking to; how long were you talking to this person; why are you talking to this person.

These are things that are normal things that if we're not in an abusive relationship we go through without second thought. I can go to store and buy milk and talk to someone for ten minutes and come home without being scrutinized.

And what that does is it creates the sense of the omnipotence, the omnipresence of the perpetrator, that it crosses time and space barriers, that they are wherever you are.

I've had clients, You have to pick up your phone on second ring. And if you don't, well, you know what's going to happen. You better answer.

You better answer this e-mail. You better text me right away when you're back.

I had a woman who was a nurse. She would have to run down the hall because he would call the nurses' station. If she didn't get there within ten seconds, he'd hang up, and then she'd get a beating later.

So, really trying to micromanage the individual's day where you feel like you have no escape. So, whether you're with the individual or not, they're using surveillance as a control tactic, permeating your existence.

DAWN HUGHES: So economic abuse can be where the person who has the power and control manipulates the finances, has control over the finances, doesn't allow you to have access to a debit card, to a slush fund, to money for things. It's all dictated about what he would like to give, when he would like to give it.

You know, it doesn't allow for the individual sometimes to have a job. Sometimes people have a job that they have to come home and give the check right to their partner who will control it. So it takes away that real tangibility to have resources to leave that relationship and also as a way of just sort of demeaning and demoralizing the victim as if she has no independent agency, that she can have her own job and own money without being dictated to every second of every day.

DAWN HUGHES: All right. So I always say that, you know, that's the number one question that's those of us who work in this field get asked and one of the things that we know is that, you know, it's not that victims remain because they're unconcerned about what happened. It's not that they remain because they are unconcerned about being assaulted and about being abused. Of all of the hundreds and hundreds of individuals that I have evaluated I have not met one woman who was not concerned about the violence and the sexual violence and the coercive control. But what they do have is this sense of powerless, this sense of passive resignation that nothing I do works, there's nothing that I can do that can get me out of this situation. And that belief is maintained by all of these abusive behaviors that I just talked about: If you're stupid, if you're less than, you're not competent, you don't know what you're doing, I have to dictate everything. You lose that sense of your own individual decision-making.

So when we do look at what the studies have shown us and in my clinical experience, we know that women do something. It just doesn't stop the violence and the abuse and the coercive control. We know that, even from our work with the perpetrators, the only person who can stop that violence and abuse and sexual assault is the perpetrator. He's the one who determines whether he wants to be controlling, if he wants to be manipulative, if he wants to sexually assault. The onus rests on him. So, the efforts that the woman uses sometimes are not effective. So what we try to do is try to figure out what else can she do in that relationship to help get out.

In the beginning, what women often end up doing is these informal strategies, these placating strategies. They try to placate their abuser. They try to anticipate demands because they're getting to know the run of the show at this point. They comply with expectations even before asked because they think that's going to keep things calm. They try to talk with their abuser and say this isn't working, I don't want this, you know, and sort of have moments where they can have some autonomy and agency about what's going on.

So they do a lot of things within the confines. Some women fight back physically, some people fight back, sort of passive resistance fighting back. Some people curse and yell at their abuser, like everyone would in a relationship, if you're angry about things.

So all of those things happen, but they happen within the confines of the relationship and they're not geared in the beginning toward getting out of the relationship.

DAWN HUGHES: Right. So they do -- victims often are going to adapt to these compliance strategies, these strategies that sort of on their face makes it look like nothing's wrong, that everything's fine, right. And there's a benefit for the victim to make it seem like nothing's wrong because confronting the perpetrator is a very dangerous proposition because of those threats and you don't know what else he is capable of.

We do see that, you know, saying the same things and, you know, after having been sexually assaulted, you know, a perpetrator might get a text later in the day oh, it was so nice to see you earlier. Well, it wasn't nice to be raped, but I'm going to keep you happy because I know that's what you want to hear because that's going to try to keep me safe.