Intimate Partner Violence Victimization Influences Suicidal Ideation via Interpersonal Dependency and Anger.

BACKGROUND: Intimate partner violence is a serious global social problem. While intimate partner violence is highly prevalent, few studies have examined its negative outcomes among victims in South Korea. The aim was to clarify the mediating roles of interpersonal dependency and anger on the relationship between intimate partner violence victimization and suicidal ideation.
METHODS: In this descriptive, cross-sectional study, 301 participants (203 women and 98 men) aged 18-65 yr completed an online questionnaire on a social networking site. Data were collected between Feb and Mar 2017 in South Korea. Structural equation modeling was used to test the fitness of the conceptual model of this study.
RESULTS: We found significant correlations between intimate partner violence victimization, interpersonal dependency, state-trait anger, and suicidal ideation. Intimate partner violence victimization influenced anger and suicidal ideation only when the victims had high interpersonal dependency.
CONCLUSION: It is necessary to develop programs for reducing interpersonal dependency and improving anger management that are specifically targeted at intimate partner violence victims to prevent suicidal ideation.

Introduction

Intimate partner violence is a common social problem worldwide (1); for example, approximately 47% of 10,187 female respondents to a survey in the United States reported experiencing intimate partner violence (2). A previous study examined the prevalence of intimate partner violence in seven European countries—Belgium, Germany, Greece, Hungary, Portugal, Spain, Sweden, and the UK- and found that it is on the rise in all of these countries, in both gender (3). Although some victims of intimate partner violence are men (4), it is much more common among women (5). Intimate partner violence occurs across a considerable age range (15–69 yr), with the highest prevalence rates being found among those aged 40–44 yr (37.8%) and those aged 15–19 yr (29.4%) (1). Therefore, people of all ages and sexes are at risk of experiencing intimate partner violence.

Intimate partner violence is defined as emotional, physical, and sexual violence in intimate relationships (6, 7). Emotional violence refers to non-physical forms of violence such as intimidating, controlling, defaming, screaming at or insulting, and making unwanted calls or visits to one’s dating partner (8). By contrast, physical violence refers to striking, kicking, and other unwanted and aggressive physical acts, and sexual violence refers to various forms of sexual coercion and assault (e.g., forced sexual intercourse) (1). Predisposing factors for intimate partner violence victimization include childhood background, such as past experience of child abuse or inappropriate parenting attitudes (9, 10); social factors such as income, education, economic gaps, and poor social support (11, 12); and personality traits (13, 14) such as dependency and obsession (15, 16). Dependency is a particularly strong predictor of intimate partner violence victimization (17), although it can also be a result of intimate partner violence (18). Individuals high in dependency tend to be afraid of being rejected in interpersonal relationships, which reinforces dependency, even if these relationships are violent (19, 20). Being in a dependent relationship can make victims passive and helpless, causing them to rely on the perpetrator rather than try to escape from the relationship (21, 22). Furthermore, victims tend to find it difficult to end these relationships, which prolongs their exposure to the violence (23).

Intimate partner violence influences both individuals and society as a whole (24). Victims of intimate partner violence frequently have multiple health problems (e.g., gastrointestinal, psychosomatic, and pelvic problems) (25). For example, women with a history of intimate partner violence are around twice as likely to be smokers or binge drinkers and to report poor mental health as women without said history (26). Many victims of intimate partner violence report excessive feelings of fear, anxiety, despair, self-criticism, and anger (11, 27, 28).

Anger is a common result of intimate partner violence victimization that can lead to aggression or, when self-directed, to suicidal behavior (29–31). In other words, intimate partner violence can lead to suicide (14, 15, 32). Women experienced intimate partner violence generally tend to have a higher risk of suicide than do men (33); although men experienced intimate partner violence also display increased suicidal ideation (33, 34).

Based on the above literature review, we developed a conceptual framework for this study (Fig. 1). The aim was to clarify the mediating roles of interpersonal dependency and anger on the relationship between intimate partner violence victimization and suicidal ideation.

Fig. 1:

Conceptual framework Note. *P < .05, **P < .01, ***P < .001

Materials and Methods

Design

This study used a cross-sectional design with survey data.

Participants and Data Collection

The criteria for selecting participants included being an adult with at least one romantic relationship/experience and being aged 18–65 years. After receiving institutional Review Board approval from Chung-ang University, we posted a survey announcement containing a description of the research purpose and procedures and the selection criteria for participants on an online community (e.g., Facebook page). When participants clicked the URL attached to the post, they were taken to a page reiterating the study details and containing a voluntary consent form. Participants were asked to place a checkmark next to the statement, “I voluntarily agree to participate in the study” if they agreed to participate. The contact information of a psychological counseling or psychiatric consultation service was included on the original study announcement on the Face-book page to aid individuals who might require counseling on intimate partner violence. Participants’ responses were saved as an Excel file in Google Docs.

Overall, 303 participants responded to the survey. They had to first login to Google for the survey to prevent participating in the survey many times. The system checked the overlapped IDs after collecting the questionnaires. There were no overlapped IDs. There were no missing values, as participants had to answer all questions to submit the questionnaires. However, there were two un-trustworthy answers; i.e., answering “1” to all questions. These two participants were excluded from the analysis process. Thus, 301 questionnaires were analyzed.

Measures

The online questionnaire asked about participants’ general characteristics, such as age, education level, sex, and marital status. It also contained the following scales.

Intimate partner violence victimization

The Partner Victimization Scale (35), was used to measure intimate partner violence victimization after obtaining permission from Hamby to translate it into Korean. To ensure the accuracy of the translation, both the translation and reverse translation were performed by a bilingual expert translator. Each item in the scale was rated as yes (1) or no (0); thus, it was not possible to calculate a Cronbach’s alpha value. The total score ranged from 0 to 5, with higher total scores indicating a more severe intimate partner violence. The scale contains 5 items assessing physical and sexual violence, with items 1 to 4 focusing on physical violence, and item 5 on sexual violence. People who answered “yes” to at least one of the items were considered victims of intimate partner violence.

Interpersonal dependency

The Korean version of the Relationship Addiction Questionnaire was used (36). The original version was developed by Peabody (37). This scale comprises 40 items assessing the feelings, thoughts, and behaviors experienced in addictive romantic relationships. Each item was rated on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree). Total scores ranged from 40 to 200, with higher total scores indicating a higher degree of interpersonal dependency. In Lee’s study (36), the validity was confirmed via a factor analysis, with an internal reliability (Cronbach’s alpha) of .94. In this study, the Cronbach’s alpha was 0.93.

Anger

The Korean version of the State-Trait Anger Expression Inventory, developed by Spielberger (38) and validated by Chon and colleagues (39), was used. According to Spielberger (38), anger can be classified into state and trait anger. State anger refers to the degree of anger emotion at the time of examination, whereas the trait anger reflects a dispositional level or tendency to become angry. This tool comprises 20 items (10 each for state and trait anger), all rated on a 4-point Likert scale: 1=not at all, 2= no, 3= yes, and 4= very much so). Total scores ranged from 10 to 40 for each subscale. Higher scores indicate a higher degree of anger. Spielberger (38) confirmed the validity of the scale through factor analysis, and the Cronbach’s alpha values for state and trait anger were .95 and .84, respectively. When the Korean version of the scale was validated, the Cronbach’s alpha values were .89 and .82, respectively (39); in this study, the Cronbach’s alpha values were .93 and .85, respectively.

Suicidal ideation

The Suicidal Ideation Scale (40) was used to measure suicidal ideation over the last month, with the permission its developers. All items were rated on a 5-point Likert scale (1=not at all, 2= no, 3=normal, 4=yes, and 5=very much so). Total scores ranged from 5 to 25, with higher scores indicating higher suicidal ideation. In this study, the Cronbach’s alpha was .81.

Data Analysis

All data were analyzed using SPSS Statistics 23.0 (Chicago, IL, USA) and AMOS 23.0 (IBM Corp., Armonk, NY). Participants’ general characteristics were analyzed by frequency and percentage. The correlations between intimate partner violence, interpersonal dependency, anger (state and trait), and suicidal ideation were analyzed via Pearson’s correlation analyses. To examine the mediating effects of interpersonal dependency and state and trait anger on the relationship between intimate partner violence victimization and suicidal ideation, we used structural equation modeling. The Multivariate Delta method was employed, which yields a z-score for the mediated effect (41). Significance was indicated by z-scores of greater than 1.96 or less than −1.96.

Results

Three hundred one participants (98 males, 203 females) were included in the analysis. Of these, 62.8% were unmarried, and 53.5% were in their 30s to 40s (Table 1). We found significant positive correlations between intimate partner violence victimization, interpersonal dependency, anger (state and trait), and suicidal ideation (Table 2).

Table 1:

Participants’ General Characteristics (N = 301)

Characteristic	Category	n (%)
Age (yr)	18 to 29	106 (35.2)
	30 to 49	161 (53.5)
	50 to 65	34 (11.3)
Education level	High school degree or less	65 (21.6)
	College or more	236 (78.4)
Sex	Male	98 (32.6)
	Female	203 (67.4)
Marital status	Married	108 (35.9)
	Single	189 (62.8)
	Divorced	4 (1.3)

Table 2:

Correlations between the Major Variables (N=301)

Variable	1	2	3	4	5	Mean	SD	Range
Intimate partner violence victimization	-					0.41	0.95	0–5
Interpersonal dependency	. 421**	-				91.23	21.10	40–200
State anger	. 443**	. 527**	-			16.24	5.79	10–40
Trait anger	. 418**	. 346**	. 712**	-		23.08	4.92	10–40
Suicidal ideation	. 428**	. 349**	. 527**	. 248**	-	8.2	3.54	5–25

Note.

P < .05,

P < .01.

The structural equation model showed an acceptable fit to the data, based on the criteria that the goodness-of-fit index (GFI), adjusted GFI (AGFI), normed fit index (NFI), and comparative fit index (CFI) were all above 0.9; and the root mean square error of approximation (RMSEA) was less than 0.05: χ2 (x, N=301) = 167.155, P<.001; GFI= .936; AGFI= .91; NFI =.912; CFI=.961; RMSEA=.049. Standardized estimates for the direct, indirect, and total effects of the exogenous variables on the endogenous variables are shown in Table 3. Significant paths to suicidal ideation were found for interpersonal dependency (β= .230, P<0.01) and anger (β=.407, P<.001). However, intimate partner violence victimization did not have a significant direct effect on suicidal ideation. Interpersonal dependency had a significant direct effect on anger (β=.460, P< .001; Fig. 1).

Table 3:

Mediation Effects of Interpersonal Dependency and Anger (N = 301)

Path	Estimate	Standard error	z
Intimate partner violence victimization → Interpersonal dependency → Suicidal ideation	0.22	0.14	1.99**
Intimate partner violence victimization → Interpersonal dependency → State anger → Suicidal ideation	0.09	0.04	2.22*
Intimate partner violence victimization → Interpersonal dependency → Trait anger → Suicidal ideation	0.14	0.8	2.64*

Note.

P < .05,

P < .01.

The mediating effect of interpersonal dependency (z=1.99, P< .01) on the relationship between intimate partner violence victimization and suicidal ideation was significant. State anger (z=2.22, P< .05) and trait anger (z=2.64, P< .05) had dual mediating effects via interpersonal dependency on the relationship between intimate partner violence victimization and suicidal ideation (Table 3).

Discussion

This study examined the mediating effects of interpersonal dependency and anger (state and trait) on the relationship between intimate partner violence victimization and suicidal ideation among adults in South Korea. The lack of previous research on interpersonal dependency in the context of intimate partner violence victimization makes it difficult to compare our findings with past research. Nevertheless, our results suggest that interpersonal dependency is an important factor in intimate partner violence (42, 43).

In this study, interpersonal dependency and anger (state and trait) were key concepts affecting suicidal ideation among victims of intimate partner violence. Particularly, intimate partner violence victimization was significantly related to state-trait anger and suicidal ideation only when victims exhibited interpersonal dependency. Therefore, it may be necessary to assess interpersonal dependency among victims of intimate partner violence and implement interventions (e.g., mindfulness therapy) to reduce it. Mindfulness therapy was shown to reduce interpersonal dependency in a study of 70 undergraduate students with high interpersonal dependency (44). As adolescence is an important period for laying the foundation for healthy and stable relationships (45), it may be important to focus on reducing interpersonal dependency and fostering autonomy in adolescence, to ensure that individuals can achieve healthy relationships in adulthood (46).

Intimate partner violence increases the risk of suicide among both men and women (14, 33). Survivors of intimate partner violence often require psychiatric (47) and suicide prevention (48) interventions. However, unlike prior results (14, 15, 33), we found no direct association between intimate partner violence victimization and suicidal ideation. One possible reason for these results is that we did not include emotional violence in our measurement of intimate partner violence victimization. Experiencing emotional violence victimization in a dating relationship was found to have a greater impact on suicidal ideation than was experiencing either physical or sexual violence (49, 50). It is therefore necessary to reconfirm whether intimate partner violence victimization relates to suicidal ideation when considering emotional violence.

Both state and trait anger were related to suicidal ideation. Excessive anger and aggressive behaviors are known to be characteristics of intimate partner violence victims (23), and anger is often the result of anxiety or stress in interpersonal relationships (31). Furthermore, individuals who experience thwarted belongingness due to hostile relationships show an increased risk of aggressive behaviors (e.g., suicidal ideation) (42, 51). The relationship between trait anger and suicide has also been studied previously, with higher trait anger being associated with a greater likelihood of suicidal ideation and suicidal behaviors (52). In contrast, we found that both trait and state anger were associated with suicidal ideation. Unfortunately, few studies have examined the association between state anger and suicidal ideation; thus, more research is needed.

This study had some limitations. First, participants were limited to those living in South Korea, and their age, sex, education, and marital status were not evenly distributed; therefore, careful interpretation is needed to generalize the results. Second, the use of self-report measures increases the possibility that participants’ responses to questionnaire items were influenced by social desirability, even though we used an online survey, which provided anonymity to participants. Third, the intimate partner violence measurement tool in this study did not include items about emotional violence; thus, emotional intimate partner violence victimization was not addressed. Finally, this study was cross-sectional; therefore, we cannot make inferences about the causal linkages between the variables. Furthermore, the time frames concerning intimate partner violence were not directly assessed.

Conclusion

Interpersonal dependency and anger were factors that affected suicidal ideation among intimate partner violence victims. Therefore, it is necessary to proactively intervene in the cycle of interpersonal dependency and anger to prevent victims’ suicidal ideation.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.