**5. An integration of abuse via a biopsychosocial framework**

Considering the multifaceted nature of dating abuse, a multidimensional framework is critical for assessment, prevention, and intervention. We argue that the biopsychosocial model should be considered for this purpose (see **Figure 1**). Further we argue that a similar framework can be useful to examine the integration of various forms of abuse (see **Figure 2**) and the progression of abuse over time (see **Figure 3**).

The biopsychosocial model is a theoretical and conceptual framework that elegantly bridges the dichotomy between the social sciences and the medical sciences and considers the role of interpersonal, intrapersonal, and psychological dynamics for an individual's health and well-being. George Engel [101, 102], the originator of the biopsychosocial model, proposes that simultaneous attention to biological, psychological, and social aspects are necessary when considering health and pathology processes (see **Figure 1**). The biopsychosocial model operates by way of a family systems perspective to understand the multiple reciprocal factors from various facets of human experience [103]. The biopsychosocial model can be applied to a variety of contexts without attempting to isolate a specific underlying cause of a problem, which is not only unlikely, but it is also highly improbable that a single factor is to blame. Similar to the biopsychosocial model, the integrative illustration of sexual, physical, psychological, and CDRA in adolescent and young adult relationships can work in similar ways. While sexual, physical, psychological, and CDRA can occur in isolation, as you can see indicated in the figure, they can also co-occur (see **Figure 2**) and even progress over time (see **Figure 3**). Assessing for various forms of dating violence can be complex. It is important that our prevention and intervention efforts utilize a multidimensional (biopsychosocial) integrative approach to exploring, treating, and preventing various forms of abuse collectively. Furthermore, considering the many biological (e.g., physical health, disability, and genetic vulnerabilities), psychological (e.g., mental health, coping skills, social skills, self-esteem, and attitudes/beliefs), and social relational factors (e.g., family relationships, peer relationships, culture, and discrimination) that influence or can be influenced by the development and progression of dating abuse further supports the necessity to understand IPV from a biopsychosocial lens.

#### **5.1 Co-occurrence**

The argument of examining various forms of IPV from an integrative perspective is supported by the literature indicating concurrent associations between psychological, physical, and sexual IPV. Among a sample of newlywed couples, Hammett et al. [63] found moderate to strong intercorrelations between self-reports of psychological and physical IPV among husbands and wives. The co-occurrence between psychological and physical IPV is also common among adolescents and young adult couples [7, 59, 66, 99]. Recently, Saint-Eloi Cadely et al. [9] showed concurrent associations between psychological and physical IPV at all five waves of data among a sample of young adults from ages 22–25. Saint-Eloi Cadely et al. [10] also found that young adults who perpetrated both minor and severe forms of psychological abuse over time also reported extensive use of physical IPV over time; these findings coincide with other studies indicating that the frequency and severity of psychological IPV is related to physical IPV [53, 92]. The relationship between psychological and physical abuse is also found based on reports of CDRA. Specifically, Borrajo et al. [40, 88] indicated that self-reports of CDRA victimization and perpetration were related to self-reports of interpersonal forms of psychological and physical IPV. Cohesively, these findings support the notion that physical abuse without psychological abuse is rare (see [104] for a review of the literature) which further supports the need for the integration of both forms of abuse.

White et al. [11] previously called for researchers to investigate the coemergence between physical and sexual abuse. Additionally, Katz et al. [5] argued that the co-victimization of physical and sexual abuse from a dating partner (i.e., "experiencing both physical violence and unwanted sexual contact from one's dating partner, but not necessarily during the same event", p. 963) ought to be treated distinctly from other forms of abuse standing alone. We argue that psychological abuse ought to be included in this co-emergence of abusive behaviors. Although understudied, the literature hints on a co-occurrence across all three forms of abuse. Within the *National Violence Against Women Survey* (NVAWS) data, Tjaden and Thoennes [105] found that 31% of women who were stalked by their current or former husband or cohabiting partner were also sexually assaulted by that partner. Katz et al. [5] indicated that young college women who were victimized by both physical and sexual IPV were more likely to have experienced psychological abuse from their dating partner. Concurrent associations between sexual abuse and other forms of dating violence among adolescents have also been found. For instance, in a large-scale study of 10 schools in the Northeast of USA (7th–12th graders), victims of CDRA were seven times more likely to have experienced sexual coercion [98]. Additionally, among a sample of adolescents from six high schools in the US Midwest, Saint-Eloi Cadely and Espelage [106] found concurrent associations for the perpetration and victimization of psychological, physical, and sexual abuse at all three waves of data.

Historically, much of the literature has focused on various forms of abuse as if they are truly distinct and occur in isolation from other forms of abuse. However, the research documents that this is not the case and that various forms of abuse often co-occur with other forms of abuse [5, 11, 104]. The co-occurrence literature across these various forms of IPV also hints on a possible progression from psychological to physical and/or sexual IPV.

#### **5.2 Progression**

Although the detrimental effects of psychological IPV should not be undermined, such behaviors are often dismissed as normative behaviors among couples (particularly minor forms of psychological IPV) [107]. Thus, it can be found easier for perpetrators to initiate psychological forms of IPV before progressing to other forms of abuse. Previous cross-sectional studies hinted on the possible progression from psychological to physical IPV among adolescents and young adults [3, 4, 59, 66, 99]. Longitudinal studies more strongly support this notion by indicating a relationship between early reports of psychological abuse and

*An Integrative Exploration of Sexual, Physical, Psychological, and Cyber-Digital Relationship… DOI: http://dx.doi.org/10.5772/intechopen.98233*

later reports of physical abuse [6–8]. More recently, stronger empirical tests using longitudinal data support the progression from psychological to physical abuse with more confidence. For instance, using cross-lag analysis among a sample of young adults (ages 22–25), Saint-Eloi Cadely et al. [9] compared the associations between early and later reports of psychological and physical IPV in one model across five waves of data. Specifically, the model controlled for the direction of early reports of psychological IPV predicting later reports of physical IPV in addition to early reports of physical IPV predicting later reports of psychological IPV across waves. Results showed that early reports of psychological IPV consistently predicted later reports of physical IPV, whereas the opposite direction either was shown to be non-significant or to work in the opposite direction. Moreover, among a sample of young adult couples (Men, *M* = 37.56 years old; Women, *M* = 35.38 years old), it was found that men and women who more frequently perpetrated psychological IPV were more likely to engage in physical IPV one year later [108].

Given the connections between psychological abuse as a segue to later physical abuse among adolescents and young adults, it stands to reason that CDRA may also serve as a pathway to physical forms of abuse should such behaviors be regarded as a new form of psychological abuse. However, this longitudinal pathway along with the longitudinal association from psychological to sexual forms of IPV remains underdeveloped. Similar to physical IPV, sexual IPV is also at times perpetrated with the intention to control one's partner [104]. The use of control in an abusive relationship is a psychologically aggressive act. Abusive partners commonly turn to physical acts of violence as an additional means to control their partner when psychological means are not perceived as enough [82, 109]. Under this notion, it is highly plausible that aggressive partners may turn to sexual abuse for the same purpose. Therefore, it is imperative to further examine the progression from CDRA to physical and sexual aggression and from psychological to sexual abuse. Furthermore, given the evidence supporting the continuation of psychological, physical, and sexual abuse from adolescence to young adulthood [10, 24–26], the progression between these various forms of IPV ought to be examined during this transitional period.

## **6. Implications and future directions**

The foundations for healthy adult romantic relationships begin with a youth's first romantic formation. As we have demonstrated in this chapter, it is clear from the literature that different forms of abuse: sexual, physical, psychological, and CDRA, rarely occur in isolation. Moreover, milder forms of abuse have the potential to develop into more severe forms of abuse over time [66, 99]. Additionally, there is a high likelihood of mutual engagement in the various forms of abuse among teens where there is not always a clear victim and perpetrator but rather both partners have been victimized and perpetrated against [69, 80, 88].

Given the high prevalence of IPV among teens, and the likelihood of mutual engagement, it is all the more imperative that prevention and intervention efforts start early and provide a multidimensional framework inclusive of various forms of dating violence and geared towards both perpetration and victimization in the same curriculum. As we design our prevention and intervention efforts, attitudes towards violence may be an important factor to consider as a potential pathway for prevention and intervention as they have been shown to predict involvement in both victimization and perpetration of dating violence [80, 110]. Moreover, understanding the developmental pathways and integrative nature of dating abuse is crucial as

we work towards preparing and supporting a foundation for healthy adult relationships. Practitioners, interventionists, high school and college counselors, and support staff should provide education around healthy relationship skill building including the development of conflict management/resolution skills, communication training, emotion regulation and de-escalation strategies, and healthy technology use. Assessment of violence should utilize a multidimensional biopsychosocial approach that includes checkups over time to look out for the progression of violence. While a teen may be experiencing only one form of violence at a cross section in time it would be beneficial to be aware of the potential co-occurrence and/or progression of violence over time. Future research must examine the co-occurrence and progression of sexual, psychological, physical, and CDRA longitudinally to better understand the causal nature and interplay among the various forms of aggression in efforts to refine and improve prevention and intervention efforts.

Targeting prevention and intervention efforts towards youth is imperative as IPV is most prevalent among youth and declines with age [111]. As youth and young adults begin to form their patterns of interaction that will then influence their later adult romantic relationships, the development of healthy relationship skills that can potentially prevent experiences of sexual, physical, and psychological abuse, and CDRA in adolescent and young adult romantic relationships is critical.
