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TRAUMA, VIOLENCE, & ABUSE 1-20 ª The Author(s) 2021 Healing After Gender-Based Violence: Article reuse guidelines: sagepub.com/journals-permissions A Qualitative Metasynthesis DOI: 10.1177/1524838021991305 Using Meta-Ethnography journals.sagepub.com/home/tva

Laura Sinko1, Richard James2 , and Kathryn Hughesdon3

Abstract Gender-based violence (GBV) is a significant violation of human rights, requiring specific understanding of how individuals heal and recover after these experiences. This article reports on findings of a qualitative metasynthesis that examined the nature of healing after GBV through the perspectives of female-identifying survivors. Empirical studies were identified by a search of peer-reviewed articles via electronic databases. Studies were included for review if they were available in the English language, reported on qualitative studies that directly engaged female-identifying survivors of GBV, and were aiming to understand the GBV healing journey, process, or goals. After our initial search, 1,107 articles were reviewed by title and abstract and 47 articles were reviewed for full text. Twenty-six peer-reviewed articles were included for the review and were analyzed using meta- ethnography. Key findings included the recovery journey as a nonlinear, iterative experience that requires active engagement and patience. Healing was composed of (1) trauma processing and reexamination, (2) managing negative states, (3) rebuilding the self, (4) connecting with others, and (5) regaining hope and power. “Shifts” or “turning points” are also mentioned which catalyzed healing prioritization. This article aggregates and examines the scientific literature to date on GBV healing and provides articu- lation of the limitations, gaps in evidence, and areas for intervention. The article considers implications for future research, policy, and practice and, in particular, focuses our attention on the need to expand our knowledge of alternative recovery pathways and mechanisms for healing.

Keywords sexual assault, domestic violence, mental health and violence, support seeking

Gender-based violence (GBV) is a global health concern and outcomes (Freyd et al., 2005). Less is known about the healing human rights issue (World Health Organization, 2013). GBV processes beyond the alleviation of symptom burden in GBV is violence perpetrated against a person due to the power survivors, particularly from the perspective of survivors. Thus, dynamics related to gender and can encompass such acts as the purpose of this review is to synthesize the current scientific intimate partner violence, sexual violence, child abuse, and literature to date to understand the recovery process after GBV stalking (Heise et al., 2002). While anyone can experience GBV, through the eyes of women who have experienced it firsthand. women face extremely high rates. For example, in the United States, it is estimated that one in four women has been exposed to GBV in some form throughout their lifetime (Walsh et al., 2015). Recovery Concepts in the Literature to Date These numbers highlight the epidemic of GBV, which dispro- portionately impacts women of color, lesbian, gay, bisexual, Most research on recovery following GBV has focused on recog- transgender, and queer or questioning (LGBTQþ) individuals, nizing factors associated with distress or adverse outcomes and women with disabilities (Abrahams et al., 2013). (Draucker et al., 2009). Scientific interest is growing, however, The range of negative psychological and physical out- comes associated with GBV has been well-documented, 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, including increased risk of depression, anxiety, substance use USA disorders, suicidality, chronic pain syndromes, gynecological 2 Biomedical Library, University of Pennsylvania, Philadelphia, PA, USA disorders, gastrointestinal disorders, and sexually transmitted 3 School of Nursing, Eastern Michigan University, Ypsilanti, MI, USA infections, among others (e.g., Bonomi et al., 2009; Heise Corresponding Author: et al., 2002). In particular, those who experience GBV at the Laura Sinko, Perelman School of Medicine, University of Pennsylvania, 423 hands of someone they know, for example, an intimate part- Guardian Drive, Philadelphia, PA 19104, USA. ner, may be at higher risk for these physical and mental health Email: [email protected] 2 TRAUMA, VIOLENCE, & ABUSE XX(X) in understanding recovery beyond the alleviation of negative in this domain. This will allow a clearer articulation of gaps in symptoms. For example, a 2009 qualitative metasynthesis understanding as well as point to areas for holistic interven- described healing after sexual violence, revealing the importance tion based on survivor needs and desires. Therefore, our pur- of feeling safe, relating to others, and reevaluating the self as pose in preparing this review is to examine the nature of elements of the sexual violence healing process (Draucker et al., healing after GBV through the perspectives of women- 2009). The authors noted, however, that only 12 of 51 reports identifying survivors. While experts have theorized about synthesized focused on healing and recovery specifically, while recovery across many disciplines, our review focuses specif- others described the “lived experience” of survivors more gener- ically on research evaluating GBV survivor perspectives to ally (Draucker et al., 2009). Hence, many aspects of the healing amplify their expertise in their own lived experience. This process may have been missed due to the limited number of studies review focuses specifically on women survivors due to the reviewed actually aiming to describe recovery directly. Addition- disproportionate rate of women affected by GBV (European ally, this review was focused on evaluating healing after sexual Institute for Gender Equality, 2020) and the differing lived trauma and did not focus on self-identified gender in its analysis. experiences and challenges other genders who experience More recently, a narrative review was conducted to synthesize GBV may have. Qualitative metasynthesis (Sandelowski & literature about recovery after intimate partner violence, which Barroso, 2007) and meta-ethnography (Noblit & Hare, was published after thepresentreview was conducted. This review 1988) techniques were used to conduct the review and explore revealed developmental aspects of recovery including disentan- and integrate healing themes. gling from the past, coping with the present, and moving toward the future (Flasch, 2020). Greater understanding of recovery after GBV broadly is needed, however, to reveal how the dynamics of Method gender and violence interplay as individuals attempt to rebuild and Qualitative metasynthesis is an approach to synthesize qualita- make meaning after these experiences. tive findings on a specific topic. Sandelowski and Barroso Other terms have been used to describe recovery in trauma- (2007) created the guidelines for synthesizing the literature exposed populations, and have been applied to survivors of used for this project. The guidelines include (1) formulating GBV. For example, resilience has been defined as “the ability the review question, (2) conducting a systematic literature of individuals facing adversity to utilize resources within psy- search, (3) screening and selecting appropriate research arti- chological, social, and cultural domains that sustain their well- cles, (4) analyzing and synthesizing qualitative findings, (5) being and promote adaptive outcomes” (Schaefer et al., 2018; maintaining quality control, and (6) presenting findings. The Ungar, 2012). This has often been compared with the concept research team included two nurse researchers (first and senior of posttraumatic growth, which focuses on meaning making authors), one with expertise in sexual violence and intimate and positive changes in the perception of the self, relationships partner violence and the other with expertise in child maltreat- with others, and one’s general philosophy of life as the result of ment, and a library scientist with expertise in the health care a traumatic event (Tedeschi & Calhoun, 1996). While the simi- and support of LGBTQþ youth as well as adverse childhood larities and differences of resilience and posttraumatic growth experiences, medical trauma, and toxic stress. have been discussed, both reflect positive psychological responses following traumatic events (Schaefer et al., 2018) and could contribute insight to how we conceptualize the pro- Data Sources cess of recovering after GBV. Other terms used in the literature Three databases, PubMed, PsychINFO, and EBSCO violence to describe GBV recovery include “thriving” (Heywood et al., abstracts/criminology/family studies, were searched in Sep- 2019; Taylor, 2004), “remaking the self” (Oke, 2008), tember 2019. Key words were created by the library scientist “transformation of identity” (Glumb´ıkov´a & Gojov´a, 2019), in consultation with the first and senior authors. Key words and “overcoming” (Flasch et al., 2017), among others. Despite included combinations of GBV (e.g., sexual violence, intimate disagreement or lack of clarity over theoretical distinctions partner violence), recovery (e.g., healing, growth, flourishing), between recovery and related concepts, it remains an important and qualitative research (e.g., ethnography, phenomenology). endeavor to better understand how women cope with and move An additional search was completed in May 2020 to determine through their experiences of GBV. Hence, for the purpose of if any new articles matching our inclusion criteria had been this review, our analysis included discussion of any of these published since the first search date. Additional relevant arti- topics, as long as it related to the recovery process. This cles were found through references cited by included studies. ensured holistic understanding of important elements of recov- ery through the eyes of survivors regardless of the lens through which the investigators explored their experience. Selection Criteria The first and senior authors independently screened titles and abstracts for eligibility. The inclusion criteria were (1) studies The Present Review that used qualitative research methods, (2) studies that focused Integrating qualitative findings on healing and recovery in on GBV or a type of GBV (e.g., intimate partner violence, survivors of GBV is essential to move the science forward sexual assault), (3) studies that discussed the healing/recovery Sinko et al. 3 process, journey, or goals from women-identifying individuals’ constructs simultaneously, contributing to our development of perspectives, and (4) empirical articles in peer-reviewed jour- third-level constructs. nals. The exclusion criteria were (1) studies that only used Research studies that met our inclusion criteria were read quantitative data, (2) studies not published in English, (3) gray and reread by both the first and senior authors to identify base- literature, (4) case studies, (5) interventions, (6) articles where line concepts. Concepts were identified based on participant the authors focused on biological or physical healing from and researcher references to recovery (and related concepts) injury, and (7) articles where the authors focused on influences after experiencing GBV. The first and senior authors then iden- of healing but not the healing process itself. Following title and tified and synthesized first- and second-order constructs simul- abstract review, the first and senior authors assessed the full taneously that were similar across studies (“reciprocal text of studies that met inclusion criteria for titles and abstracts. translation”; Noblit & Hare, 1988) by grouping common con- Uncertainty and disagreement were resolved by reconciliation cepts and gathering similar themes into “piles” or categories of meetings until a mutual decision was reached. An audit trail shared meaning (France et al., 2019). These constructs were and journal containing analytic, theoretical, and personal notes then discussed by the first and senior authors at length, were was maintained by both the first and senior authors to promote defined, and served as a preliminary code list for synthesis. awareness of reflexivity and potential bias. Articles were coded independently using the defined first- and second-level constructs in ATLAS.ti software (Muhr, 2006), with reconciliation meetings occurring to understand contra- Data Extraction and Quality Appraisal dictory themes and concepts (refutational translation; Noblit & Once all articles were reviewed and final articles chosen, the Hare, 1988) as well as additional areas of inquiry not initially first and senior authors extracted data from each study into an recognized by the preliminary code list. Third-order constructs evidence table. For the sake of parsimony, Table 1 is an abbre- were then identified through systematic identification of first- viated version of this table. To assess the quality of the articles, and second-order constructs and abstracting upward to main the Critical Appraisal Skills Programme (CASP; 2018) Quali- categories, allowing “systematic comparison” and tative Checklist was used. Since there is no consensus in regard “conceptualizing” (Strauss & Corbin, 1997) which was the to excluding articles based on the quality of the study (Daly most common data translation method in a review of meta- et al., 2007; Dixon-Woods et al., 2006; Sandelowski, 2006), all ethnography studies (France et al., 2019). This was followed articles were included in the analysis regardless of the CASP by a repeat coding process in ATLAS.ti based on third-order score, although the overall quality of articles synthesized was constructs and definitions to ensure each applied construct was high. Detailed information on the quality appraisal of each represented across the majority of the studies reviewed. This article is available upon request. created a “count” of articles that contributed to our understand- ing of each third-order construct (Feder et al., 2006; see Table 2 for details). The findings presented below are organized by Analysis third-order constructs identified, with supporting and conflict- Our analytic methods are based on meta-ethnography (Noblit ing first- and second-order constructs listed under each identi- & Hare, 1988), though at present, there is varying theory and a fied domain. We create a visual metaphor to link these concepts lack of standardization for synthesizing qualitative research together in a line of argument to create a new “metaphor,” (Tacconelli, 2010). Meta-ethnography has been used in quali- “story line,” or overarching explanation of the phenomena tative metasyntheses of similar nature in the past (see Trevil- (France et al., 2019; Noblit & Hare, 1988). lion et al., 2014, for an example) and is one of the most widely used techniques for the synthesis of health research (Bondas & Hall, 2007; Campbell et al., 2011). This method uses primary Results studies explanations as “data” by applying the views of study participants as “first-order constructs” and the interpretations Description of Sample/Articles of study authors as “second-order constructs” (Noblit & Hare, The study selection process for retrieving and screening stud- 1988). These constructs are then compared and contrasted by ies is found in Figure 1 (Moher et al., 2009). After screening reviewers before being translated to produce new insights or abstracts, a total of 47 articles were identified for potential “third-order constructs” (Noblit & Hare, 1988). Some have inclusion. After screening full-text articles and hand- argued, however, that the distinction between first- and searching references, a total of 25 studies were included for second-order constructs are often murky due to authors select- our synthesis. Details of these studies and sample character- ing participant quotes to support their second order constructs istics can be viewed in Table 1. Authors used a variety of (Toye et al., 2014). Others believe that first-order constructs words to describe the concept of healing, including resilience can be analyzed and synthesized along with their correspond- (n ¼ 6), healing (n ¼ 5), recovery (n ¼ 14), growth (n ¼ 3), ing second-order constructs but not in isolation due to the identity transformation/reconstruction/remaking self/ inability for reviewers to fully understand first-order constructs reclaiming self (n ¼ 4), and thrivership/survivorship thriving without having access to the full context of the primary studies (n ¼ 2). Some authors used multiple healing descriptors, so (France et al., 2019). Thus, we analyzed first- and second-order these are not mutually exclusive. 4

Table 1. Abbreviated Evidence Table of Articles Synthesized.

Title/Authors Country Sample Characteristics Methodology

Ahmad, F., Rai, N., Petrovic, B., Erickson, P. E., & Stewart, D. E. Canada Survivors of intimate partner violence (IPV). South Asian Constant comparison (2013). Resilience and resources among South Asian immigrant immigrant women to Canada. Most participants had college women as survivors of partner violence. Journal of Immigrant education but low income. and Minority Health, 15(6), 1057–1064. Allen, K. N., & Wozniak, D. F. (2010). The language of healing: United States Survivors of domestic violence (DV). Mean age was 35 years. Thematic analysis Women’s voices in healing and recovering from domestic Majority of women had completed some college. About half of violence. Social Work in Mental Health, 9(1), 37–55. the women were working and the other half were receiving state assistance. Anderson, K. M., Renner, L. M., & Danis, F. S. (2012). Recovery: United States Survivors of IPV. 75.68% White, 10.81% African American, 5.41% Qualitative inquiry Resilience and growth in the aftermath of domestic violence. Hispanic, 5.41% Native American, and 2.7% Asian American. Violence Against Women, 18(11), 1279–1299. Mean age was 42.62 years. Barnes, R. (2013). “I’m over it”: Survivor narratives after woman- England and Wales Survivors of women-to-women partner abuse. All but four Thematic analysis to-woman partner abuse. Partner Abuse, 4(3), 380–398. participants were White (n ¼ 40). Most participants self- defined as gay or lesbian. Crann, S. E., & Barata, P. C. (2016). The experience of resilience Canada Survivors of IPV. 50% White/European sample, 12.5% Caribbean, Phenomenology for adult female survivors of intimate partner violence: A 12.5% South Asian, 6.25% Latin American, 6.25% First Nations/ phenomenological inquiry. Violence Against Women, 22(7), 853– Native, and 12.5% biracial. Level of education ranged from 875. some elementary education to having a graduate degree. dos Reis, M. J., Lopes, M. H. B. D. M., & Osis, M. J. D. (2016). “It’s Brazil Survivors of sexual violence. Participants from Brazil. Thematic analysis much worse than dying”: The experiences of female victims of sexual violence. Journal of Clinical Nursing, 26(15–16), 2353– 2361. Duma, S. E., Mekwa, J. N., & Denny L. D. (2007). Women’s South Africa Survivors of sexual assault trauma. Black women. Grounded theory journey of recovery from sexual assault trauma: A grounded theory—Part 1 [combined with part 2]. Curationis, 30(4), 4–11. Farrell, M. L. (1996). Healing: A qualitative study of women United States Survivors of physical, sexual, or psychological abuse. Race or Phenomenology recovering from abusive relationships with men. Perspectives in ethnicity not discussed. Women were high school graduates or Psychiatric Care, 32(3), 23–32. had a GED. Over half were supported by welfare. Flasch, P., Murray, C. E., & Crowe, A. (2017). Overcoming abuse: United States, Survivors of IPV. 83.7% White, 8.9% Hispanic/Latino/Latina, 4.1% Phenomenology A phenomenological investigation of the journey to recovery Australia, African American/Black, 2.4% Native American, and 3.3% from past intimate partner violence. Journal of Interpersonal Europe, and “Other.” Mean age was 41 years. About 83% of sample was Violence, 32(22), 3373–3401. Other from the United States, and 42.3% of sample had an income less than US$30,000. Glumb´ıkova,´ K., & Gojova,´ A. (2019). Transformation of the Czech Republic Survivors of DV. Participants from the Czech Republic. Participatory research approach identity of homeless women with an experience of domestic and thematic narrative analysis violence: Changing from a victim to a survivor: An example from shelters for mothers in the Czech Republic. Journal of Social Work Practice, 34(2), 151–162 Heywood, I., Sammut, D., & Bradbury-Jones, C. (2019). A Central England Survivors of DV. Personal data not gathered, but participants Thematic analysis qualitative exploration of “thrivership” among women who from a range of ethnic backgrounds. have experienced domestic violence and abuse: Development of a new model. BMC Women’s Health, 19(1), 1–15. (continued) Table 1. (continued)

Title/Authors Country Sample Characteristics Methodology

Hou, W. L., Ko, N. Y., & Shu, B. C. (2013). Recovery experiences Taiwan Survivors of IPV. Taiwanese women. Half of participants had a Phenomenology of Taiwanese women after terminating abusive relationships: A college education. phenomenological study. Journal of Interpersonal Violence, 28(1), 157–175. Lewis, S. D., Henriksen, R.C., Jr., & Watts, R. E. (2015). Intimate United States Survivors of IPV. Mean age was 39.6 years. Sample was 66.7% Phenomenology partner violence: The recovery experience. Women & Therapy, African American/Black, 16.7% White, 16.7% Black/White, and 38(3–4), 377–394. multiple heritage background. All participants employed. Matheson, F. I., Daoud, N., Hamilton-Wright, S., Borenstein, H., Canada Survivors of IPV. Sample was 54% White, 15% Black, and the Grounded theory Pedersen, C., & O’Campo, P. (2015). Where did she go? The remainder is a mix of ethnic groups. Majority unemployed transformation of self-esteem, self-identity, and mental well- (39%) or on disability (42%). being among women who have experienced intimate partner violence. Women’s Health Issues, 25(5), 561–569. Oke, M. (2008). Remaking self after domestic violence: Mongolian Mongolia and Survivors of IPV. All of the Mongolians were ethnic Mongolian. Feminist, narrative approach and Australian women’s narratives of recovery. Australian and Australia The Australian women were 45% Anglo-Celtic, 9% Indigenous New Zealand Journal of Family Therapy, 29(3), 148–155. Australian, 9% Italian, 9% Dutch, 9% Maltese, 9% Indian, and 9% African. Ranjbar, V., & Speer, S. (2013). Revictimization and recovery from United Kingdom Survivors of sexual assault. Mean age was 31.59 years. Essentialist, inductive thematic analysis sexual assault: Implications for health professionals. Violence and Victims, 28(2), 274–287. Sinko, L., Burns, C. J., O’Halloran, S., & Arnault, D. S. (2019). United States and Survivors of GBV. American women were from Southeast Ethnography and thematic analysis Trauma recovery is cultural: Understanding shared and Ireland Michigan. The American sample was 84.21% White, 10.53% different healing themes in Irish and American survivors of African American, and 5.26% Asian. The Irish women were gender-based violence. Journal of Interpersonal Violence. from rural areas of Ireland. The Irish sample was 92% White and 8% Black. Sinko, L., Munro-Kramer, M., Conley, T., Burns, C. J., & Saint United States Survivors of sexual violence. Sample was 68.4% White, 15.79% Holistic and cross-sectional data Arnault, D. (2019). Healing is not linear: Understanding the African American/Black, and 15.79% Asian. Sample was current analyses day-to-day healing processes of female survivors of undergraduate students or alumni of a 4-year institution. undergraduate unwanted sexual experiences. Journal of Community Psychology. Sinko, L., & Saint Arnault, D. (2019). Finding the strength to heal: United States Survivors of gender-based violence. Sample was 85.71% White, Modified grounded theory analysis Understanding recovery after gender-based violence. Violence 9.5% African American, and 4.76% Asian. Against Women, 26 (12–13), 1616–1635. Smith, M. E. (2003). Recovery from intimate partner violence: United States Survivors of IPV. Sample was 93.3% White and 7.1% African Phenomenology analyzed using a A difficult journey. Issues in Mental Health Nursing, 24(5), American. hermeneutic process 543–573. Smith, M. E., & Kelly, L. M. (2001). The journey of recovery after a United States Survivors of sexual assault. Sample was 100% White. Hermeneutic process rape experience. Issues in Mental Health Nursing, 22(4), 337–352. Taylor, J. Y. (2004). Moving from surviving to thriving: African United States Survivors of IPV by an African American male or male partner of Womanist ethnographic investigation American women recovering from intimate male partner color. Sample was 100% African American. Mean age was 39 abuse. Research and Theory for Nursing Practice, 18(1), 35–50. years. Median income was US$20,500. (continued) 5 6

Table 1. (continued)

Title/Authors Country Sample Characteristics Methodology

Thompson, M. (2000). Life after rape: A chance to speak? Sexual United Kingdom Survivors of sexual assault. Sample was 60% White UK, 20% Feminist-standpoint research. analysis and Relationship Therapy, 15(4), 325–343. White Jewish, and 20% Black British. influenced by discourse analytic methodology Wuest, J., & Merritt-Gray, M. (2001). Beyond survival: Reclaiming Canada Survivors of DV. Sample was 100% White. Lived in small towns Grounded theory from a feminist self after leaving an abusive male partner. Canadian Journal of and geographically isolated areas in Eastern Canada. perspective Nursing Research Archive, 32(4). Zraly, M., & Nyirazinyoye, L. (2010). Don’t let the suffering make Rwanda Survivors of genocide rape. All participants were members of Grounded theory and content analysis you fade away: An ethnographic study of resilience among Abasa or Association des Veuves du Genocide´ (AVEGA). Mean survivors of genocide-rape in southern Rwanda. Social Science age was 39.75 years. & Medicine, 70(10), 1656–1664. Table 2. Critical Findings: Healing Domains, Definitions, and Contributing Articles.

Subtheme Definition Number of Articles Article Citations

Trauma processing and reexamination

Meaning making The process of accepting the reality of her experience, reexamining 19 Barnes (2013), Crann and Barata (2016), Duma et al. (2007), Flasch et al. (2017), Glumb´ıkova´ and her role, and making sense of her violence encounter to allow her to Gojova´ (2019), Heywood et al. (2019), Matheson et al. (2015), Oke (2008), Ranjbar and Speer move forward. (2013), Smith (2003), Smith and Kelly (2001), Taylor (2004), Thompson (2000), Wuest and Merrit-Gray (2001), Sinko and Saint Arnault (2019), Zraly and Nyirazinyoye (2010), Anderson et al. (2012), Farrell (1996), and Hou et al. (2013) Self-evaluation Growing to understand one’s trauma responses, needs, and potential 14 Barnes (2013), Crann and Barata (2016), Duma et al. (2007), Glumb´ıkova´ and Gojova´ (2019), for healing. Heywood et al. (2019), Matheson et al. (2015), Ranjbar and Speer (2013), Smith (2003), Smith and Kelly (2001), Thompson (2000), Wuest and Merrit-Gray (2001), Sinko, Burns, et al. (2019), Farrell (1996), and Hou et al. (2013)

Managing negative states

Negative internal Negative internal thought processes related to one’s gender-based 11 dos Reis et al. (2016), Duma et al. (2007), Glumb´ıkova´ and Gojova´ (2019), Heywood et al. (2019), dialogue violence (GBV) event that perpetuates feelings of blame and Matheson et al. (2015), Oke (2008), Ranjbar and Speer (2013), Sinko, Burns, et al. (2019), negative self-concept. Thompson (2000), Wuest and Merrit-Gray (2001), and Sinko and Saint Arnault (2019) Distressing Troubling feelings experienced after the abuse, impacting ability to 14 Barnes (2013), Crann and Barata (2016), dos Reis et al. (2016), Flasch et al. (2017), Glumb´ıkova´ and emotions function in society or connect with others. Gojova´ (2019), Matheson et al. (2015), Oke (2008), Ranjbar and Speer (2013), Smith (2003), Smith and Kelly (2001), Thompson (2000), Sinko and Saint Arnault (2019), Sinko, Munro-Kramer, et al. (2019), and Hou et al. (2013) Trauma symptoms Physical, mental, social, and behavioral responses to GBV that 17 Barnes (2013), dos Reis et al. (2016), Flasch et al. (2017), Glumb´ıkova´ and Gojova´ (2019), Heywood and reactions interfered with one’s ability to function in society or connect with et al. (2019), Lewis et al. (2015), Matheson et al. (2015), Oke (2008), Ranjbar and Speer (2013), others. Sinko, Burns, et al. (2019), Smith (2003), Wuest and Merrit-Gray (2001), Thompson (2000), Sinko and Saint Arnault (2019), Sinko, Munro-Kramer, et al. (2019), Anderson et al. (2012), and Hou et al. (2013)

Rebuilding the self

Identity Creating an identity that one is proud of either by returning to who 18 Barnes (2013), Crann and Barata (2016), Duma et al. (2007), Flasch et al. (2017), Glumb´ıkova´ and construction they were before their experience or incorporating new aspects Gojova´ (2019), Heywood et al. (2019), Matheson et al. (2015), Oke (2008), Sinko, Burns, et al. into a creation of a “new” self. (2019), Smith (2003), Smith and Kelly (2001), Taylor (2004), Thompson (2000), Wuest and Merrit-Gray (2001), Sinko and Saint Arnault (2019), Farrell (1996), Allan and Wozniak (2010), and Hou et al. (2013) Improving self- A positive transformation and acceptance of the self to rebuild self- 17 Ahmad et al. (2013), Barnes (2013), Crann and Barata (2016), Flasch et al. (2017), Glumb´ıkova´ and concept worth, self-esteem, competence, and/or mastery. Gojova´ (2019), Heywood et al. (2019), Matheson et al. (2015), Sinko, Burns, et al. (2019), Smith and Kelly (2001), Smith and Kelly (2001), Thompson (2000), Wuest and Merrit-Gray (2001), Sinko and Saint Arnault (2019), Sinko, Munro-Kramer, et al. (2019), Farrell (1996), Allan and Wozniak (2010), and Hou et al. (2013) Renewing the spirit Nurturing the spiritual, emotional, and physical self to find inner peace 16 Ahmad et al. (2013), Crann and Barata (2016), Duma et al. (2007), Flasch et al. (2017), Heywood et al. and prioritize one’s well-being. (2019), Lewis et al. (2015), Oke (2008), Sinko, Burns, et al. (2019), Smith and Kelly (2001), Taylor (2004), Thompson (2000), Zraly and Nyirazinyoye (2010), Sinko and Saint Arnault (2019), Sinko, Munro-Kramer, et al. (2019*), Anderson et al. (2012), and Allan and Wozniak (2010)

Connecting with others

Letting people in Feeling able to be authentic with trusted others about the impact of 17 Ahmad et al. (2013*), Barnes (2013), Duma et al. (2007*), Flasch et al. (2017*), Glumb´ıkova´ and their violent encounters and needs going forward. Gojova´ (2019*), Heywood et al. (2019), Lewis et al. (2015*), Matheson et al. (2015), Ranjbar and Speer (2013*), Sinko, Burns, et al. (2019*), Smith and Kelly (2001), Taylor (2004), Thompson (2000), Wuest and Merrit-Gray (2001*), Zraly and Nyirazinyoye (2010), Sinko and Saint Arnault

7 (2019*), and Sinko, Munro-Kramer, et al. (2019*) (continued) 8

Table 2. (continued)

Subtheme Definition Number of Articles Article Citations

Building support Building and maintaining positive personal and professional 20 Ahmad et al. (2013*), Barnes (2013), Crann and Barata (2016*), dos Reis et al. (2016), Duma et al. networks relationships that resist violence and cultivate feelings of belonging (2007), Flasch et al. (2017), Heywood et al. (2019), Lewis (et al. (2015*), Oke (2008), Ranjbar and Speer (2013*), Sinko, Burns, et al. (2019*), Smith and Kelly (2001), Taylor (2004), Wuest and Merrit-Gray (2001), Zraly and Nyirazinyoye (2010*), Sinko and Saint Arnault (2019*), Sinko, Munro-Kramer, et al. (2019*), Anderson et al. (2012), Allen and Wozniak (2010), and Hou et al. (2013) Regaining hope and power

Embracing freedom Being liberated, executing plans, or taking steps to embrace their 18 Ahmad et al. (2013), Barnes (2013), Crann and Barata (2016), dos Reis et al. (2016), Duma et al. freedom based on their own choices and self-determination. (2007), Flasch et al. (2017), Heywood et al. (2019), Matheson et al. (2015), Oke (2008), Sinko, Burns, et al. (2019), Smith (2003), Smith and Kelly (2001), Taylor (2004), Wuest and Merrit-Gray (2001), Zraly and Nyirazinyoye (2010), Sinko and Saint Arnault (2019), Sinko, Munro-Kramer, et al. (2019), and Farrell (1996) Finding purpose Engaging in activities that make them feel competent or that life is 17 Ahmad et al. (2013), Barnes (2013), Crann and Barata (2016), Flasch et al. (2017), Heywood et al. worth living and gives them a sense of fulfillment. (2019), Matheson et al. (2015), Oke (2008), Sinko, Burns, et al. (2019), Smith (2003), Taylor (2004), Thompson (2000), Wuest and Merrit-Gray (2001), Sinko and Saint Arnault (2019), Anderson et al. (2012), Farrell (1996), Allan and Wozniak (2010), and Hou et al. (2013) Building hope Feeling as though things will get better in time by releasing negativity 14 Ahmad et al. (2013), Crann and Barata (2016), Glumb´ıkova´ and Gojova´ (2019), Heywood et al. (2019), and reframing one’s mindset to make room for new possibilities. Lewis et al. (2015), Matheson et al. (2015), Sinko, Burns, et al. (2019), Smith and Kelly (2001), Taylor (2004), Wuest and Merrit-Gray (2001), Sinko and Saint Arnault (2019), Sinko, Munro- Kramer, et al. (2019), Anderson et al. (2012), and Farrell (1996) Sinko et al. 9

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for article review (Moher et al., 2009).

The Healing Process: A Journey of Patience and Active abuse experiences, and that they need to take measures to Engagement work towards a successful recovery” (Barnes, 2013, p. 392). Ultimately, while healing does take time, the articles counter Healing was found to be a multidimensional (n ¼ 2), nonlinear that time alone is not enough, and active engagement and (n ¼ 10), and iterative (n ¼ 4) journey requiring courage support from your environment is essential to make meaningful (n ¼ 7), active engagement (n ¼ 12), and patience (n ¼ 4) strides forward. See Table 2 for critical findings and Table 3 for when setbacks arose. We identified five main third-order con- refutational translations or contradictions noticed in the litera- structs that described the healing process. This included (1) ture. Healing objectives did not appear to differ by the type of trauma processing and reexamination, (2) managing negative violence as evidenced by the diversity of studies contributing to states, (3) rebuilding the self, (4) connecting with others, and each theme, however, individualized nuances based on trauma (5) regaining hope and power. While some studies postulated history characteristics, individual identity, and culture are the order of these objectives, there was not enough consistency important to consider as we attempt to create interventions to create a hierarchy or order to these themes, as many appeared under each domain listed. to develop simultaneously. It is important to note that these themes do appear to build on crisis stabilization and establish- ing safety and autonomy (Allen & Wozniak, 2010). Trauma processing and reexamination. An important element of Recovery was viewed as an active process, specifically healing consisted of processing one’s trauma and reexamining mentioned in 14 of our included articles, underpinned by one’s experience, recognizing broader contextual factors that “recognition that they have been adversely affected by their reinforce negative states and uphold social and cultural norms 10 TRAUMA, VIOLENCE, & ABUSE XX(X)

Table 3. Refutational Translation.

Concept Explanation

Role of forgiveness in meaning-making process Most studies that mentioned forgiveness in their findings (n ¼ 9) were in agreement that forgiveness of the self is essential to allow individuals to “stop punishing themselves for what happened” and “discontinue trying to change the past” (Flasch et al., 2017; Ranjbar & Speer, 2013). Heywood et al. (2019) countered that some participants viewed “self-forgiveness as irrelevant” due to the fact that the perpetrator “chose you, you did not choose him.” This was mentioned with the caveat that individuals had to recognize the abuse was never their fault. It was unclear whether forgiving your perpetrator was essential to move forward. Flasch et al. (2017; IPV) and Smith and Kelly (2001; rape) explicitly mentioned forgiving ones’ perpetrator as a core healing theme. Despite this, Flasch et al. (2017) said “many but not all” of their participants agreed with this idea while Smith and Kelly (2001) said “some” saw it as part of the healing process. The only article (N ¼ 37) that explicitly stated that they asked survivors about forgiveness was Heywood et al. (2019). This study revealed that “all except three participants said that they could never forgive their abuser.” Identity: A return to old self or the building There was a slight tension about whether or not healing is a process of “identity lost and of a new self? found” (Oke, 2008) or rather a process of “recreation” (Flasch et al., 2017). Eight articles used verbiage referring to a “return” to the self (e.g., “regaining a sense of true self” [Crann & Barata, 2016], “reestablishing one’s identity” [Matheson et al., 2015], and “connecting aspects ...fragmented by abuse” [Farrell, 1996, p. 30]). Five articles referenced the self as a new self (e.g., “change of identity”; Glumb´ıkova&´ Gojova,´ 2019) or a self “before and after the violence” (Sinko, Burns, et al., 2019), with one article stating that the word recovery itself “may not be right because it implies a complete return to what once was” (Ranjbar & Speer, 2013). Two articles referred to both processes happening differently depending on the individual (Oke, 2008) or potentially at different times in the healing process (Flasch et al., 2017). Flasch et al. (2017) shares that perhaps survivors must first find a way back to their old selves prior to creating a new identity post abuse. The role of spirituality and religion While spirituality was found to be an important support to healing, there was a discrepancy surrounding its tie to religious institutions. Heywood et al. (2019) mentioned that religion provided more “practical support” from people within the community, while Anderson et al. (2012) mentioned that religious communities offered “emotional support, a sense of belonging and security.” Other studies refuted that religion was not necessary for recovery (Heywood et al., 2019), with two studies citing some harm religious institutions can incite. For example participants from Sinko, Burns, et al. (2019) and Anderson et al. (2012) mentioned that familial values tied to religion (e.g., divorce) caused some survivors to feel shame for ending their violent relationships. Do you need to leave a gender-based violence (GBV) Some articles discussed a low point of being in imminent danger and thus leaving their relationship to begin healing? relationship as a significant turning point (e.g., Lewis et al., 2015). Contrastingly, other women discussed how they started to heal while they were still in the abusive relationship (e.g., Crann & Barata, 2016; Farrell, 1996), while others did not believe they engaged in their healing until long after the abuse was over. Thus, it is unclear if women need to leave GBV relationships to begin their healing process or even if leaving an abusive relationship truly starts one’s healing. We synthesize that perhaps leaving the relationship is an important part of the healing journey but is not always the catalyst to initiating the healing process.

of violence against women (Crann & Barata, 2016). While Meaning making. Nineteen articles discussed meaning mak- social and cultural norms differed by study context, trauma ing as we defined it with a specific focus on first-/second-order processing and reexamination generally consisted of two constructs of accepting reality and reexamination. In the second-order constructs: meaning making and self- domain of accepting reality, five studies alluded to the idea evaluation. Through making sense of her violent encounter, that “overcoming denial is the first step” (Ranjbar & Speer, putting it in context, and looking inward to understand one’s 2013, p. 278) and that accepting what had happened, by responses and needs, individuals were able to let go of self- acknowledging the experience and one’s resulting emotions, blame and envision a path forward. was a significant part of their definition of recovery (dos Reis Sinko et al. 11 et al., 2016; Flasch et al., 2017; Ranjbar & Speer, 2013; Sinko, aspects of themselves (Duma et al., 2007). Others found poten- Burns, et al., 2019; Sinko & Saint Arnault, 2019; Zraly & tial through looking forward. This process allowed individuals Nyirazinyoye, 2010). This acceptance was not to be confused to find flexibility “enhancing the individual’s capabilities to be with complacency. For example, one participant mentioned in self-sustaining and resulting in a broader perspective of life as a Flasch et al. (2017), “First I had to recognize it as abuse, which whole beyond the limited view of life created by the abuse” was very difficult for me. From there, it became easier to over- (Farrell, 1996, p. 28). come” (p. 3388). Another important construct as someone made meaning of Managing negative states. While managing one’s negative inter- their experience was reexamining their situation and their nal dialogue, emotions, and trauma reactions were not consid- role in their experience objectively in context to allow them ered to be a survivor’s sole recovery goal, it was important to to forgive themselves and potentially those around them. One their functioning to understand the origins of and learn strate- article described this process as shifting toward resistance to gies to manage negative states. Most frequently, women allow women to “push back against the abuse and its negative described “enduring emotional or psychological impacts such effects, the abuser and abusive relationships, and the broader as anxieties about future relationships or struggles with their social environment that upholds social and cultural norms self-concepts” (Barnes, 2013, p. 389). Negative states that were of violence against women” (Crann & Barata, 2016, p. 860). important for survivors to manage included three second-order Reexamination often involved education consisting of (1) constructs: negative internal dialogue, distressing emotions, learning about the dynamics of abusive relationships and (2) and trauma reactions and symptoms. Developing perceptions using that knowledge to examine past experiences with abuse of increased agency and control over negative states, influ- (Flasch et al., 2017). Ultimately, reexamination often catalyzed enced the control women felt they had over specific aspects a process of grieving and letting go of negative internal dialo- or overall outcomes of their lives, relationships, and other gues, allowing the individuals to “give up the painful feelings experiences. about the past” and allow it to not control them (Smith, 2003, p. 562). Negative internal dialogue. GBV caused many survivors to ruminate about their experiences, creating patterns of negative Self-evaluation. Fourteen of our articles discussed self- internal dialogue that made it difficult for them to make mean- evaluation as we defined it, with a specific focus on first-/ ing of their situations. Eleven articles discussed the impact of second-order constructs of self-awareness and recognizing one’s internal dialogue as we defined it. Common internal one’s potential. Self-awareness included recognition of the reactions survivors had to their experiences included self- physical and/or mental health consequences stemming from blame, feelings of failure, feelings of weakness, and blaming the abuse they experienced (Flasch et al., 2017) as well as God. As mentioned above, by processing their trauma and recognizing one’s tendencies and healing needs going forward. reexamining their experience, survivors were able to start the Self-awareness was often facilitated by self-reflection, process of letting go of this dialogue. enabling survivors to “connect with their emotions, appreciate Distressing emotions. Emotions that were important to survi- themselves and the things around them, and identify what was vors to manage focused on cumulative negative feelings expe- working for them and what their needs were going forward” rienced after the abuse, impacting one’s ability to function in (Sinko, Munro-Kramer, et al., 2019, p.12). Through an honest society or connect with others. Fourteen articles discussed assessment of self, others, and events, survivors learned to managing distressing emotions as we defined it. Common emo- discover the realities of the self (Farrell, 1996), enabling them tions included feelings of shame, fear, worry, anger, sadness, to discover the areas they would like to grow and improve upon hopelessness, guilt, confusion, and self-doubt. Interestingly, for as they journeyed toward healing. By growing self-aware, par- some participants, recognizing that it was okay to have these ticipants were able to chart negative and positive changes in feelings and that allowing themselves to feel negative emotions their lives (Barnes, 2013), define their own landmarks (Duma aided in their recovery. For example, one woman stated, et al., 2007), gradually recognize their imperfections, and feel “ ...And I saw my friend being angry and somehow I felt it comfortable in different situations (Hou et al., 2013). This laid was okay for me to be angry ...recovery for me ...staring the foundation to enable people to recognize their potential and down my assailant and expressing my anger” (Smith & Kelly, visualize a path toward healing. 2001, p. 345). Thus, although these emotions were typically Self-evaluation also consisted of recognizing one’s own viewed as challenging, expressing these feelings also aided in potential, which often catalyzed feelings of self-efficacy and the healing process. hope. As Farrell (1996) reflected, “increased self-awareness provided the fuel for flexibility, enhancing the individual’s Trauma reactions and symptoms. Sixteen articles addressed capabilities to be self-sustaining and resulting in a broader the impact of trauma reactions and symptoms on survivor perspective of life as a whole beyond the limited view of life well-being. These reactions and symptoms included isolation, created by the abuse” (p. 28). Some found their potential negative self-concept, powerlessness, lack of trust, hypervigi- through reflecting back on what was lost. This could motivate lance, and flashbacks. Others experienced more clinical post- individuals to engage in active strategies in reclaiming those traumatic stress, depression, or anxiety symptoms that 12 TRAUMA, VIOLENCE, & ABUSE XX(X) interfered with their day-to-day life. As one article reflected: Saint Arnault, 2019). In order to do this, survivors needed to “for most participants, recovery also meant being free from the “recognise one’s own positive aspects and strengths” trauma symptoms associated with the experience and being (Glumb´ıkov´a & Gojov´a, 2019, p. 7). This often involved con- able to ‘move on with [their] life without having anxiety sultations with professionals to ensure they were “doing the attacks, nightmares, flashbacks’” (Ranjbar & Speer, 2013, right thing” (Hou et al., 2013, p. 164), however, some were p. 279). Living a life not dominated by mental health struggles able to do it on their own. allowed survivors to feel more optimistic about their healing moving forward. Renewing the spirit. Sixteen articles addressed this construct Some studies addressed trauma reactions that we termed as we defined it, with a specific focus on first-/second-order “survival strategies” that survivors engaged in as they constructs listed in the definition. In order to do this, survivors attempted to survive and cope with their GBV experience. In identified “refocusing their energy, time, and thoughts” (Crann 11 articles, authors discussed survival strategies as we defined & Barata, 2016, p. 864) to build feelings of “lightness, serenity, it. For example, some women utilized substance use and self- peace, and calm” (Sinko, Burns, et al., 2019, p. 12). Survivors injury to help manage their pain (e.g., Glumb´ıkov´a & Gojov´a, of the genocide in Rwanda, in which GBV played a significant 2019; Matheson et al., 2015; Sinko, Munro-Kramer, et al., role, used the phrase “Kwongera kubahonow” to describe this 2019; Sinko & Saint Arnault, 2019). Others discussed discon- process, which allowed survivors to “feel there is peace in you, necting from their body and/or emotions as a means of protec- on your body and inside in your heart you feel there is peace tion (disembodiment; e.g., Matheson et al., 2015; Sinko & and you have means to develop yourself in order to live” (Zraly Saint Arnault, 2019). While survival strategies such as these & Nyirazinyoye, 2010, p. 1660). Survivors engaged in a variety may have been necessary for a period of time, letting go of of activities to renew their spirit including reading, exercise, these habits and replacing them with more sustainable outlets gardening, writing, spending time with their children, and was important to survivors for long-term recovery. religion.

Rebuilding the self. Rebuilding the self consisted of three second- order constructs: identity construction, improving self-concept, Connecting with others. Connecting with others consisted of two and renewing the spirit. Regaining a sense of their “true selves” second-order constructs: letting people in and building support was an important goal to survivors, as many reflected that their networks. By relating and being authentic with others, individ- GBV experiences caused them to need to “start from scratch” uals were better able to find support, build, and maintain impor- (Sinko, Burns, et al., 2019) due to their symptom burden, com- tant relationships in their life and feel less alone. plex trauma, and shifts in worldviews. In order to rebuild, survivors needed to both accept the things about themselves Letting people in. Seventeen articles addressed this construct they could not change, while also embracing curiosity to learn as we defined it. While this did not always mean being open to more about themselves and their needs. everyone about their abuse experiences, it did recognize that survivors should not need to face their recovery alone (Sinko & Identity construction. Eighteen of our articles addressed Saint Arnault, 2019). Talking about the experience, particularly rebuilding the self as we defined it, with a specific focus with people who “wants to know her story and the person on first-/second-order constructs of self-discovery, self- behind the story” was found to be exceptionally validating on acceptance, and recognition of potential. One of the partici- the journey to recovery (Matheson et al., 2015, p. 566). Letting pants in the Matheson et al. (2015) article described it this way, people in may also have other benefits, including learning “I was like a sponge just soaking every knowledge and infor- about others survivorship experiences and hearing views which mation that I could. Now I have so much self-respect for may cause the survivor to look at their experience in a different myself. Self-morals. Self-values. Dignity. Pride. Self-confidence” way (Thompson, 2000). While some participants stayed silent (p. 565). about their experiences, we identified a consensus in the body Improving self-concept. Seventeen articles addressed this con- of articles reviewed that disclosure to at least one supportive struct as we defined it, with a specific focus on the first-/ personal or professional relationship can encourage the survi- second-order constructs mentioned in the definition. Six vor during difficult stages of the process and combat feelings of articles included mentions of improving self-worth (Flasch self-blame. et al., 2017; Heywood et al., 2019; Hou et al., 2013; Matheson Foundational to letting people in is the development of trust, et al., 2015; Sinko & Saint Arnault, 2019; Sinko, Burns, et al., discussed specifically in 10 of the articles reviewed (indicated 2019), improving self-esteem was mentioned in five articles by * in Table 2). As Farrell (1996) said, “trust involved belief in (Ahmad et al., 2013; Crann & Barata, 2016; dos Reis et al., the self and others, allowing the women to let go of the pro- 2016; Flasch et al., 2017; Glumb´ıkov´a & Gojov´a, 2019; Hou tective walls that isolated them from others” (p. 30). Rebuild- et al., 2013; Matheson et al., 2015; Smith, 2003; Thompson, ing trust for themselves and others allowed survivors to be 2000), and five articles addressed building competence and/or better able to connect with them and form new lasting relation- mastery (Glumb´ıkov´a & Gojov´a, 2019; Hou et al., 2013; Sinko, ships, requiring patience, compassion, and understanding Burns, et al., 2019; Sinko, Munro-Kramer, et al., 2019; Sinko & (Flasch et al., 2017). Sinko et al. 13

Building support networks. Twenty articles addressed this about their problems and helped them regain feelings of con- construct as we defined it, with a specific focus on second- fidence and competence. Reinforcing feelings of competency order constructs of validation, belonging, and community. As was important to survivors, as it allowed them to prevent the mentioned previously, survivors often needed a balance of violence from “destroying their lives” (dos Reis et al., 2016, personal and professional support, providing education to p. 2357) and instilled beliefs that they could effectively manage allow them to see their experience differently, while also help- their external world on their own (Sinko, Burns, et al., 2019). ing them recognize that they do not need to do it alone (Sinko, Outside of personal activities, survivors were also able to Burns, et al., 2019). embrace freedom through “refocusing their energy, time, and Specific elements of belonging and community as one thoughts” (Crann & Barata, 2016, p. 864). Some women did builds their support network were discussed in nine articles this through using their freedom to focus on caring for them- (indicated by * in Table 2). Like letting people in, finding selves and their children, while others simply tried to focus on belonging was often intertwined with the actions and responses the present and enjoy each day (Crann & Barata, 2016). Edu- of others, creating supportive environments which allowed sur- cation was also another way women enabled a new life course, vivors to feel accepted or, if nothing else, distracted from their by pursuing knowledge, reconnection with the world, and a trauma responses. People found belonging in their personal strengthened and empowered identity (Oke, 2008). Ultimately, relationships, through meeting others who had similar experi- feeling able to embrace freedom without fear allowed survivors ences, and engaging in community activities (e.g., volunteer- to take risks and make mistakes in pursuit of their goals and ing, activism, faith, leisure groups, school events). While not aspirations. all individuals became connected with other GBV survivors, Finding purpose. Seventeen articles addressed this construct those who did seemed to greatly benefit from it, with one article as we defined it, with a specific focus on second-order con- calling those connections “perhaps the most important informal structs of achievement, helping others, and advocacy. Personal network” survivors engaged in (Lewis et al., 2015, p. 389). No achievement in education and work life was often a vehicle in matter where survivors ended up finding their place within the which women felt able to take care of themselves and push community, establishing an environment that fosters connec- against the gender norms of their societies (Sinko, Burns, tions with others allowed survivors to escape from their trauma, et al., 2019; Sinko & Saint Arnault, 2019). Additionally, being develop empathy, help others, and find purpose (Oke, 2008). engaged in paid or voluntary work, particularly in spaces that helped others, enabled a sense of purpose, connection with Regaining hope and power. Regaining hope and power consisted others, and potentially income (Oke, 2008). Directly interfa- of embracing freedom, finding purpose, and building hope. cing with other survivors was another way purpose was found. This required a critical awareness of the survivor’s individual For example, in one study, nearly half of the women shared a autonomy and potential, allowing survivors to develop increas- feeling of reciprocity through “helping other women in similar ingly positive perspectives about their future by focusing on situations by providing emotional support and/or assisting oth- what they wanted to achieve for themselves (Ahmad et al., ers with finding employment or training to enhance work 2013). By looking toward the future and finding meaningful skills” (Ahmad et al., 2013, p. 1061). Another study described fulfillment in their lives, survivors were able to build a future this as “cohesion tension” which involved a sense of duty to the that works for them separate from their abuse experiences. greater good of the community either through volunteerism or advocacy (Crann & Barata, 2016). In families with transge- Embracing freedom. Eighteen articles addressed this con- nerational abuse, some women expressed a desire to channel struct as we defined it. Particularly in situations with ongoing their desires to help the community through raising their chil- abuse that exerted power and control over survivors, embracing dren (particularly boys) with a norm of gender equality to stop freedom was an important step of regaining hope and power by the cycle of violence (Ahmad et al., 2013; Sinko, Burns, et al., illuminating a new reality for them and reminding survivors 2019). While not all women directly engaged in the survivor that they have the choice to direct their own lives (Flasch et al., space, those who did expressed a sense of justice through being 2017). Survivors of genocide in Rwanda used the phrase guko- a part of a movement to end violence and oppression (Crann & meza ubuzima to describe this concept, conveying a sense of Barata, 2016). willingness, effort making, or participation in one’s own life, despite one’s experiences (Zraly & Nyirazinyoye, 2010). New- Building hope. Fourteen articles addressed this construct as found freedom and empowerment yielded a powerful journey we defined it. Building hope allowed survivors to envision of self-discovery, allowing survivors to figure out who they themselves actively in the world and in their lives (Taylor, would be happy as and how they could reinvent themselves 2004). This frequently co-occurred with the idea of future (Heywood et al., 2019). orientation (Glumb´ıkov´a & Gojov´a, 2019) and challenged sur- One way survivors embraced their freedom was through vivors to approach opportunities with a commitment to oneself. engaging in daily activities (e.g., keeping oneself busy, spend- By anticipating new relationships, the possibility of furthering ing time with friends, learning a language, learning job skills, their education or career, among other things, survivors felt volunteering, engaging in hobbies; Ahmad et al., 2013). Survi- better able to overcome suffering (dos Reis et al., 2016). One vors felt that these activities distracted them from ruminating article described a “shift to positivity” allowing survivors to 14 TRAUMA, VIOLENCE, & ABUSE XX(X) acknowledge progress in their lives (Crann & Barata, 2016). and labeling the abuse in the healing process. Other articles Hope as a motivator for survivors to continue on the path of included discussion of the importance of sharing the secret healing despite hardship (Farrell, 1996) was essential to recov- abuse with trusted family and friends as an important start to ery (Lewis et al., 2015). Hope of healing or of a safer world the healing process (Duma et al., 2007; Flasch et al., 2017; allowed survivors to propel forward when they felt stuck in Taylor, 2004). their recovery process (Sinko, Burns, et al., 2019). One survi- External motivations. External motivations were defined as vor described it in this way: recognizing others in a survivor’s life who were impacted by their “lack of” recovery, and using that as motivation to start Well, I’d say someone who’s thriving ...they’ve got more of a positive outlook or not even just positive, but being able to see their process. Four articles addressed external motivations as further into the future and have a long-term plan whereas when we defined it. In all of these articles, external motivation was you’re not thriving, you are just surviving, you’re not looking long- discussed in the context of protection for one’s children term you’re just looking to get through the here and now. (Hey- (Ahmad et al., 2013; Matheson et al., 2015; Smith, 2003; wood et al., 2019, p. 6) Taylor, 20041), however, other external motivations were also mentioned. For example, Taylor (2004) also discussed external motivations related to how their silence was harming their Turning points. An important element discussed in the articles community. While external motivators helped survivors recog- were turning points or things that contributed to turning points. nize that a change needed to be made, it is important to also Turning points were defined as moments that propelled survi- recognize the continued internal perseverance that was neces- vor healing forward and for many, encouraged them to begin sary to continue the healing process when these motivators working toward recovery. While some turning points over- were no longer relevant. lapped with healing themes, the examples mentioned below were specifically mentioned by survivors in the studies synthe- Social support/pressure. Social support/pressure was defined sized as critical moments that promoted recovery engagement. as encouragement and support from others to make decisions to Turning points consisted of significant low points, trauma rec- benefit themselves and/or others. Eight articles addressed ognition and speaking out, external motivations, and social social support/pressure as we defined it. Many women dis- support/pressure. cussed how having supportive family and friends pushed them to heal (Duma et al., 2007; Smith, 2003; Smith & Kelly, 2001), Significant low points. Significant low points occurred when allowing participants to let go of self-blame (Crann & Barata, women could no longer avoid their pain and thus began think- 2016) or encouraging participants to seek help (Sinko & Saint ing about how they might relieve their suffering. Glumb´ıkov´a Arnault, 2019). Social support and pressure held survivors and Gojova´ (2019) describe it as “hitting rock bottom.” accountable for their actions and encouraged them to begin “Hitting rock bottom is characterised as a moment when noth- engaging in help-seeking behavior. ing seems to make any sense. It is a moment of total disempo- werment and maximum hurt. Hitting rock bottom is the moment when one cannot get any further down” (p. 5). There A Metaphor for Healing: Weaving Life’s Tapestry were many examples of significant low points women experi- With Knotted Silk enced that catalyzed their healing throughout the five articles We use the image of weaving a tapestry with knotted silk to that highlighted this. For some women, the low point was when describe what healing may look and feel like for survivors the participant was in imminent danger (Lewis et al., 2015; based on our synthesis results. The creation of a metaphor is Oke, 2008). Recognizing this imminent danger also was often typical in qualitative meta-ethnography, although we take a the motivating factor for women to leave the relationship. For more visual approach (see Figure 2). other women, the significant low point was recognizing the We visualize survivors as a spool of silk thread, weaving the impact the experience was having on their everyday lives tapestry that is their life. When a GBV event happens, it can (Smith & Kelly, 2001) or realizing they do not deserve to be have a great impact on the integrity of their thread, unraveling treated that way (Smith, 2003). While the low point may be it and creating kinks and knots along the once smooth strands. different person to person, these experiences encouraged sur- At first, the survivor may think they can continue using this vivors to reach out and seek help, starting their healing journey. thread to build the tapestry they envisioned. The survivor has in Recognition and speaking out. Recognition and speaking out their mind what they have woven before and what they want was defined as acknowledging and labeling experiences as their tapestry to eventually look like and become. They may abuse and/or sharing secrets of abuse with selected, trusted therefore try to continue on weaving despite the knots, but family or friends. Five articles addressed this as we defined eventually smaller knots may become bigger knots and it feels it. A participant in the study by Flasch et al. (2017) stated, “The impossible to move forward without addressing them. While biggest hurdle (and most rewarding triumph was when I ‘came the survivor may recognize this, false starts can occur, and out’ as a survivor .... I no longer have to hold my secrets and frustration may push them to put their tapestry away for a while let them distill into shame” (p. 3386). Ranjbar and Speer (2013) because starting over is just too hard. Then, a shift happens, and Thompson (2000) discussed the importance of recognizing where the survivor recognizes that untangling the knots is Sinko et al. 15

catalyzed healing prioritization. These results have built a framework for discussing GBV healing with women survivors as well as revealed important discrepancies and gaps in the literature on this topic. While our findings have some overlap with concepts in the resilience and posttraumatic growth literature, our analysis reveals important nuances related to GBV trauma recovery that may warrant specific attention. For example, important sub- concepts of posttraumatic growth include relating to others, new possibilities, personal strength, and appreciation of life (Tedeschi & Calhoun, 1996). While some of our synthesized themes overlap with these concepts, particularly with relating to others and new possibilities, this concept is missing impor- tant facets of GBV recovery: processing one’s trauma experi- ences and reexamining the GBV situation, managing negative states, rebuilding one’s relationship with themselves, and developing feelings of freedom and power. Similarly, while resilience has been measured in different ways throughout the scientific literature, it conceptually focuses more on evaluating Figure 2. Healing after gender-based violence: a metaphor of weaving one’s ability to bounce back from adversity, rather than how knotted silk. one might bounce back. For example, the Connor–Davidson (2003) Resilience Scale captures the domains of personal com- unavoidable and necessary in order to move forward. For some, petence, trust/tolerance/strengthening effects of stress, accep- this turning point happens sooner than others. This causes the tance of change and secure relationships, control, and spiritual survivor to refocus on starting anew. influences. The inability of these measures to capture the full Whether it is alone or with the help of a loved one or pro- domain of healing after GBV is not surprising, as these con- fessional, the survivor begins to address each knot, and as they cepts were initially created to understand healing from trauma do the knots grow smaller. Some even disappear completely. and adversity generally. Interpersonal traumas (i.e., trauma that This process requires active engagement and patience. Some- occurs as a result of actions by another person), particularly times as the survivor attempts to untangle, they uncover even GBV, may require additional healing considerations due to the bigger knots. These knots may be too big to untangle on their fact that their experience of violence was an intentional viola- own, and they may need the help of trusted others or profes- tion of bodily autonomy perpetrated by another person. These sionals to get through that section of thread. They may also nuances can be demonstrated by quantitative evaluations com- need others to work side by side with them as they untangle or paring these outcomes by trauma type. For example, may need encouragement as they continue to do it on their own. Shakespeare-Finch and Armstrong (2010) found that survivors Other times, they may just need a distraction from the untan- of sexual assault had greater difficulty relating to others, appre- gling so that they have the strength to rest to go back to it. ciating life, and higher rates of post-traumatic stress disorder Through this process, the survivor is eventually able to look compared to survivors of motor-vehicle accidents and those in inward, recognizing they have all the tools necessary to rebuild, bereavement. Outside of these growth concepts, the majority of but just have lost sight of the path and where they left off. quantitative studies to date have used mental health outcomes Ultimately, regaining their vision for what their tapestry will and symptom checklists as a proxy for recovery (see Linhorst look like and actualizing that vision allows them to create & Beadnell, 2011; Ahrens et al., 2010, for examples). Our something beautiful and new, inspiring others they encounter review reveals the need for more survivor-centered and holistic to continue their own weaving. Our tapestries tell a story. It outcome measurements to better evaluate the efficacy of inter- depicts all that we are: strengths, triumphs, and traumas. ventions in this population as well as expand survivor-driven recovery ideas to future quantitative studies. Our finding that healing goals did not substantially differ Discussion qualitatively by GBV type or severity may seem surprising on In this review, we synthesized qualitative literature to date the surface but has been verified by some quantitative studies describing the healing process after GBV from the perspectives (e.g., Abrahams et al., 2013). This could be explained by the of women-identifying survivors. While the relationships importance of the centrality of one’s GBV event, defined as between these themes will need to be tested in future research, “the degree to which an individual believes a [GBV] event has healing was found to be composed of (1) trauma processing and become a core part of their identity” (Boals, 2010, p. 107), reexamination, (2) managing negative states, (3) rebuilding the which may be a better predictor of psychological distress and self, (4) connecting with others, and (5) regaining hope and healing than the actual GBV event itself in this population. The power. “Shifts” or “turning points” were also explored which centrality of one’s event has been found to be a unique 16 TRAUMA, VIOLENCE, & ABUSE XX(X)

Table 4. Implications for Practice, Policy, and Research.

Practice Understand and promote recovery beyond the alleviation of mental and physical health symptoms implications Interventions to promote key ingredients of the process: active recovery Engagement, patience with setbacks Infrastructure to promote trauma recognition and disclosure, key turning points found Importance of finding purpose and fulfillment in survivors could call for more tailored career and volunteer opportunities through community organizations Policy implications Laws that take away voice and choice from survivors (i.e., mandatory reporting of violent crimes in health care depending on state mandates) may inhibit recovery by taking away autonomy, control, and choice Trauma and violence informed care to ensure therapeutic interactions with survivors Research Exploration into relationship of identity to recovery needs implications Exploration of contexts that promote and inhibit healing are important to understand how to create environments where survivors can flourish Alternative trauma recovery pathways and mechanisms of healing Need for better gender-based violence (GBV) recovery measurement for quantitative studies GBV healing in men, transgender, and nonbinary individuals predictor of posttraumatic growth above and beyond one’s survivors of GBV to understand and promote recovery beyond trauma history and mental health burden in quantitative studies the alleviation of adverse mental and physical health symp- (Boals & Schuettler, 2010; Groleau et al., 2013; Sinko et al., toms, as managing negative states was mentioned as only one under review). Hence, assessing for the centrality of one’s facet of survivor’s recovery desires. Additionally, interventions GBV experience in the service setting may promote greater to promote active recovery, reexamination and self-evaluation, understanding of one’s healing trajectory than current assess- and patience when setbacks arise may be important for GBV ments alone, which tend to focus solely on the number or type survivors, particularly at the start of one’s healing journey. In of trauma events experienced (e.g., Felitti et al., 1998; Hooper the policy realm, it is interesting to note that no survivors et al., 2011). mentioned the concept of justice as a part of their recovery Turning points that promoted recovery engagement journey. While this could be for a number of reasons, it may revealed in this study consisted of significant low points, because the needs and wishes of survivors have often been trauma recognition and speaking out, external motivations, and found to be “diametrically opposed to the requirements of for- social support/pressure. These findings were verified by a mal legal proceedings’’ (Herman, 2005) and many who have recent review on recovery after intimate partner violence gone through the process have been disappointed by their lack (Flasch, 2020) in which the authors discovered similar of control or voice in the process (Ju¨lich, 2006; McGlynn et al., recovery-facilitating elements of informal and formal social 2012). While this may or may not be the reason justice was not support and relationships, resources and education, and social mentioned, it does warrant questioning of many current state action and advocacy. The influencing role of significant low policies mandating certain professions (i.e., health care provi- points has been discussed at length in the intimate partner ders) to report violent crimes despite survivor wishes (Jacoby violence literature related to reasons for leaving relationships et al., 2018). This directly takes power and control from survi- (e.g., Enander & Holmberg, 2008) and help-seeking vors, an important aspect of the process mentioned by those (Oyewuwo-Gassikia, 2020), however few studies have interviewed through the studies reviewed. There are also many described its relationship with recovery engagement. Finally, implications of this review that can be expanded to future the most significant external motivation found in this study that research studies. First, given the importance of identity and the catalyzed recovery was a desire to protect one’s children or “self” in these findings, intersectional exploration of the role of serve as a better caretaker for one’s children. While this has identity in healing is needed, particularly for communities that been referenced in GBV studies (i.e., Katz et al., 2015; Rasool, have experienced compounded historical trauma or face unique 2016), one’s children may also influence one’s desire to stay in challenges to accessing services. Additionally, healing does not an abusive relationship or to not seek help for their feelings and occur in a vacuum and exploring the relationship of culture and symptoms (Rasool, 2016; Williams et al., 2020). This reveals context in relation to reaching one’s healing goals will be the potential importance of incorporating children or other rel- important to understand how structural violence and social evant family members into healing interventions to allow for a norms may impact this process. In particular, individuals who more survivor-centered approach, leveraging the trusted bonds experience GBV at the hands of someone they know more that already exist within their social network. intimately, or those who experience institutional betrayal in the aftermath of their experiences, may face unique challenges to recovery which warrant further exploration (see betrayal Implications for Practice, Policy, and Research trauma theory; Freyd, 1996, 2008; Freyd et al., 2005). While Implications for practice, policy, and research can be seen in some authors of the articles reviewed noted that there may be Table 4. To summarize, it is important for those who work with differing pathways to recovery (e.g., Crann & Barata, 2016), Sinko et al. 17 these pathways have not been well described. Further investi- References gation is needed to understand contributing factors of these Abrahams, N., Jewkes, R., & Mathews, S. (2013). Depressive symp- healing differences as well as mechanisms of recovery. Finally, toms after a sexual assault among women: Understanding victim- as stated above, improved measurement to evaluate recovery is perpetrator relationships and the role of social perceptions. African needed to provide a better baseline and subsequent follow-up as Journal of Psychiatry. https://doi.org/10.4314/ajpsy.v16i4.39 survivors engage in treatment. Ahmad, F., Rai, N., Petrovic, B., Erickson, P. E., & Stewart, D. E. (2013). Resilience and resources among South Asian immigrant Limitations women as survivors of partner violence. Journal of Immigrant and There are limitations to this review that are important to keep in Minority Health, 15(6), 1057–1064. https://doi.org/10.1007/ mind when interpreting our findings. Only articles written in s10903-013-9836-2 English were included, so healing processes discussed in other Ahrens, C. E., Stansell, J., & Jennings, A. (2010). To tell or not to tell: languages may have been missed. Additionally, despite work- The impact of disclosure on sexual assault survivors’ recovery. ing with a library scientist, there is a chance some studies that Violence and Victims, 25(5), 631–648. https://doi.org/10.1891/ met our inclusion criteria were not picked up by our search 0886-6708.25.5.631 strategy. Thus, some relevant aspects of GBV survivors’ lived Allen, K. N., & Wozniak, D. F. (2010). The language of healing: experience may not be fully captured through this review. We Women’s voices in healing and recovering from domestic vio- additionally did not include males in our study and no articles lence. Social Work in Mental Health, 9(1), 37–55. https://doi.org/ came up in our review processes that discussed healing in 10.1080/15332985.2010.494540 transgender and gender nonconforming individuals. Therefore, Anderson, K. M., Renner, L. M., & Danis, F. S. (2012). Recovery: future research is needed to understand the unique healing Resilience and growth in the aftermath of domestic violence. journeys and challenges of these communities. Healing may Violence Against Women, 18(11), 1279–1299. https://doi.org/ also vary across cultures, although we did include English 10.1177/1077801212470543 studies from all countries that met our inclusion criteria. Barnes, R. (2013). “I’m over it”: Survivor narratives after woman-to- Finally, although we sought to describe the recovery process woman partner abuse. Partner Abuse, 4(3), 380–398. https:// for those who experienced GBV, the included articles did not doi.org/10.1891/1946-6560.4.3.380 always provide context to a specific order for the healing Boals, A. (2010). Events that have become central to identity: Gender themes experienced. Therefore, we could not expand on the differences in the centrality of events scale for positive and nega- potential order the themes may occur in. Future research would tive events. Applied Cognitive Psychology: The Official Journal of benefit from examining if there is a specific, chronological the Society for Applied Research in Memory and Cognition, 24(1), order of the healing process. Despite these limitations, this 107–121. https://doi.org/10.1002/acp.1548 review provides an important foundation to understand and Boals, A., & Schuettler, D. (2011). A double-edged sword: Event promote recovery in women survivors of GBV. Understanding centrality, PTSD and post-traumatic growth. Applied Cognitive recovery from the survivor perspective is important to ensure Psychology, 25, 817–822. https://doi.org/10.1002/acp.v25.5 our research, policy, and practice is survivor-centered and pro- Bondas, T., & Hall, E. O. (2007). Challenges in approaching meta- motes recovery for all survivors. synthesis research. Qualitative Health Research, 17(1), 113–121. https://doi.org/10.1177/1049732306295879 Acknowledgments Bonomi, A. E., Anderson, M. L., Reid, R. J., Rivara, F. P., Carrell, D., & Thompson, R. S. (2009). Medical and psychosocial diagnoses in The authors want to thank the survivors interviewed through the arti- cles identified who trusted the scientific community with their stories women with a history of intimate partner violence. Archives of of pain, hope, and healing. Internal Medicine, 169(18), 1692–1697. https://doi.org/10.1001/ archinternmed.2009.292 Campbell, R., Pound, P., Morgan, M., Daker-White, G., Britten, N., Declaration of Conflicting Interests Pill, R., Yardley, L., Pope, C., & Donovan, J. (2011). Evaluating The author(s) declared no potential conflicts of interest with respect to meta-ethnography: Systematic analysis and synthesis of qualitative the research, authorship, and/or publication of this article. research. https://doi.org/10.3310/hta15430 Connor, K. M., & Davidson, J. R. (2003). Development of a new resi- Funding lience scale: The Connor-Davidson Resilience Scale (CD-RISC). The author(s) disclosed receipt of the following financial support for Depression and Anxiety, 18(2), 76–82. https://doi.org/10.1002/ the research, authorship, and/or publication of this article: The authors da.10113 would like to acknowledge the National Clinician Scholars Program Crann, S. E., & Barata, P. C. (2016). The experience of resilience for for supporting the research effort of the first author. adult female survivors of intimate partner violence: A phenomen- ological inquiry. Violence Against Women, 22(7), 853–875. https:// ORCID iDs doi.org/10.1177/1077801215612598 Richard James https://orcid.org/0000-0003-1672-0259 Critical Appraisal Skills Programme (2018). CASP qualitative check- Kathryn Hughesdon https://orcid.org/0000-0003-3025-6317 list. https://casp-uk.net/casp-tools-checklists/ 18 TRAUMA, VIOLENCE, & ABUSE XX(X)

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Wuest, J., & Merritt-Gray, M. (2001). Beyond survival: Reclaiming these processes. She is interested in leveraging creative research meth- self after leaving an abusive male partner. Canadian Journal of odologies to bridge the gap between survivor lived experience, the Nursing Research Archive, 32(4). scientific community, and policy makers. Zraly, M., & Nyirazinyoye, L. (2010). Don’t let the suffering make you fade Richard James, MSLIS, is the nursing librarian for the University of away: An ethnographic study of resilience among survivors of genocide- Pennsylvania Biomedical Library. He is a patient/family research rape in Southern Rwanda. Social Science & Medicine, 70(10), partner with several national pediatric cardiology advocacy, support, 1656–1664. https://doi.org/10.1016/j.socscimed.2010.01.017 and research groups concerned with identifying and ameliorating the effects of iatrogenic medical trauma, a PCORI Ambassador, and is interested in infusing trauma-informed care into nurse education. Author Biographies Kathryn Hughesdon, PhD, RN, is an assistant professor at the School Laura Sinko, PhD, RN, is a practicing sexual assault nurse examiner of Nursing, Eastern Michigan University. Her research focuses on and National Clinician Scholar at the University of Pennsylvania. Her improving mental health outcomes in those exposed to trauma, with research focuses on promoting gender-based violence recovery across a specific focus on childhood trauma. She is interested in implement- the life span, particularly understanding sociostructural influences of ing trauma-informed care into nursing practice.