Patricia Evans estimates that she has spoken with more than 45,000 people, 97 percent of them women, who have dealt with severe verbal abuse by a partner.

The phrases and speech patterns used by their abusers — insults such as "lazy" and "stupid," statements ("That never happened" or "I never did that") meant to distort past events, and accusations that slowly isolate them from family and friends — were strikingly similar. As opposed to a bad-tempered partner or someone who occasionally says something cruel and then apologizes, verbal and emotional abusers engage in abuse over years and decades, convincing the victim she's at fault, finding ways to cut off her emotional or financial support, and slowly "erasing her consciousness," as Evans, an expert on domestic abuse, put it.

"We definitely see this as an epidemic," said Cameka Crawford, a spokeswoman for the National Domestic Violence Hotline, an advocacy group based in Austin. "It doesn't happen overnight. It's gradual and continues to happen for years."

The Office on Women's Health, part of the Department of Health and Human Services, lists 11 signs of emotional, or nonphysical, abuse, including humiliating victims, monitoring what they are doing, discouraging them from seeing friends or relatives, constantly accusing them of cheating, and telling them what to eat or wear. The Justice Department's Office on Violence Against Women adds "name-calling" and "constant criticism." Crawford's group adds: trapping a victim in her home, blaming her for the abuse, damaging objects, threatening to hurt loved ones or pets, and "gaslighting" (distorting the victim's reality by, for example, denying past events or saying the abuse is "all in your head").

None of these actions involve physical abuse, but they can be severely harmful. The Office on Women's Health notes, "Attempts to scare, isolate, or control you also are abuse. They can affect your physical and emotional well-being. And they often are a sign that physical abuse will follow."

The Domestic Violence Hotline — which has received more than 4 million calls since 1996 — says that while 58 percent of the calls, emails and texts it received in 2016 involved physical violence as one component of the call, 84 percent of those 323,000 contacts involved emotional or verbal abuse.

"Domestic abuse is about an imbalance of power and control," Crawford said. "One person tries to control the other using lots of different tactics to keep the power over them in the relationship."

Jeanne King, a psychologist who has specialized in domestic abuse since 1999, said she often gets calls from women or men who reach out only after years of emotional abuse turn physical.

"It's the physical abuse that helps them wake up to what's happening," she said. "If you're dealing with intimate-partner violence, you are usually coming in with lots of exposure to emotional abuse, verbal abuse and often financial abuse.

"The potential for it to become physical is often there, but it doesn't always happen. I've had people say, 'I don't hit my wife. I'm above that. I'm a CEO, I'm a physician, I'm an attorney; that's beneath me.' But they'll keep their partner in a room, block the door, prevent their partner from leaving. They're violating their rights without putting their hands on them."

Evans said some verbal abusers never use physical violence "because they know hitting means jail." But they engage in demoralizing or trivializing behavior, such as deciding for their partner what they should think, feel or want, saying such things as "You're not really hurt" or "You just want to argue."

A woman in her 50s living in California, who spoke on the condition that she not be identified by name, said it took two decades to leave her abusive marriage. She met her husband when they were in their late 20s. They had mutual friends, and she said he struck her as easygoing and "comfortable to be with."

But when they returned from their honeymoon, things took a dark turn. She said he would rage at her for up to an hour at a time, calling her names, such as "lazy," "stupid" and "dumb," wag his finger in her face, say she was the "worst mother," and threaten to leave her with no money and take away their child. Most frighteningly, some of this raging occurred while they were in the car, and he was driving. During their last year of marriage, she said, he started holding her down when he was yelling, claiming he had to do that "because I don't listen." By the time she filed for divorce, she felt scared, twisted and "devastated," with no self-esteem. She felt better only when she read a book about verbal abuse.

Crawford and King said that if a person recognizes abuse and is not in immediate danger, the first thing to do is get educated — by contacting the hotline, finding a domestic-violence group or reading about the issue online.

Surprisingly, the hotline and other experts recommend against marriage counseling for an abusive situation. They say marriage counselors focus on a 50/50 split of responsibility to improve the marriage rather than addressing the fact that one person is abusing the other. Also, the abuser may manipulate the counselor or become enraged later about what happened in the session.

"Both parties need to feel safe during the sessions," Crawford said. "A lot of the time, the victim doesn't feel safe and is worried about retaliation. Oftentimes what can happen is, couples can go in and the couple presents one way in the session, so the counselor is unaware of how the abuse is occurring. So they may provide feedback inadvertently that allows the abuse to escalate."

Crawford said that abusive partners who want to change could enter a program to address their behavior, particularly a "battering intervention and prevention program."

King said: "Marital therapy is not recommended when there's domestic violence. That's pretty much standard in the literature. The reason is that marital therapy is based on a systems approach, which means you spread the responsibility across the system, but that's the very thing that supports the abuse dynamic."

She said that it takes years of training and experience to understand the abuse dynamic. As a clinical psychologist trained in domestic violence, she sees couples together, but she also meets with the individuals separately. She calls what she does "domestic-abuse intervention in the context of relationship therapy."

Evans said: "Marriage counseling does not work if the therapist is trained to see it as 50/50. Every day I hear from women who go to marriage therapy and are told, 'Can you be sweeter? Try harder and he'll try, and everything will be fine.' Abuse is not 50/50."

Sandra Stith, a licensed marriage counselor and professor of family studies and human services at Kansas State University, has developed counseling programs for couples in certain types of abusive relationships.

She said that graduate students in psychology are learning more about domestic violence than was taught decades ago, so there may be couples therapists who can help, but they must be well educated in domestic violence. She said a good counselor should be trained to screen for domestic abuse, thus determining early whether couples counseling is appropriate. Also, someone seeking help with a domestic abuse situation should ask therapists, "Do you have experience in this area, or can you refer me to someone who does?"

Stith agrees that a caller to the hotline should probably not be referred to couples counseling as a first response. "If you're in a situation in which you call the hotline, you likely need to talk to a ­domestic-violence expert who hopefully will work on a coordinated community response," she said.

Not everyone who recognizes emotional abuse wants to end the marriage immediately. Some may hope the abuser will change. And some don't want to share custody of young children or may not have the financial or familial resources to leave.

Evans said whether an abusive partner can change depends on many factors, including his desire to not want his partner to leave or to want her back if she has left, and how hard he is willing to work. King said the reasons behind the abuse matter in terms of treatment, too. There's no one psychiatric diagnosis or situation that explains why some people are abusive. Some may suffer from trauma or have a mental-health issue, such as a mood disorder, addiction or a personality disorder.

Crawford said education about emotional abuse is important. "People are just starting to have more of a conversation about it," she said. "What I've seen just in the last three years at the hotline, there used to be a lot of conversation and questions that placed blame on the victim, such as 'Why do they stay?' Now more conversations are about 'What are some of the signs?' The questions we're getting are about the complexities of this issue."

Evans said verbal abuse is not new, but some factors allow it to continue. "It's still a ­male-dominated society," she said. She also noted that abusers may see "people on the news" engaging in name-calling and think it's acceptable.

Evans stressed that people who want to get out of an abusive relationship should understand that the most dangerous time for them is when they're about to leave or are in the midst of leaving — and need to plan cautiously.

The Domestic Violence Hotline can be reached at 800-799-SAFE or thehotline.org.