Sam tells me he is going to change, he loves our kids, he's a good dad, I know he doesn't mean it, he just needs some help managing his temper. Besides I don't know where I would go, the kids need their home.” The despair is often palpable but still the hope remains that maybe the man they love can be the man they need; they just want the violence to stop.
Intimate partner violence (IPV) cannot be understood systemically as a problem of communication, poor conflict resolution or projected rage. IPV must always be placed within the context of a sociocultural and gender based understanding of the impetus for men to use power in acts of violence against women and children. The heterosexual relationship where the man is the user of violence and where there are children involved is by far the most common form of violence and will be the focus of this article.
A high proportion of presenting problems in therapy are about relationships – with the couple or individual experiencing IPV very likely to present to a private practice rather than a domestic violence service to avoid the stigma associated with naming one’s relationship as abusive. These families may have already had police attendances in their home or family interventions and legal interventions placed that have broken down. This adds to their sense of shame, particularly when they have been told that the only solution is to separate. Separation is also not always a solution to ending IPV and is often a high risk time for families.
Domestic violence is complex, varied and difficult to treat, however the central aim of all treatment modalities is to keep women and children safe. Couples therapy alongside individually targeted interventions such as behaviour change programs can offer some important contributions to stopping IPV and repairing the impact such that some families, that choose to, can stay together safely.
Assessment
Since there is always potential for a psychologist to misdiagnose or miss IPV altogether, there is a clinical imperative that all couples are globally assessed for violence from the outset. This is not dissimilar to assessing for mental health conditions or addictions. Many couples will deny IPV if simply asked about the presence of violence. This is because most people associate the word violence with physical abuse rather than emotional abuse or control. There may also be a concern about escalating conflict or being reported to authorities. The naming of abuse or violence can be quite confronting for both therapist and clients.
The assessment for IPV should include assessing the individuals separately, preferably female first so an overall sense of the extent of the violence can be established. The use of an ‘abuse inventory’ will provide the most thorough assessment for both parties and evidence of minimisation by the male will be established via differences in self-report. In addition, the level of fear and lack of safety must be clarified and a safety plan put in place when needed. This is exceptionally important when the couple have children. This individual assessment phase is essential to making a clinical decision about the utility of couple work.
Indicators of Intimate Partner Violence
- Subjective fear and attempts at minimisation of conflict
- Gendered use of power and control
- Blaming and justification
- Jealousy and social isolation
- Arguments that result in one or other partner leaving
- Stonewalling or contempt in communication
- Constant and repetitive arguments that end in leaving
- Using sexual intimacy for emotional regulation
- Involvement of children in conflictual patterns
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When to proceed with couple therapy?
Research has shown that male violence can be differentiated into sub-types and that these exist along a continuum of severity (Johnson and Ferraro, 2000; Holtzworth-Munroe et al, 2000; Jacobsen and Gottman, 1998). The most clinically useful is the distinction made by Gottman between Characterological Violence and Situational Violence. In characterological IPV the violence is severe, there is more minimisation and denial and no matter what the woman does to avoid episodes of violence, she has no impact on the escalation. This implies very high levels of danger for women as the violence is unpredictable, gendered and focussed on control. There is absolutely no utility for couples therapy in these cases. In fact, it is contraindicated as the therapy room will most often become another place to control and manipulate. Threats to the safety of therapist may also be of concern. The best treatment options lie within correctional or family violence services, so the intervention here is to facilitate a referral to these services.
At the lowest level of the IPV continuum is the man who displays the less severe ‘situational’ violence called so because there is often a clear precipitating event. These men are likely to be remorseful and will readily take responsibility. While the behaviour should always be considered as potentially dangerous, the man will not be expressing the need to control. There may sometimes be a tendency in these relationship for the female to act out too as the relationship becomes more reactive and triggering.
In cases of situational violence, couples therapy may be considered as a treatment option. Ideally this is an adjunct to individual therapy particularly in cases of addiction or other mental health disorders. The following questions should be answered positively as a guide of when to proceed.
- Are both parties reporting the same severity of violence in individual interview?
- Is this violence of the less severe and less frequent type?
- Is there evidence that arguments are mutual?
- Is the female reporting that she wants to stay in the relationship?
- Is the female reporting that she feels safe in the relationship?
- Are the children safe and well cared for?
- Is the man willing to accept full responsibility for his potential to do harm?
- Has the man expressed empathy and remorse?
- Are both parties working on their mental health problems? (if relevant)
Some important features of couples work
- Limited confidentialit
Full disclosure will ensure that episodic violence can be effectively targeted rather then perpetuated by secrecy and collusion. This agreement establishes a strong and honest therapeutic alliance and is a good method of tracking the progress of the work. Within the contract of limited confidentiality, the couple needs to agree to regular individual check in sessions as an adjunct intervention for ongoing assessment.
- Safety planning for the whole family
Here the couple agree upon appropriate methods of emotional regulation to avoid conflict escalation and keep the whole family safe. The couples capacity for safety and trust in their relationship will increase over time so the first steps should involve simple de-escalation methods such as time out. Regular sessions will also give the couple a safe place to process conflict and should be part of the agreed safety plan.
- Cycle of violence and the cycle of feeling avoidance
Episodic violence does not usually occur without some build-up and triggering. Understanding the patterns of build-up is an essential part of stopping escalation. The cycle of feeling avoidance can be very useful in helping the couple understand how violence becomes cyclical, perpetuated and inevitably escalated within the relationship dynamic (please see diagram 1).
- Family of origin/attachment work
It is very likely that the couple have histories of insecure attachments. The intra-personal is as important as the interpersonal in healing from IPV. However the therapist must ensure the safety of the bond before this work can proceed. The risk is that personal issues can be used against the other which will cause severe rupturing of trust. An emotion-focused couples approach can lead to strong reactivity and inadvertently heighten risk. A clinical decision needs to be made regarding the need for referral to individual therapy.
- Working with Children
Children who have witnessed or experienced more directly any form IPV will be at risk of mental health and adjustment problems. The couple must be encouraged to get appropriate assistance for their children. This involves a capacity of the couple to be ‘on the same page’ around the well being of their kids and to ensure that that their children are not brought into their conflict (triangulated). Ideally the couples own bond should be strengthened to enable the success of clinical intervention with the children.
Couples work with IPV is a specialist area. The substantial duty of care in IPV means that an ethical decision about professional capacity must be made before taking this work on. Psychologists need training in domestic violence to provide this type of intervention. Supervision should be enlisted on a regular basis to ensure that the therapist is not inadvertently colluding with any subtle perpetuation of violence. Debriefing is also an essential component of therapist self-care as we attempt to hold the painful and confronting process that most couples will have to go through in repairing from IPV.
"The work of treatment is to convene a conversation that takes up the terrible questions, emotions and memories that violence creates, and then keeps the process moving until safety, equity, remorse and reparation are achieved or until it becomes clear that they cannot be" (Goldner, 1999).
The author can be contacted at [email protected]