By Albert Dytch
Many therapists, including those of us with extensive clinical experience, frequently plunge into doing therapy before we have adequately assessed whom and what we are treating. It is in the nature of the therapist-client relationship that we cannot know the whole story from the outset. Our clients may be lost, confused, withholding, or in denial. They aren't ready to divulge everything at a first session (and if they were, we would probably wonder why). In the cause of establishing a working alliance, we leave avenues of assessment unexplored until a more opportune moment. Assessment and treatment necessarily walk hand-in-hand as the ongoing process of discovery and healing unfolds.
However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. Sometimes we collude with our clients' denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment. Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.
The purpose of this article is to address one specific error I encounter with troubling frequency: the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation--or the threat to use any of those methods--to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently they are also more effective, and they can be more emotionally damaging in the long run.
I have met with couples in treatment for several years with seasoned therapists who missed the extent and severity of the physical and emotional abuse taking place at home. While it is true that clients bear some responsibility for staying silent on the issue (whether out of fear, or outright denial), the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe to bring up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting with separately with one member of a couple they are treating jointly.
Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. "Suffering" is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile clients incur a sizeable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.
COMMON MISCONCEPTIONS
Several common misconceptions hamper or prevent an adequate assessment of partner abuse.
"The couple reports that they yell at each other, so they both contribute to the problem." Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, they probably contribute disproportionately to the abuse.
"I spoke to them about partner abuse and they deny it is going on." As therapists, we know better than to accept a client's analysis of their difficulties and to probe more deeply. If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?
"It is my policy never to meet individually with clients I see in couples therapy." Adequate assessment cannot be accomplished with both partners in the room. Asking directly about abuse in a couples session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.
"I have a 'no secrets' policy, so clients know that anything they share with me individually will be brought into the couples session." In my view, such a policy is designed to relieve the therapist's anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.
"Even if there is undiagnosed partner abuse, I'm helping them resolve the underlying relationship dynamic." By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner's hands.
"I can teach them better communication skills until they trust me enough to disclose the issues they are withholding." Communication skills are easily subverted at home by abusive partners. "I statements" are meaningless if the intent is to hurt, control, or manipulate.
"I'm not taking a stand on the issue because I'm afraid the abusive partner will bolt from treatment." Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.
INDICATORS OF PARTNER ABUSE
Clients in abusive relationships present with typical complaints: "We don't know how to communicate with each other." "We've been arguing a lot." "We're both under a lot of stress." "We've needed counseling for a long time and he/she finally agreed." "We disagree about disciplining the children." Their level of intimacy usually has declined.
More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. There may be a marked difference in the way and the degree to which each partner participates in the session. The abusive partner may always start the session or alternatively always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly--or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.
They may disagree on basic facts and have widely divergent views of the same events. Frequently both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.
Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.
ASSESSMENT PROTOCOL
When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.
Alternatively, a couple may come to see me because they're having difficulties and have decided to try therapy. I might not begin to suspect partner abuse until they have seen me a few times. At that point, I might say something like:
"During the last several sessions, I've been able to observe how you interact with each other. As part of my work and to get to know you a little better, I'd like to schedule an individual appointment with each of you. That will give me a chance to get to know you better, find out more about you, your childhood, family history--that sort of thing."
I wait until the individual session to address the issue of confidentiality and "secrets." I typically begin that session with:
"This is kind of a rare opportunity to get together with you, and I'm wondering if there's anything you'd like me to know that you're not comfortable saying with your partner in the room? If it's something you want to tell me in confidence, I can keep it to myself. If it's something I think would be helpful to discuss in a joint session, I'll let you know that today, but I won't disclose anything you don't want me to."
I also tell the client that I would like to ask a series of questions about the kinds of behaviors that happen in relationships. I use an Abuse Behavior Inventory I developed after several years of working in the domestic violence field. (A slightly abridged version is included at the end of this article.) These specific questions can be supplemented by inquiring about the first, last, and worst conflicts that have occurred.
The individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information--factual, psychological, and emotional--than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.
Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other's answers generally exhibit greater awareness of problems in their relationship and are more often motivated to do something about them.
RECOMMENDATIONS FOR TREATMENT
If the individual sessions reveal a pattern of partner abuse, my recommendations to the couple might go something like this:
"I have some thoughts about your therapy and where we go from here. We've discussed the issues and difficulties you experience together (name them), and I think it's clear to all of us that the two of you need couples therapy. But I think it's premature at this point. It's really just a matter of timing. You're going to be spinning your wheels until you both have a chance to address your own issues. Then you'll be able to take advantage of what couples therapy has to offer."
In the typical abusive heterosexual relationship, I generally refer the man to one of my men's groups with a focus on partner abuse; I refer the woman to a colleague who offers groups for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.
In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I base my recommendation primarily or solely on what the abusive partner told me and what I observed in meeting with the two of them together.
There is not sufficient room here to address the arguments for and against conjoint treatment in cases of partner abuse. Before I will consider treating an abusive couple together, they must meet several conditions.
- Their answers to the Abusive Behavior Inventory match closely.
- Past abuse was moderate to mild; currently, abuse is mild or absent.
- The couple can adhere to a contract of no further abuse.
- The abused partner is safe, unafraid, and able to mobilize resources if needed.
- Both partners are motivated for treatment out of a sincere desire to grow and change.
- Both partners are willing to be accountable for their behavior, without blaming the other.
- The couple can use basic communication skills in a non-manipulative manner.
In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.
RESOURCES
Treating partner abuse is a specialized field. Trainings in recognizing and treating partner abuse are helpful, but the only way to develop expertise is through direct experience. Practice administering the Abusive Behavior Inventory with colleagues. The next time you suspect partner abuse, assess for it. Consult with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to leaving partner abuse undiagnosed and untreated.
Abusive Behavior Inventory. Click here to download this form in PDF format (85Kb).
Albert J. Dytch, Licensed Marriage and Family Therapist, has been treating partner abuse and domestic violence since 1984. He has worked at Men Overcoming Violence and STAND! Against Domestic Violence and was co-founder of The Center for NonAbusive Relationships. He currently leads four men's anger management/partner abuse groups in his private practice in Oakland, where he also sees individuals, couples, and families. Albert has been a frequent presenter on the topic of partner abuse and consults with other therapists on their difficult or dangerous cases. He can be reached at 510-452-6243 or on the web at www.mensangermanagement.com.
