3. Couple Therapy? - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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A common but difficult boundary for the couple in therapy is that a partner who acts in a verbally and emotionally or psychologically hurtful manner is held responsible to stop such behavior.  Interventions and steps are taken to prevent recurrence so that the target of the verbal "violence" can be safe.  In lieu of physical aggression or abuse, however, there is often greater tolerance of emotional or psychological transgressions.  The degree of non-physical abuse may be quite egregious.  This tolerance is arguably quite counter-productive to the relationship health.  On the other hand, domestic violence treatment programs take a stricter approach.  In such work, there are essentially two parallel messages and principles: the perpetrator of domestic violence is held accountable for his or her aggression and abuse, and the victim must be protected from further violence.  This often results in two concurrent parallel programs as well.  One program works with the abuser to curtail his or her (a male in most programs) aggression.  The second part is a social service program to work the victim of domestic violence (usually female).  The male perpetrator is seen individually often with required participation in group therapy with other perpetrators.  The perpetrator, his violent behavior, and rationalizations are often challenged and confronted by the group facilitator or therapist and by other group participants.  The modalities of treatment may include psycho-education, cognitive-behavioural, psychoanalytic, or attachment orientations.  The female victims may also have individual therapy and participate in a group process with other victims.  In addition to group support, victim support services or agencies may also provide legal, housing, financial, and other resources.  All interventions intend to empower the victim to resist further victimization.  A third strategy or process of conjoint therapy or couple therapy is not universally accepted in domestic violence treatment.  Such an approach is very controversial among professionals and victim advocates.  At best, the therapist should take great caution to consider whether couple therapy is appropriate or safe when domestic violence is a part of the relationship.

"Although the efficacy of parallel approaches has been mixed, numerous authors (e.g., Avis, 1992; Bouchard & Lee, 1999; Gondolf, 1995; Rosen et al., 2003;Stith et al., 2003) have noted that the use of conjoint therapy for domestic violence situations is highly controversial.  It has been reported that within conjoint therapy for domestic violence there can be potential for: (a) physical and psychological risk to the victimized partner through being re-victimized, (b) the offender to use the therapy time to self-justify and to justify to the victim the abuse, (c) the victim to be held responsible for the abuse, and (d) the power imbalances within the relationship to be ignored (Avis, 1992; Bograd, 1992; Goldner, 1998; Gondolf, 1995; Rosen et al., 2003).  Thus, it seems that there are legitimate concerns for the application of conjoint therapy for domestic violence cases" (Harris, 2006, page 375).  If domestic violence had been a part of Dirk and Madeline's relationship, their prior two experiences of couple therapy arguably condoned the abuse.  Whether the therapist knew it or not… whether she knew it or not, Madeline had hope that her victimization would be recognized.  She hoped to be acknowledged, helped, and protected.

In the new therapy, the therapist can see that Madeline is uncomfortable when Dirk gets upset and makes accusations against her.  Discomfort is intrinsic to the therapeutic and change process, but the therapist often cannot tell initially whether Madeline is uncomfortable but able to otherwise care for herself.  Madeline may be intimidated by Dirk, but more than that, feel abused… again.  Perhaps, worse than having experienced victimization alone at home might be to be victimized again without intervention in front of a witness- the therapist.  Madeline's complaint that a prior therapist gave Dirk too much time and attention may predict Dirk will again recruit the therapist to condone his justifications for his treatment of Madeline.  From the principles of individual choice and therapist neutrality, the therapist may inadvertently collude with blaming Madeline for being victimized.  Since Dirk brings in all the income in the family, his sense of greater equity in the couple drives his entitlement to make choices and to criticize Madeline.  The therapist risk deferring to the implicit and explicit power dynamics, if he or she does not address balance or imbalance between Dirk and Madeline.  Since imbalance may be key to aggressor entitlement, failure to challenge it perpetuates Dirk asserting control and continuing to dominate Madeline.  Prior couple therapy had failed to stop the aggression, abuse, or uncover much less stop domestic violence before.  It may have intensified Madeline's victimization and increased Dirk's entitlement to aggress.

The negative consequences of couple therapy with domestic violence in the relationship may advise against the process.  "However, research suggests (e.g., Bouchard & Lee, 1999; Gauthier & Levendosky, 1996; Goldner, 1998; Rosen et al., 2003; Stith et al., 2003) that this is not a universal rule that should be applied to every case…  There have been some significant reasons forwarded as to why couple therapy should be a potential option when working with domestic violence cases.  For example, perpetrators are a heterogeneous group (Stuart & Holtzworth-Munroe, 1995) that requires individual treatment plans for each unique individual.  Stuart and Holtzworth-Munroe (1995) reported that male perpetrators who were violent specifically toward their families and had no psychopathology can benefit from couple therapy.  Second, reciprocal violence can occur between partners (Stith et al., 2003; Straus, 1993), which needs to be addressed in order to effectively reduce the overall violence in the relationship (Feld & Straus, 1989).  Gondolf (1998) reported that if women use violence in relationships, they are at an increased risk of being severely injured by their partners.  Third, typical perpetrator groups do not address underlying relationship dynamics that influence the violence in the relationship (Holtzworth-Munroe, Beatty, & Anglin, 1995).  Pan, Neidig and O'Leary (1994) found that marital discord and underlying relationship issues were the most accurate predictors of aggression within the couple.  With many victims of abuse staying, or returning, to their partners who have been abusive (Bouchard & Lee, 1999; Heyman & Neidig, 1997), there seems to be a strong case for the inclusion of couple therapy to address relationship dynamics in treatment.  Fourth, many couples are too afraid or ashamed to enter treatment for violence, and thus a couple therapy label can be more appealing (Shamai, 1996).  Finally, conjoint therapy offers the opportunity for role modeling and practicing techniques with each partner (or between partners) during the session (Geffner, Barrett, & Rossman, 1995).  This can lead to opportunities to: (a) correct problems during the session, (b) offer support to each partner in implementing the technique, and (c) tailor techniques to fit the individual couple during the session" (Harris, 2006, page 375-76).  Harris further discussed research where conjoint therapy with domestic violence issues was effective in reducing violence and where women did not have greater risk for violence.

Whenever there is a history of domestic violence and subsequently, a risk for renewed or repeated abuse, the safety of the victim is paramount.  The sense of safety may be important along with protection from actual harm.  If the victim does not feel safe in couple therapy, it would replicate the sense of danger in the relationship.  Complete physical separation and subsequent legal and marital or relationship termination thus may be an appropriate goal.  However, it may not be the goal of the couple or of either partner.  If the partners pursue couple therapy, the therapist must examine for safety issues before proceeding with and throughout therapy.  Past and current abuse would tend to predict further abuse that therapy may condone unknowingly.  "Stith, Rosen, & McCollum, 2002) have suggested that ensuring there is no current severe/moderate violence or abuse (e.g., emotional, physical) needs to occur before couples work is initiated.  Furthermore, even if couple therapy is going to be utilized for more mild forms of physical aggression/violence (e.g., pushing, shoving) there still need to be precautions taken, such as a contract stating there will be no violence or battering of any kind (Bouchard & Lee, 1999; Jacobson & Christensen, 1996).  Although some approaches to couple therapy for domestic violence (e.g., Rosen et al., 2003) have included couples with low-level physical aggression/violence, this is controversial (Bouchard & Lee, 1999; Jacobson & Christensen, 1996). Mack (1989) reported that couple therapy will be appropriate if expressive violence (e.g., violence that is primarily an expression of an emotion, lack of prior severe violence, mutual and reciprocal violence, genuine remorse) is apparent as opposed to instrumental violence (e.g., violence that is used to mainly achieve a goal, history of severe violence, unilateral violence, serious psychological repercussions such as helplessness or depression, lack of remorse)" (Harris, 2006, page 376).

The use of contracts or agreements may help set boundaries to prevent further abuse.  However, they are inherently problematic depending on the intensity of the dynamics and the emotional/psychological stability or reactivity, the honesty or integrity, and the degree of compulsivity of the perpetrator.  The suggested conditions for using couple therapy may be a part of a circular rationale.  Couples and perpetrators who qualify may be inherently those who can benefit from couple therapy due to their lesser degree of pathology.  Those who do not qualify may inherently be too dysfunctional to benefit from couple therapy.  These guidelines or requirements for deciding the suitability of couple therapy for domestic violence suggest that among domestic violence and perpetrators there are important qualitative differences.  Certain sub-groups of domestic violence perpetrators may be more or less amenable or significantly resistant to couple therapy or any intervention.  That includes common therapeutic interventions that are often otherwise productive: contracts, homework, breathing exercises, or cognitive-behavioral interventions.  Dirk may be aggressive and abusive with Madeline.  The extent of aggression or abuse may not involve physical behavior.  However, there may be physical actions that would be considered clearly domestic violence as defined legally and by social/cultural and professional standards.  In considering couple therapy when there is domestic violence, the therapist would need to determine if the aggression is largely emotionally reactive versus intentional to serve some gain for Dirk.  If the aggression is instrumental along with history of severity, such characteristics and history may advise against couple therapy.  Couple therapy may not be beneficial.

"Geffner et al. (1995) reported that prior to commencing domestic violence conjoint therapy, specific preconditions should be apparent, such as: (a) each partner wants this type of treatment, (b) the victim has a safety plan and understands the potential dangers of this approach, (c) therapists (i.e., preferably one male and one female for the couple) are trained in systems approach and domestic violence issues, (d) neither partner is abusing alcohol or drugs, and (e) the risk for danger to the victim is low, based on a thorough evaluation.  In addition, Walker's (1979) stage model of the cycle of violence can be used to conceptualize the current state of the relationship.  This is important as couples in the honeymoon phase (i.e., the abuser is remorseful and makes promises to change) may have unrealistic expectations and perceptions of the treatment and the level of dangerousness involved.  Clearly, safety needs to be a focus of couple therapy with domestic violence issues" (Harris, 2006, page 376-77).  Walker's conceptualization of the cycle domestic violence has three parts: the tension building phase, acute battering episode, and the honeymoon phase.

1. Tension building phase—Tension builds over common domestic issues like money, children or jobs.  Verbal abuse begins.  The victim tries to control the situation by pleasing the abuser, giving in or avoiding the abuse.  None of these will stop the violence.  Eventually, the tension reaches a boiling point and physical abuse begins.

2. Acute battering episode—When the tension peaks, the physical violence begins.  It is usually triggered by the presence of an external event or by the abuser's emotional state—but not by the victim's behavior.  This means the start of the battering episode is unpredictable and beyond the victim's control.  However, some experts believe that in some cases victims may unconsciously provoke the abuse so they can release the tension, and move on to the honeymoon phase.

3. The honeymoon phase—First, the abuser is ashamed of his behavior.  He expresses remorse, tries to minimize the abuse and might even blame it on the partner.  He may then exhibit loving, kind behavior followed by apologies, generosity and helpfulness.  He will genuinely attempt to convince the partner that the abuse will not happen again.  This loving and contrite behavior strengthens the bond between the partners and will probably convince the victim, once again, that leaving the relationship is not necessary (domesticviolenceroundtable.org, 2012).

The willingness of the abuser while in the honeymoon phase may not persist as the couple moves pass the stage and cycles again into the tension-building phase.  Entry into couple therapy may be a manifestation of the honeymoon phase.  Applying the five preconditions suggested by Geffner et al. suggests that the couple has revealed that domestic violence is in the relationship.  The partners may not tell the therapist that an abusive episode precipitated the initiation of therapy.  Dirk and Madeline had never mentioned domestic violence.  They told the therapist they started therapy because of communication problems, stress, and not having enough time together as a couple.  An initial goal of therapy may therefore be along with the identification of abuse, getting them to identify themselves as a couple with abuse problems.  If the couple admits to abuse in the relationship, (Dytch, 2012) says, "Before I will consider treating an abusive couple together, they must meet several conditions.

1. Their answers to the Abusive Behavior Inventory (see appendix) match closely.

2. Past abuse was moderate to mild; currently, abuse is mild or absent.

3. The couple can adhere to a contract of no further abuse.

4. The abused partner is safe, unafraid, and able to mobilize resources if needed.

5. Both partners are motivated for treatment out of a sincere desire to grow and change.

6. Both partners are willing to be accountable for their behavior, without blaming the other.

7. The couple can use basic communication skills in a non-manipulative manner.

Dytch succinctly adds, "In short, couple therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment."

The therapist should consider that intimacy is both the goal and the challenge to the couple's relationship.  Intimacy in a couple may have to do with a certain quality or lack of quality of communication.  Distressed husbands who are aggressive towards wives- "D/H-to-W spouses reported less use of silly voices, baby talk, and special communication than did D/NA (Distress NonAggressive) spouses.  One result of marital aggression could be less silly, childlike and trusting behavior between spouses.  This type of communication may be a marker of intimacy.  Alternatively, it may be that the lack of this type of relationship communication is one of the risk factors for the occurrence of H-to-W (husband to wife) violence" (Langhinrichsen-Rohling, 1998, page 209).  Failed attempts to experience and invite intimacy lead to emotional injuries, which often (usually) cause frustration, upset, and/or anger.  Anger as a secondary emotion can trigger empowering actions to get needs met.  Assertion and thus, aggression are primary behavioral expressions of anger.  Individuals vary in their practice and expression of boundaries when aggressing.  Emotional assertion, aggression, and abuse are probably intrinsic to the couple's relationship, and particularly to many if not most couples seeking therapy.  Therefore, the therapist may find it theoretically and therapeutically reasonable to assume that every couple, is somewhere on a continuum of assertion, aggression, and abuse. And, that those couples in therapy are problematically on the continuum.

The therapist should therefore always anticipate that the dynamics of the relationship includes the probability of psychological aggression.  And, may include the possibility of domestic violence, which must be investigated through the therapeutic discovery process.  Whether Dirk or Madeline volunteer incidents of verbal, emotional, or physical aggression, the therapist should actively ask direct questions and carefully probes any implicit cues.  The therapist must assess for whether the partners and couple fit preconditions for therapy genuinely: desire for therapy, safety plan, no alcohol or drug abuse, and low risk of danger.  This is fundamental to the other precondition- a knowledgeable skilled therapist.  These considerations do not leave the therapist with simple clear indicators or boundaries to conduct couple therapy or not.  They are principles that the therapist has to integrate with in-person assessment of the couple to determine whether to treat or not, as he or she determines therapeutic strategies and interventions. This is a fundamental and extreme challenge as a therapist.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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