When domestic violence occurs in the couple, it may be hidden to everyone outside of the home. It may be hidden from the therapist in couple therapy. The question of whether couple therapy is appropriate to treat domestic violence overlaps with the question of how to conduct couple therapy when domestic violence is uncovered. The therapist who works with couples may not have any intention to solicit for or specialize in couples where domestic violence is present. However, he or she may discover that emotional or psychological violence, which are the focus of therapy are part of a pattern of physical domestic violence. The victim and/or the perpetrator and/or the couple may desperately look to the therapist as the one and only hope for change. The therapist at this point early or well into the process of therapy may not be ethically advised to terminate "regular" couple therapy and refer the couple to a domestic violence specialist or program. Revelation of domestic violence into the process of therapy may be indicative of rapport and trust that has developed among the partners and the therapist. The partners and especially, the victim may feel abandoned if the therapist begs off of continuing therapy to deal with the physical abuse.
If the therapist continues with the couple, there needs to be some to substantial shifts in his or her conceptualization and conduct of the therapy. Couples, individual, and group therapy or treatment for domestic violence may derive from various theoretical orientations, have different structure, and varied techniques. The treatment goal is to deal with domestic violence: to protect the victimized partner and to stop and prevent future intimate partner abuse. Inherent with protection and prevention is an often necessary and applicable goal of terminating the relationship. That often involves enabling the victim to end the relationship and to not return to it later, and for the perpetrator to stay away from the abused partner. Couple therapy however ordinarily is about improved communication, emotional healing, layers of problem-solving, and so forth in order to remain physically, economically, spiritually, emotionally or psychologically, and intellectually connected- to stay together. Staying together is usually the expressed goal of the couple, with determining if the partners can or should stay together an implicit corollary goal. Partners and the therapist often consider separation a failure of the relationship and of the couple therapy. In contrast, in domestic violence treatment termination of the abusive relationship through physical separation and/or divorce is often necessary and considered successful treatment. The therapist should bring up separation as a viable choice for the partners Dirk and Madeline. An overt discussion will help them determine the goals for the relationship and for therapy. The goals may be hopeful, unrealistic, practical, tentative, freeing, or confining. The discussion may bring up unspoken goals, expectation, fears, and boundaries important to relationship functionality.
Couple therapy often has to address whether and how one or both partners express feelings, thoughts, opinions, and needs and whether the other partner hears and understands at different levels. When communication over mundane issues and emotionally charged issues somehow fail to wholly transmit from one to another, therapy usually addresses how the expressing partner reacts. Having failed to get the other partner to hear or understand, therapy will examine if the expressing partner repeats the communication exactly or fundamentally the same way, intensifies in some manner, reframes or adapts the communication to possibly be more in sync with the other's more receptive channels, or stops trying either immediately or after one or more attempts. If the expressing partner stops attempting to get the other to hear or understand, therapy often explores his or her emotional reaction and cognitive interpretation of the transactions. In addition, therapy will explore subsequent actions and reactions between the partners- often in innumerable cycles. The style and quality of these actions or reactions are categorized as useful or not useful, helping or making things worse, informative or confusing, relevant or irrelevant, focusing or distracting, and a multitude of other considerations. They are also placed in more than merely dyadic categories since there may be multiple categorical subsets, as well as objective and subjective degrees- of helpfulness or confusion for example. As the therapist considers these many issues, characteristics, and behaviors for their functionality or dysfunctionality, therapy often directs adapting or changing interactional dynamics.
One major area to examine and address may be how passive versus how assertive one or both partners may be when needs are not met or communication is ineffective. Therapy may direct and train a partner to be less passive and more assertive with communication and getting needs met. Being too passive or deferential may not work in the partners' dynamics. This may involve exploring family-of-origin and cultural models, experiences, and background. On the other hand, therapy may direct or train a partner to be less assertive and more deferential or accepting of the other. Being too assertive and demanding may not work well for the relationship. Family-of-origin and other formative experiences also may be important to examine. For some couples, a core problem may be not issues with being too passive or assertive, but becoming aggressive- that is, subjectively too aggressive for the other partner and their dynamics. Anger as a component of aggression can be triggering. And some couples- often the same couples with difficulties with asserting self appropriately and being judiciously aggressive, do or say things that are hurtful to each other.
When hurtful communication and actions are unintentional, therapy adjusts to help partners become more aware of each other's sensitivities. Partners are prompted to reshape words and deeds not to harm feelings while maintaining healthy assertiveness and judicious aggression. In a significant boundary crossing, partners may violate a basic relationship agreement and purposely say and do things not accidentally, but intentionally to cause some injury. Assertiveness, aggression, unintended harm, and intentional injuring- that is, emotional wounding are often the fundamental targets of couple therapy to mend relationships. Within this common or normal couple therapy is a subjective to objective point in a spectrum where the frequency, intensity, and pattern of intentional harming is considered abuse by a partner, the therapist, culture (differing among particular cultures), and mainstream society. There are societal/cultural, ethical (within a profession), and legal definitions that are more or less objective that define abuse that requires specific professional actions. When behavior meets legal criteria for abuse or cross a threshold of suspected abuse, then the therapist is mandated to take action- report to governmental authorities. Short of meeting these criteria or crossing a threshold, in couple therapy the therapist regularly deals with emotional hurt and often deals with abuse.
While domestic abuse can be compared to child abuse, reporting requirements and laws usually include a more definitive description and mandate for addressing emotional abuse as a category within child abuse. In actuality and practice, child emotional abuse is not as easily defined or as acted upon by authorities as for physical or sexual abuse. Emotional partner or psychological abuse is similarly vague in comparison to physical or sexual domestic violence. All types of child abuse: physical, sexual, emotional and psychological abuse and neglect are emotional and psychological abuse. All types of intimate partner violence: physical, sexual, emotional and psychological partner violence are also emotional and psychological abuse. As with child abuse, the therapist mandates are much clearer- legally and ethically compelling for physical and sexual domestic violence than emotional abuse. As such, along with reporting mandates, cautions and prohibitions about or against couple therapy for domestic violence, it is simpler for the therapist to act or consider when there is current physical or sexual partner violence. For many therapists, couple therapy is appropriate to address subjectively mild to moderate emotional partner abuse. It becomes more complicated as the emotional abuse becomes more severe. In addition, while all physical and sexual domestic violence includes emotional partner abuse, not all couples where there is emotional abuse include or will develop into physical or sexual domestic violence. It is difficult if not impossible to accurately predict or quantify domestic violence as abuse occurs on some spectrum or continuum. Assertion and aggression as well as aggression and abuse also occur on some spectrum. Assertion, aggression, and abuse can but are not always continuous on a spectrum as well. And for some individuals, there are important distinctions among these dynamics for which a spectrum or continuum perspective is not as informative. Examining domestic violence treatment protocol and guidelines offers conceptualization and direction for how assertion, aggression, and abuse often becomes critical considerations in couple therapy.
SAFETY AND RISK REDUCTION
Therapy or treatment has to start with safety and reducing the risk of further abuse. "…the most successful therapies are those that seek first to eliminate violence or the threat of it from the relationship and that, second, focus on dysfunctional or coercive interactions between the partners. What is implied is that those therapies that are not concerned with risk reduction are unlikely to be appropriate for violent couples" (d'Ardenne and Balakrishna, 2001, page 241). Safety first is a clear boundary, yet still requires anticipation, interpretation, and prediction of both the victim's and perpetrator's subsequent actions and choices. Absolute safety can only be achieved by blocking further interactions between an abuser and a victim. This is beyond the capacity of friends, therapists, other professionals, the police, and the court unless the perpetrator is incarcerated. Even then, the victim may renew the relationship upon the perpetrator's release. Or, the victim because of emotional and psychological vulnerabilities may enter another relationship with another abuser. Given the victim's right to self-determination (including returning to abusive partners), risk reduction in many cases may be the logical strategy. Risk reduction of the perpetrator re-abusing, of being triggered, of the victim putting self in unsafe situations or relationships, of minimizing or denying danger signals, or failing to cultivate and use safety resources, and so on hopefully shifts individuals towards healthier and safer positions on a continuum of danger and safety.
STATIC AND DYNAMIC RISK FACTORS
Domestic violence treatment as well as therapy dealing with non-physical violence between partners should focus on issues that are related to and reduce the likelihood of perpetrators re-abusing. The risk factors can be categorized as dynamic risk factors that are possible to change and static risk factors from the history or experience of offenders. "The dynamic factors are appropriate targets for intervention. However, further refinement of our understanding of risk has suggested a need to recognize not only the difference between static and dynamic risk factors but also a difference between stable dynamic risk factors and acute dynamic risk factors (Hanson & Harris, 2000). Stable dynamic risk factors are as described as being those which can be expected to remain relatively constant over a lengthy period of time, for example alcoholism, whilst acute dynamic risk factors are factors closely linked to the actual time of re-offending, for example, negative mood or intoxication. Hanson and Harris (2000) suggest that it is the stable dynamic factors, which are the better risk predictors and appropriate targets for intervention, especially if the aim is for enduring change. The acute risk factors are seen more as linking to when re-offending may occur but not the likelihood of this happening. This suggests that there would be some benefit in exploring how anger and alcohol use might contribute to risk as stable dynamic factors, reflecting more enduring tendencies and, as such, be appropriate targets for interventions and assessment of risk. This might also address some of the concerns around using anger or drinking immediately prior to the offending as excusing behaviours, since these acute problems would not be the target of interventions" (McMurran and Gilchrist, 2006, page 110).
The difference and relationship between stable versus acute dynamic risk factors would vary for each individual and each couple. Exploring Dirk's background helps both partners better understand the precursors and contributor to his behavior- the static risk factors and stable dynamic risk factors, while continuing to hold him responsible for current and subsequent choices and behavior. Identifying alcoholism for example would keep him accountable for staying in recovery or maintaining continual self-care comparable to managing diabetes. Exploring Dirk's current functioning would take his treatment or therapy beyond generic domestic violence approaches to more specific interventions targeted at his acute dynamic risk factors. For example, identifying his pattern of alcohol use and how he reacts would be guide interventions to reduce his susceptibility to loss of inhibitions, anger process, and potential triggers. Madeline could also benefit from knowing what triggers him to shift from upset to anger, from emotional anger to rage to problematic behavior. She could avoid triggering him if possible, help him be aware of his becoming triggered, and avoid him when he is or is likely to be triggered. The argument about whether this inappropriately makes Madeline responsible for his abuse may be less important than Madeline avoiding being abused. Exploring her static risk factors and stable dynamic risk factors may help her understand how and why she is drawn to Dirk. It would help her identify and be responsible for characteristics that make her susceptible to her forms of acting out in life and with Dirk. Identifying her acute dynamic risk factors can help her mitigate or eliminate specific behaviors that increase personal disruption and relationship conflict.
Dirk is not necessarily like other perpetrators of domestic violence or emotionally reactive or abuse partners. It is important to ascertain motivations for aggression, abuse, and violence in order to develop or choose different targeted treatment or therapy to address them. More comprehensive and in depth understanding directs probable areas for preventing violence. Specific warning signs for specific couples and effective safety and coping strategies and behaviors can be utilized. "…the violence of certain men (e.g., those diagnosed with BPD) is particularly unpredictable, thus requiring a very different set of intervention and prevention strategies with these men and their partners. Consideration of the function of partner violence in terms of it being proactive or reactive may prove useful in terms of treatment matching with IPV adults" (Ross and Babcock, 2009, page 615). Is Dirk's abuse reactive to some emotional distress? Or is it contemplated purposeful hurtful aggression? What is the relationship? Who is Dirk? Why is Dirk the person he is? How does Madeline fit with Dirk? What issues are the most relevant and amenable to therapeutic intervention with the greatest possibility of preventing abuse?
Emotional or psychological abuse, as well as domestic violence can be examined from both systemic perspectives and cause and effect perspectives. Treatment looks for triggers and conditions that increase the potential for emotional, psychological, or physical abuse that are embedded within the system of the couple. These can be targeted to establish safety from continued domestic violence. Once the behaviors of abuse are restrained or blocked, then the dynamics of the relationship can be further examined. "This blending of systems and cause and effect perspectives filters into our interpretation of differentiation. Highly differentiated partners possess an emotionally neutral sense of personal responsibility. For example, unhooking oneself emotionally from a partner's aggressive behavior does not mean one is condoning the behavior. In fact, it frees the potentially battered partner to rationally explore options to maintain physical safety and nonviolence in relation to an abusive partner" (Perez and Rasmussen, 1997, page 233). The prohibition against violence and practical barriers or interruptions automatically challenges the homeostasis of the couple. If Dirk and Madeline are relatively differentiated individuals, Madeline can better understand and accept Dirk's emotional process and reactivity and Dirk can relate to Madeline's frustration and needs. Within these empathetic and intellectual connections, they can still practice self-care actions. Unfortunately, lower differentiation causes both partners to have conflict between having compassion for the other and holding ones own needs and grievances. Dirk would find Madeline trying to assert her needs as oppositional to his interests. Madeline would experience validating Dirk's stressful work situation as invalidating her perspective.
Dirk and Madeline definitely hurt one another emotionally and may degenerate into more severe abusive interactions. The power relationship works but does not work for them. There is some degree of functionality but it comes at great stress and potential volatility. Despite this and protestations of not "wanting to live like this anymore," the inertia of their relationship finds change difficult. "At-risk couples with power imbalances often resist changing relationship patterns to correct them. Male partners fear the loss of power, control, and role certainty. Female partners either minimize their partner's emotional abusiveness, experience fear of physical retribution and/or other barriers to leaving the relationship (e.g., minimal financial resources, limited social support network, child care responsibilities, social stigma associated with battering, and/or psychological dependency). When correcting power imbalances, clinicians balance a respect for the couple's cultural values and autonomy to make their own decisions with a responsibility for providing safe, effective treatment" (Perez and Rasmussen, 1997, page 233). The couple is encouraged to differentiate in order to better resist coercive habits and physical aggression. Improved differentiation lowers emotional reactivity, improves logical thinking, and individual ownership of outcomes. Greater responsibility helps individuals recognize available choices. Differentiation also helps individuals and the couples incorporate the unacceptability of physical aggression within the relationship. Greater differentiation for Dirk and Madeline helps release them from emotional triggers from their family-of-origins that trigger dysfunctional choices in their relationship. Through improved differentiation, greater self-awareness identifies ones responsibility in current dynamics and helps to break the habit of blaming others for problems. "At-risk couples have a diminished capacity to balance their thinking and feeling (intrapersonally and inter-personally) when experiencing intense differences or "hot topics." The degree to which partners can maintain this balance determines their level of differentiation" (Perez and Rasmussen, 1997, page 237-38). Dirk and Madeline are often at their worse rather than being able to amp up to deal rationally, efficiently, and effectively when under duress.
Perpetrators of domestic violence are often referred to anger management programs. Standard anger management programs emphasize techniques for relaxation and improving impulse control. Anger management classes tend to focus on more superficial aspects of anger and are more effective for individuals already highly motivated to change. Upset or anger that can readily addressed with relaxation and impulse control techniques may be less intense and less compulsive than the rage characteristic of many abusers. The challenge occurs when anger is explosive and erupts too quickly for rational evaluation or diversion. Since rage is often driven by guilt and shame, interventions that cause individuals to feel badly about their behavior such as abusive actions can become counter-productive. An angry individual who has a self-righteous sense of victimhood justifying abusive choices is further triggered. Getting to the core issues for the anger is necessary for the individual to calm emotional reactivity. McGowan (2005, page 58) described Stosny's HEAL process.
"H: At the first sign of anger, call up the word heals in your mind—if a particular person is making you mad, you should actually picture that person with the word on his face. E: Explain to yourself what Stosny calls your 'deepest core hurt' that lies behind the anger, such as feeling unlovable, disregarded or powerless. A: The third step is to 'access your core value': Take an inventory of what makes your life worth living good deeds you've done, loving relationships or values you want to uphold, like honesty and bravery. L: Next, 'love yourself.' S: Finally, 'solve the problem'; Address the conflict that underlies the anger. He prescribes 750 repetitions over the course of four to six weeks, training angry people to automatically draw on this process during moments of stress. What we try to do is condition this core value experience to occur with the arousal itself,' Stosny says. 'As soon as you start to get angry, you think about how you love this person. You have to practice getting angry, think about something that got you angry, feel the arousal and then practice it. It's like basic training in the military.'" (McGowan, 2005, page 58).
The prescription should be effective if the individual is able to follow through on it. However, the first sign of anger may be so intense and cycle so quickly that cognitive intervention is precluded. The individual may also find it difficult or impossible to own inner wounds. Or if he or she can, it may not be sufficient to intervene. Accessing ones core values can be problematic if the core fears or hurts overwhelm the individual. In addition, for some individuals their core values are of vindictive retaliation or of maintaining domination and control. This direction assumes a core value of intimacy and mutual nurturing. Lastly, solving the problem depends on what the individual perceives as the problem. If the problem is that one cannot tolerate "losing," giving up control, or being exposed as antisocial, then the solution can continue to be further intimate partner abuse. Applying these strategies should begin with assessing whether the individual is able to attempt and integrate them. Dirk and Madeline cannot readily or simply follow through with the strategies. The beginning of therapy may be getting them to develop the capacity to follow through. That should involve understanding what their current process may be.
Dirk and Madeline have verbal battles that become aggressive and hurtful without any real potential for resolving practical issues or emotional needs. The arguments need to be broken down to show their frustrating unproductive repetitious quality. There are often unacknowledged underlying assumptions about gender and power that create violent potential. Domestic violence can be considered in some circumstances to be extreme dysfunction from gender stereotypes that form heterosexual intimacy. "A couple's aggressive escalation and cycle of tension contain many highly condensed triggers rooted in contradictory family of origin/parental loyalties related to gender. For men, we look for oscillations between 'feminized' devotion and 'macho' domination, which characterizes the stance of abusive men. We assume that women form a sense of self, self-worth, and a feminine identity through their ability to build and maintain relationships with other. Independent aspirations and attempts to differentiate and separate are often labeled as destructive or crazy. For women, we attempt to co-construct an explanation for their getting 'caught' in an aggressive relationship. The contrition and redemptive phase of a couple's cycle of tension is quite powerful. Goldner and colleagues (1990) assert that for abusive relationships, the redemptive moment in a couple's cycle is as complexly structured as the violent tide that produced it. Both parts of this cycle must be deconstructed, their elements unpacked, and critiqued. It is assumed that a very similar process is necessary for at-risk couples" (Perez and Rasmussen, 1997, page 240).
Couples often engage repeated in destructive patterns of interaction compulsively with little or no awareness or understanding. Dirk and Madeline for example know that what they do is ineffective and painful, but such knowledge is ineffectual in keeping them from repeating the same argument. Dirk may hold himself to macho premises without conscious awareness or contemplation. Madeline may unknowingly get her self-worth from being able to please Dirk. Therapy attempts to get both partners to uncover their underlying assumptions and expectations for self and the partner. Rather than acting out from a vague uncomfortable sense of being unfulfilled and frustrated over unidentified personal and relationship standards, the therapist should guide the partners the "logic" of their choices. When and as each partner becomes clearer about expectations and disappointments, each partner can choose whether such unconscious or semi-conscious rules are beneficial or harmful personally and interpersonally. Or, to what degree such expectations should direct their choices.
In heterosexual couples, gender role assumptions and expectations often define choices that can prove problematic when partners are out of sync or when personal needs are unfulfilled. Dirk and Madeline may disagree about their relative roles as partners and co-parents based on gender roles. The partner's failure to agree on expectations can feel like a betrayal of the implicit cultural contract between husband and wife. On the other hand, they may both agree on their gender roles. For example, both Dirk and Madeline may commit to a patriarchal system with Dirk as the husband-leader and Madeline as the wife-helper. While agreeing to a male dominant structure, one or both partners may find that he or she has unexpected disappointment and unaddressed deficiencies. Dirk may find the burden of financial leadership and showing male strength and stoicism to be stressful and without adequate recompense. Without sufficient appreciation from Madeline and feeling inadequate economically, Dirk can feel trapped. Madeline on the other hand, despite accepting her role may find childcare and housekeeping to be intellectually simplistic and fundamentally unfulfilling. Compelled by their choice and cultural training, she cannot get Dirk to appreciate or understand her spiritual suffering. Kim and Sung (2000, page 343) in examining domestic violence in Korean American couples and comparing traditional Korean and American models of relationships believe that couples "must be counseled that family harmony can effectively be developed through egalitarian relationships rather than hierarchical ones." This suggestion concurs with feminist philosophy and the direction of American mainstream society towards greater or full equality. While it may also be compatible with therapist attitudes, the therapist should take care not to promote personal views. However, the functionality of an inequitable gender role relationship can be addressed if and as it may be ineffective for the couple. Suggestions for greater functionality may be compatible with a more egalitarian model. The therapist needs to make choices in session with attention to the particular dynamics and functioning of the specific couple being treated, without being driven by a cultural/political gender agenda.
This process distancing of early or internalized instincts from current interactions often cannot occur without first creating structural distance with negotiated boundaries. "The three most common contracts created for at-risk couples are 'no-harm,' 'in-house,' and 'out-of-home' therapeutic separation. All are used to structurally facilitate differentiation by creating and clarifying mutually agreed upon interpersonal boundaries. It is assumed structural changes decrease emotionality by creating space and time for partners to reflect on their process" (Perez and Rasmussen, 1997, page 242-43). A no-harm contract lays out a mutual agreement identifying aggressive spoken and non-verbal communications and behaviors- triggers that each partner is to avoid. The contract defines how to response to each other and triggers. More sensational triggers from the relationship and families-of-origin are identified. The partners work out the contract with the assistance of therapist incorporating history of prior arguments and battles. What is considered verbal and non-verbal aggression is defined behaviorally in the relationship and a safety plan worked out to be activated when needed. The safety plan lays out family, community, and legal resources to be used if intensity rises, and especially if abuse occurs- in particular, physical aggression or violence.
Contracts are negotiated for separating in-home and out-of-home to give space and safety and to interrupt negative intensity. "In-home and out-of-home therapeutic separation contracts specify duration and locations of separation, frequency of conjoint and/or individual therapy sessions, frequency and nature of contact with partner, boundaries around sexual contact with partner or others, contact with children, financial arrangements, commitment to completing homework assignments, and the contract duration. Terms are mutually agreed upon, put in writing, and signed by both partners and the therapist. Couples are instructed that fine tuning the contract is often necessary during the first week or two" (Perez and Rasmussen, 1997, page 242-43). Implicit with developing contracts is that prior responses to triggering events have not been productive and are badly destructive. Concrete actions with clear direction and limitations counter the dangerous ambiguity and unpredictability of previous responses by the partners. While the results of holding selves to a contract for temporary separation may not be automatically beneficial, they offer a reprieve from virtually automatic dysfunction and likely abuse. A couple such as Dirk and Madeline often persist in spiraling intensifying negativity resulting in some explosion of aggression or abuse. Contracts seek to break that cycle. Strategic therapy suggests breaking a negative cycle to doing something- virtually almost anything else as a precursor to developing productive behavior.
Breaking negative cycles is more difficult with a variety of complicating problems. Impulsivity in particular is a compelling characteristic to address. "Our finding that aggressive personality disordered offenders show evidence of a broad range of deficits in executive and memory function, particularly concept formation and logical memory, fits with much of the existing literature in antisocial populations (see Moffitt and Henry, 1991 and Dolan, 1994 for reviews). However, we have shown that it is offenders with high trait impulsivity that have deficits of this nature: a finding that may have specific implications for therapeutic interventions. Treatment modules incorporating strategies that deal with impulsivity and with social and cognitive processing deficits are clearly needed and subjects need to be matched to specific types of intervention (Serin and Kuriychuk, 1994)" (Dolan and Anderson, 2002, page 522). Once again simply not being impulsive is not easy. Not doing what is compelling is inherently difficult. Underlying causes and influences for impulsivity and compulsivity cross-validate and are mutually impactful. Treatment of any sort, including domestic violence treatment or couple therapy works with simple interventions and strategies when the issues are relatively simple. However, when the issues are convoluted and calcified by years and decades of stress or trauma, much more sophisticated work is required.