The Obligation to Assess
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 client’s 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.
Undiagnosed Partner Abuse
One error I encounter with troubling frequency is 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 ways of controlling, hurting, or frightening another, and they can be more emotionally damaging in the long run.
I have met with couples whose seasoned therapists, over the course of several years’ treatment, 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 pale description of the soul-damaging, spirit-deadening impact that ongoing abuse has 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. Therapists have said:
“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.” Abusive partners easily subvert communication skills at home. “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 uninterrupted.
Indicators of Partner Abuse
Clients in abusive relationships present with typical complaints:
- “We’ve been arguing a lot.”
- “We’re both under a lot of stress.”
- “We hardly ever have sex anymore.”
- “We disagree about disciplining the children.”
- “We don’t know how to communicate with each other.”
- “We’ve needed counseling for a long time and he/she finally agreed.”
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 my 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. I might say to them:
“During the last several sessions, I’ve had a chance to see how you interact with each other. As part of our work together, and in order to get to know you better, I’d like to schedule an individual appointment with each of you. I want to find out more about you, your childhood, family history, that sort of thing.”
I wait until each partner’s individual session to address the issues of confidentiality and “secrets.” At that point, I might say something like:
“This is 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.”
The Abusive Behavior Inventory
I also tell each partner that I would like to ask a series of questions about the kinds of behaviors that have happened in their relationship. With the abusive partner, I am especially interested to learn whether similar behavior has occurred in any previous relationships, because it counters the common belief that the current partner is in some way responsible for the abuse.
For this purpose I use my own Abusive Behavior Inventory, which I developed after several years of clinical work in the domestic violence field. (You may download a slightly abridged version here.) I frequently supplement the specific questions on the inventory by inquiring about the first, last, and worst conflicts the couple has had.
Using this inventory in 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
When individual sessions reveal a pattern of partner abuse, my recommendations 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. 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 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 the behavior I observed or heard about in meeting with the two of them together. If the abusive partner has acknowledged any abusive behavior–and it is extremely rare for the Abusive Behavior Inventory to bring no abusive behavior to light–I refer to that as well.
In the typical abusive heterosexual relationship, I generally refer the man to a men’s group with a focus on partner abuse (one of my own groups, or a colleague’s). I refer his partner to a group 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.
It is important to be resolute about my recommendations prior to the final assessment session so that I keep to them, whether or not the couple finds them acceptable. One or both partners will sometimes attempt to mount a persuasive argument for being seen together, and occasionally one of them will insist on having therapy together or not at all.
However, my express purpose is to send a clear and unwavering message at this stage of treatment that couples therapy is premature–just as I would regarding family therapy with a parent who currently abused the children or who was an active alcoholic.
Problems with Couples Therapy
Arguments for and against conjoint treatment in cases of partner abuse are often heated and polarized among treatment professionals, in a process that runs parallel to the typical dynamics in an abusive relationship.
By training and experience, I believe in the paramount importance of holding the abusive partner (or partners) accountable for his or her actions, regardless of what the other partner says or does. Couples therapy can communicate, either overtly or by implication, that both partners bear equal responsibility for the abuse.
There are practical considerations as well. Abusive couples who leave a session with unresolved issues are more likely to erupt afterwards. Additionally, conjoint therapy is generally not productive when control issues distort the therapeutic process or when either party fears serious repercussions for speaking the truth.
Before I would consider treating an abusive couple together, they would have to meet several conditions:
- Their answers to the Abusive Behavior Inventory match closely.
- Past abuse was moderate to mild; currently, abuse is extremely mild or entirely 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.
Conclusion
Treating partner abuse is a specialized field. Trainings in recognizing and treating the problem are helpful, but the only way to develop real expertise is through direct experience.
To that end, I recommend that you become familiar with an assessment tool like the Abusive Behavior Inventory and practice administering it to a few colleagues. As with any new tool you add to your clinical repertoire, the greater your comfort in using it, the more at ease your clients will be when you do.
Then, the next time you suspect partner abuse, you’ll be ready to assess for it. When you do, share your findings 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 the danger of leaving partner abuse undiagnosed and untreated.
Without intervention, the frequent outcome is an uninterrupted, escalating pattern of abusive behavior, accompanied by additional years of unnecessary pain and suffering and the possible transmission of abuse to the next generation.
Albert J. Dytch, Licensed Marriage and Family Therapist, has been treating partner abuse and domestic violence since 1984. He worked at Men Overcoming Violence and STAND! For Families Against Violence and was co-founder of The Center for NonAbusive Relationships. He currently leads three 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.