J Fam Viol DOI 10.1007/s10896-016-9810-6

ORIGINAL ARTICLE

Perspectives on Treating Couples Impacted by Intimate Partner Violence Nandini Maharaj 1

# Springer Science+Business Media New York 2016

Abstract Intimate partner violence remains a persistent social and clinical problem with far-reaching effects for families and communities. With considerable debate surrounding its treatment, two main approaches are commonly described in outcome research and clinical practice literature: gender-specific (e.g. male-only groups) and systemic approaches (e.g. conjoint treatment for couples). Proponents of the former approach cite the risks of systemic approaches that unwittingly sustain the oppression of women, while proponents of the latter highlight the importance of addressing reciprocal patterns of violence and cumulative sources of stress upon a couple. In this review, the author describes some of the issues pertinent to this debate, highlighting areas of risk and hope. The combined use of gender-specific and conjoint treatment may be beneficial for some couples under particular circumstances. The paper closes with considerations for conducting conjoint treatment. Keywords Adult . Intimate partner violence . Family/ domestic violence . Intervention . Treatment . Clinical issues . Trauma Intimate partner violence (IPV) represents a pervasive social and clinical problem with harmful and, in some cases, fatal effects (Bradley and Gottman 2012; LaTaillade et al. 2006). IPV may include physical, sexual, and psychological violence

Nandini Maharaj, School of Population and Public Health, University of British Columbia. * Nandini Maharaj [email protected] 1

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada

(Sylaska and Edwards 2014). Conjoint treatment for couples experiencing IPV arouses considerable debate among researchers and practitioners in the field of marital and family therapy (Lechtenberg et al. 2015; McCollum and Stith 2008; Todahl et al. 2012). Advocates of conjoint treatment have even been called Banti-feminist^ (George and Stith 2014). While conjoint treatment has garnered some support in research and clinical practice (Stith et al. 2012), there are a number of concerns involved in safeguarding the physical and emotional well-being of clients. Drawing upon some pertinent literature, both sides of this controversial topic are explored. The first section of this discussion examines the claims made by researchers and practitioners that argue against the use of conjoint treatment for couples. Central to this side of the debate are important considerations regarding the risk for increased violence and injury following treatment (Bograd 1984). The next section examines the literature supporting the use of conjoint treatment. Underlying this side of the debate is the view that the criticisms of conjoint therapy are based on an oversimplified interpretation of systems theory (McCollum and Stith 2007; Stith et al. 2012). This debate defies simple resolution considering the complexity involved in treating IPV. Nevertheless, one common thread is apparent among researchers and practitioners. Regardless of their theoretical orientation, the safety of victims is of paramount importance when conducting research and treatment (Bograd and Mederos 1999; McCollum and Stith 2007; O’Leary 2001). While acknowledging the immense diversity among those impacted by IPV, the literature on violence among same sex couples tends to be sparse (Stith et al. 2012). As such, this discussion focuses upon male perpetrators of violence against women in heterosexual relationships. To facilitate this discussion, a review was undertaken in an effort to understand the debate surrounding the treatment for

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IPV. Accordingly, this paper is intended to be a selective, rather than an extensive, review of the literature. Relevant literature was identified through a search of the following databases: CINAHL, PsycINFO, PubMed, and Academic Search Premier. Considering that our understanding of IPV has evolved considerably since the 1980s and continues to evolve in light of empirical research and clinical experience, papers published between 1980 and 2015 were included for review. I used the following search terms: (intimate or partner or spouse) and (violence or aggression or abuse). The search was limited to scholarly peer-reviewed papers that were published in English. After removing duplicate entries, the initial search returned over 500 results. To help narrow the scope of the review, I excluded papers addressing violence against children and adolescents, same sex couples, and people from nonWestern countries. Additional sources were found by reviewing the reference lists of peer-reviewed papers.

A Case against Conjoint Treatment

in an individual or group format, while treatment for women and children focuses upon providing support and empowerment (Stith et al. 2012). Shelter programs and victim support services may also be used by women when needed (O’Leary 2001; Stith et al. 2012). Concerns Associated with Conjoint Treatment Conjoint treatment, as a systemic approach, is intended to help couples learn how to lessen and gain control of their violent behaviours (McCollum and Stith 2007), without necessarily requiring that partners work together (i.e. in the same room) with the therapist (Bograd 1984). Violence is seen as evolving from an interactional sequence between the partners, and as having a functional role in maintaining the homeostatic balance of the relationship (Hattendorf and Tollerud 1997). The following issues were identified in the literature as shortcomings of systemic approaches for which gender-specific treatments may be more suitable: problematic language, responsibility for violence, misuse of conjoint treatment, risk of further harm, and safety planning.

Feminist Critique of Conjoint Treatment Consistent with a feminist perspective, violence is seen as being rooted in the inequality in power that characterizes many marriages and intimate relationships (Davis and Hagen 1992; Yodanis 2004). Ever-changing expectations regarding appropriate gender roles can lead to family conflict as members negotiate new roles and responsibilities (Hattendorf and Tollerud 1997). Some authors have criticized traditional family systems approaches for treating IPV, asserting that the underlying theories contain biases against women (Belknap 2001; Bograd 1984). Systemic approaches run the risk of neglecting the inequities in resources available to women and men, thus, supporting indirectly the social, cultural, and historical forces that contribute to the oppression of women (Bograd 1984; Dobash and Dobash 1979). Conjoint treatment may be particularly appealing among couples who wish to preserve their relationship. This appeal can obscure the risk of endangering women and exposing them to lethal violence (Bograd 1992). The end of a relationship can signify a potentially beneficial outcome for both partners rather than a failure of treatment (Bograd 1984). Gender-specific approaches to treating IPV highlight the importance of male offenders being held accountable for their actions. These approaches are often geared toward men with a history of criminal activity or psychopathology, in addition to men whose violent behaviour is considered severe (i.e. involving the use of weapons, resulting in injury or hospitalization) (LaTaillade et al. 2006). Some proponents of this approach argue that attributions of blame belong solely to the male perpetrator (Barnett et al. 1997; Bograd 1984). In this parallel model, male offenders receive treatment and psychoeducation

Problematic Language Early formulations of systems theory have characterized couples experiencing IPV as displaying patterns of symmetrical escalation, complementarity of roles, and overadequate-underadequate patterns (Bograd 1984). This terminology can be problematic for a number of reasons. To illustrate, the notion of an overadequate woman/ underadequate man represents a relational structure wherein violence is employed by the male partner to restore balance to the relationship. While the term overadequate is intended to refer to the woman’s capacities and resources (e.g. her occupational status), the term underadequate may have negative implications including the perpetuation of traditional gender roles. For example, labelling the male partner as underadequate can be used to convince the woman to allocate more decision-making power to the man in order to reestablish balance in the relationship (Bograd 1984; Dobash and Dobash 1979). Although systemic formulations can be useful for conceptualizing recurring patterns of violence, they can also be used to imply that violence is somehow normal or acceptable (Hattendorf and Tollerud 1997). Responsibility for Violence The systemic view of violence as being reciprocal is often construed as an assumption that each partner’s role in aggressive or violent interactions is commensurate (Barnett et al. 1997). This assumption is problematic, not only for the treatment of IPV, but also for understanding dynamic interactions in general. The relational dynamics of any couple are much more complex and varied than any singular interaction pattern and, as such, cannot be understood as the responsibility of one partner alone (Bradley and Gottman 2012; LaTaillade et al. 2006; McCollum and Stith 2008).

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When both partners are held accountable for escalating violence in the relationship, male violence may be seen as situated in the context of ongoing developmental and familial patterns. Accordingly, violence tends to be seen as merely one problem among a host of other concerns faced by the couple such as alcohol or drug abuse (Bograd 1984). While systemic approaches can help practitioners empathize with the couple, they can also be used to excuse the perpetrator’s behaviour. For instance, responsibility for violence can be overshadowed by therapeutic goals such as improving interaction patterns and conflict resolution (McCollum and Stith 2007). Rather than being treated as the primary target for intervention, violence may be attributed to some underlying dysfunction or pathology in one or both partners (Bograd 1992). Some interventions even focus upon intervening with the female victim to facilitate an overall change in the system (McCollum and Stith 2007; O’Leary 2001).

Safety Planning Some authors question the helpfulness of safety contracts that prohibit the use of violence before initiating conjoint treatment (Bograd 1992; Hattendorf and Tollerud 1997). While these contracts are intended to eliminate violence and ensure safety, they can be used to promote traditional gender roles and responsibilities. Some conjoint programs include a structured separation component with the provision that this treatment is contraindicated when there is severe violence in the relationship (O’Leary 2001). One significant problem with this approach is that definitions of severity and the actual consequences of violence for the victim can vary tremendously. While this criterion is designed to protect victims, it can permit milder forms of violence that are no less traumatic or harmful (Bograd 1992). Developing a safety plan requires an ongoing assessment of the level of risk and the services available to women.

Misuse of Conjoint Treatment Conjoint treatment is predicated upon the notion that a therapeutic relationship can be built with both partners in a couple. This assumption raises a number of important concerns regarding the motivations of perpetrators for entering conjoint treatment. Practitioners’ well-meaning efforts to enlist the cooperation of male perpetrators can lead to forming an alliance with them (Hattendorf and Tollerud 1997). Some men may use therapy to avoid consequences from the legal system, downplaying the severity of their behaviour (Bograd and Mederos 1999). In an effort to appease their partner, some perpetrators may enter treatment with the intent to use therapy sessions as a means to observe and control the content of the discussions (Bograd 1992). Moreover, by overlooking the power differential between the victim and perpetrator, practitioners who adopt a systems approach can unwittingly convey that the victim is responsible for her abuse (Dobash and Dobash 1979; Harris 2006).

A Case for Conjoint Treatment

Risk of Further Harm In addition to inadequately addressing IPV, conjoint treatment can cause further harm to victims with potentially lethal consequences. For women who are considering leaving their partner, conjoint treatment can restrict their ability to explore the costs and benefits of staying in their relationship. These women may not be able to communicate their views openly and honestly without compromising their safety (O’Leary 2001). Disclosing information in the presence of their abuser can place women at an increased risk for retaliatory violence (Maiuro and Eberle 2008; McCollum and Stith 2007). Some women have been killed following their attempts to seek support from professional services (Bograd 1992). The promise of treatment programs for men and women can lead to a false sense of optimism about the process of recovery. Providing yet another means to manipulate their partner, conjoint therapy can result in the re-victimization of women already in a vulnerable position (Harris 2006).

Advocates of conjoint treatment have challenged the criticisms made by feminist scholars (McCollum and Stith 2007; McPhail et al. 2007). Some of the more compelling arguments in favour of conjoint treatment highlight the limitations of gender-specific treatment and the benefits of systemic approaches for particular couples (Gurman and Burton 2014; LaTaillade et al. 2006; Stith et al. 2012). These aspects are discussed along with the impact of state regulations upon treatment options and practical considerations for conducting conjoint treatment. Empirical research suggests that conjoint approaches produce similarly beneficial outcomes as traditional gender-specific programs (O’Leary 2001). Although gender-specific treatment has demonstrated moderate success in decreasing violence, a number of issues limit the usefulness of this outcome research (Holtzworth-Munroe 2001). Methodological limitations include high dropout rates, a lack of clearly operationalized outcome measures, inconsistent reliance upon the reports of victims and perpetrators, and little indication of how long positive outcomes are sustained (Harris 2006; Maiuro and Eberle 2008; Stith et al. 2012). Limitations of Gender-Specific Treatment Programs Our understanding of what constitutes appropriate treatment for couples reflects a growing appreciation that IPV is far from a homogenous experience (Bradley et al. 2014). Different typologies of IPV and violent offenders have been identified, informing the development of current treatment approaches, including conjoint treatment (Bradley and Gottman 2012; LaTaillade et al. 2006; Stith et al. 2012). These treatment approaches are not all alike, nor are they applied uniformly in different practice settings (Bradley et al. 2014). For example, therapists who work with couples to improve their

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communication patterns are not necessarily practising from a systemic perspective (Vall et al. 2014). Consequently, not all conjoint treatments are systemic in nature. Excluding cases involving lethal violence, conjoint treatment appears better suited for couples who display a form of IPV called situational violence (McCollum and Stith 2008). In situational violence, one or both partners may use physical aggression to exert control in specific situations. This form of IPV less commonly escalates over time resulting in severe injury (McCollum and Stith 2007). In cases involving situational violence, genderspecific approaches only treat one source of the problem. Furthermore, some couples may not be willing or able to fulfill the demands of completing gender-specific treatments. More than hindering therapeutic progress, when couples drop out of treatment, neither partner is helped (Lechtenberg et al. 2015). Eliminating violence may require that reciprocal patterns of violence be addressed with both partners (Gurman and Burton 2014). The inclusion of women seems warranted as mounting evidence suggests that women also initiate and engage in violent behaviour (Bradley et al. 2014; O’Leary 2001). This finding is particularly troublesome as the risk for severe injury increases for a woman when she also engages in physical aggression (Rosen et al. 2003). However, as LaTaillade et al. (2006) emphasize, attending to aggression by women in no way implies that women should be held responsible for their partner’s aggression. Another weakness of gender-specific treatment programs is that these approaches can overlook factors (e.g. relationship dynamics, marital discord, emotional distress) that precipitate violence or increase its likelihood (McCollum and Stith 2007). Gender-specific treatments have limited utility for couples who are currently nonviolent but are at risk for future violence (LaTaillade et al. 2006). Conjoint treatment can assist the couple with managing factors that precede violence (Bradley and Gottman 2012), particularly, in cases involving violence against the family rather than the general public and among perpetrators who display no evidence of psychopathology (Harris 2006; Stith et al. 2012). Promising Aspects of Conjoint Treatment Clinical experience tells us that couples often stay together in spite of ongoing violence (Bradley and Gottman 2012; Harris 2006; McCollum and Stith 2007). These couples must contend with ongoing role demands including parenting and managing finances. Though ineffective, violence can be used as a way of coping with stressors and interpersonal problems. Conjoint therapy can be helpful for addressing these cumulative sources of stress on a couple (McCollum and Stith 2007). Conjoint therapy emphasizes skill development, allowing each partner to practise new patterns of interaction under the guidance of their counsellor (Harris 2006; Todahl et al. 2012). Interventions can be adapted according to the couple’s needs and concerns as they arise. Counsellors can offer

encouragement and support to the couple, as well as, model adaptive behaviours and communication skills. The intersection of IPV and alcohol and substance abuse presents another challenge for which conjoint treatment is especially promising (McCollum and Stith 2008; O’Leary 2001; Stith et al. 2012). Research has demonstrated the effectiveness of behavioural couples treatment (BCT) for decreasing IPV (Stith et al. 2012). In BCT, the couple learns to develop skills and change dysfunctional patterns in an effort to abstain from drug and alcohol abuse. In addition to helping the substance addicted partner, BCT provides the couple with coping mechanisms and skills to manage safety in their relationship. Compared to programs that treat perpetrators and victims separately, conjoint treatment may reduce the stigma evoked by entering treatment for IPV, thereby removing an important barrier to accessing services (Harris 2006). The Impact of State Regulations Therapeutic interventions may not be equally appropriate for all client populations, given the considerable heterogeneity that characterizes perpetrators and the treatment programs available (Harris 2006; Holtzworth-Munroe 2001; O’Leary 2001). In compliance with some U.S. standards, group therapy represents the primary modality for treatment (Maiuro and Eberle 2008). Approaches specifically targeted at violent offenders have not garnered consistent support (Lechtenberg et al. 2015; McCollum and Stith 2007). For example, the traditional group format for male perpetrators can provide a context for reinforcing violence. Engaging in social comparison, some men may minimize the harm they are causing and conclude erroneously that they are less violent than their peers (Stith et al. 2012). Although some states permit conjoint therapy, a number of them prohibit the inclusion of victims in treating perpetrators of IPV. Hindering the development of alternative approaches to treatment, some of these state standards have been imposed on the basis of preliminary clinical reports rather than rigorous empirical research (HoltzworthMunroe 2001; Stith et al. 2012). These standards require attention to ethical safeguards and an ongoing process of examination and revision to stay in line with the available research (Lechtenberg et al. 2015; Maiuro and Eberle 2008). Considerations for Conducting Conjoint Treatment In light of the methodological shortcomings of research on gender-specific approaches, it seems wise to explore the viability of alternate approaches such as conjoint treatment. Provided that safety remains a primary concern, conjoint treatment might be useful in conjunction with individual treatment for particular couples (Lechtenberg et al. 2015; McCollum and Stith 2007). Systemic approaches can attend to the transmission of violence from one generation to the next (Maiuro

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and Eberle 2008). A noteworthy commonality among abusers and victims is having previous experience with violence in their family of origin (Hattendorf and Tollerud 1997). Both men and women may learn patriarchal attitudes that grant men supreme power over decision-making (Dobash and Dobash 1979; Stith et al. 2012). Rooted in the family of origin, rigidly defined rules and gender role expectations may contribute to the belief that violence is normal (Hattendorf and Tollerud 1997). It should be clarified, however, that an emphasis on patriarchy and male privilege as the primary cause of IPV is considered an Boutdated^ explanation (George and Stith 2014; McPhail et al. 2007). In response to the critique of feminist scholars, systemic approaches can be used to acknowledge the power imbalance between the partners and facilitate the development of more egalitarian patterns of interaction. Recognition of the intergenerational transmission of violence can help to understand current behaviours in the context of ongoing patterns of violence (Hattendorf and Tollerud 1997). Rather than providing justification for the perpetrator’s actions, this systemic approach can be employed to encourage the man to accept full responsibility for his behaviour and empower the woman to take control over her safety and emotional well-being (Lechtenberg et al. 2015; McCollum and Stith 2007). The concerns raised about the potential for therapists to form an alliance with the perpetrator at the victim’s expense do not appear warranted in light of clinical reports. As with any therapist who is trained within a particular theoretical tradition, receiving training in systems theory does not imply that a therapist will necessarily use systemic approaches in his/her actual practice (McPhail et al. 2007; Stith et al. 2012; Vall et al. 2014). Among therapists who do adopt a systemic orientation, few actually prioritize maintaining therapeutic neutrality ahead of taking a stance against violence and aggression (Bradley and Gottman 2012; Stith et al. 2012). Additionally, regardless of their theoretical orientation, many therapists do not attribute one partner’s aggression as a response to the other partner ’s actions or behaviour (LaTaillade et al. 2006). Underlying this perspective is a belief in the importance of providing treatment options that can empower vulnerable members of our society to seek help (Bradley and Gottman 2012). Given that abuse can be a profoundly isolating experience, practitioners have a valuable role in offering support to their clients regardless of their decisions about their relationships. In seeking help from healthcare providers and law enforcement agencies, some women may experience secondary victimization. Diminishing the severity of the woman’s trauma, some service providers may blame the victim or attribute the abuse to some underlying pathology (O’Leary 2001). Secondary victimization can perpetuate the belief that IPV is a private matter rather than a criminal offence. According to Hattendorf and Tollerud (1997), individual counselling is

needed to resolve the trauma associated with IPV. Accordingly, delaying a couple’s referral to conjoint treatment has been recommended to enable the woman to initiate the process of trauma resolution (Hattendorf and Tollerud 1997). For couples who wish to stay together, treatment programs for male perpetrators can neglect important relationship dynamics (Bradley and Gottman 2012; McCollum and Stith 2007). Withholding services that can accommodate the needs of both partners does a particular disservice to the female partners who remain in the relationship (Bradley and Gottman 2012; McCollum and Stith 2008; Rosen et al. 2003). Conjoint approaches can address the victim’s involvement in violence without blaming her. Efforts to grant women a more inclusive role in implementing strategies to reduce violence can be seen in the use of the negotiated time-out procedure (Rosen et al. 2003). The couple can use the deescalation tool to learn how to recognize and gain control over their anger. Teaching this tool conjointly allows both partners to be involved in defining and practising the procedure. When couples receive information about the rationale for the tool and its appropriate use, they tend to feel more invested in managing safety and in developing skills to negotiate current and future conflicts (Rosen et al. 2003; Todahl et al. 2012). While in the traditional format for couples therapy, both partners share responsibility for their interaction patterns (Maiuro and Eberle 2008), conjoint treatment encourages the offender to assume responsibility for his behaviour and express a commitment to changing his behaviour (Bograd and Mederos 1999; Lechtenberg et al. 2015). Before considering conjoint treatment, careful screening of couples at intake is necessary (O’Leary 2001; Stith et al. 2012). It is not uncommon for couples attending therapy to avoid disclosing the existence of physical violence in their relationship (Bradley and Gottman 2012; LaTaillade et al. 2006). Both partners must enter treatment voluntarily and feel safe disclosing information without fear of retaliation (Stith et al. 2012). In addition to specialized training and experience with IPV, conjoint treatment requires competence with using systemic approaches in order to detect and respond to signs of escalating violence (Bradley et al. 2014; Gurman and Burton 2014; Todahl et al. 2012). Specifying educational requirements and providing practitioners with ongoing education can improve the delivery of services (Maiuro and Eberle 2008; Sylaska and Edwards 2014). Practitioners would be wise to keep abreast of ethical and legal issues regarding confidentiality (Bograd and Mederos 1999). Finally, safety assessment is not a one-time issue but rather an ongoing aspect of risk management and treatment that requires practitioners to be knowledgeable about safety planning (O’Leary 2001; Stith et al. 2012). Conjoint treatment is not suited for couples when either partner wishes to end the relationship or when there is evidence of severe violence. Given the potential for escalating violence, conjoint therapy

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can be suspended to ensure the safety of both partners (McCollum and Stith 2007). Even if conjoint treatment is not clinically contraindicated, it is important to determine whether other modes of treatment are more beneficial such as a support group for female victims (McPhail et al. 2007; Todahl et al. 2012). These last points have some important implications that are worth emphasizing. Considering the prevalence of IPV, many therapists will encounter individuals and couples who are experiencing IPV, irrespective of the therapist’s theoretical orientation or clinical specialization (Stith et al. 2012). While the debate continues in the literature regarding the treatment of IPV, in actual practice, there is some consensus that listening to what couples need and want is preferable to imposing predetermined or standardized interventions, the outcome of which may be that neither partner receives the help they are seeking (McPhail et al. 2007; Todahl et al. 2012). What is clear from the literature is that understanding and addressing IPV is much more nuanced and complex than merely aligning oneself with a particular side of the debate. IPV is no more amenable to explanation by a single cause as it is to resolution by a single treatment (McPhail et al. 2007).

Conclusion The foregoing discussion has provided an overview of each side of the debate surrounding the use of conjoint therapy with couples contending with IPV. At the forefront of these competing theoretical perspectives are concerns for holding the perpetrator responsible and safeguarding the well-being of the victim (Stith et al. 2012). In addition to the harmful impact of IPV upon a couple’s physical and emotional well-being, there are profound implications for children, families, communities, and the larger society. Although this issue is beyond the scope of the paper, the well-being of children is crucial in light of concerns regarding the intergenerational transmission of IPV (Maiuro and Eberle 2008). While this attempt to offer a balanced perspective by no means resolves this contentious issue, it does offer some hope that the combined use of individual and conjoint treatment may be beneficial for some couples. Bearing in mind that there is no one preferable mode of treatment, the decision to impose standards that prescribe one mode of treatment to the exclusion of alternatives seems shortsighted (O’Leary 2001; McPhail et al. 2007). On the basis of careful screening and the implementation of safety precautions, treatment can be tailored to each couple. Finally, more research is needed to understand and address the needs of same sex couples. Acknowledgments The author acknowledges the anonymous reviewers and Gayatri for their help with improving the paper. Thanks must also go to Dally.

Compliance with Ethical Standards Conflict of Interest interest.

The author declares no financial conflicts of

Human and Animal Rights The paper does not involve a study with animal or human patients. Informed Consent state.

There are no informed consent notifications to

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