Conducting effective family therapy is never a one-size-fits-all proposition. In our work with families, we must keep in mind that, just as the dynamics in each family are different, so, too, must be our approaches. This is particularly the case for people who are experiencing intimate partner violence, or IPV.

The cases of three patients described below illustrate that point well; I’ve changed the patients’ names to protect their anonymity.

Belkis

Conducting effective family therapy is never a one-size-fits-all proposition. In our work with families, we must keep in mind that, just as the dynamics in each family are different, so, too, must be our approaches.

She is a hardworking immigrant making minimum wage as a housekeeper. She presents to her psychiatric outpatient appointment with complaints of being sad and anxious. When asked about her husband and their relationship, she says tentatively that they disagree about things. She doesn’t acknowledge any abuse until she is asked directly, then she hangs her head down and looks ashamed. "He tells me I am not a good wife." With encouragement, she admits that she would like to leave him but has nowhere to go and is afraid that he will really hurt her if she tries to leave. "I tried before, and he threatened to kill me if I tried again."

Melanie

She is a well-educated women working as a writer and has a good income. She presents to her psychiatric outpatient appointment with complaints of being sad and anxious. When asked about her husband and their relationship, she says that he is abusive to her. She states that she would like to come into therapy to figure out why she has not been able to leave him. "What ties me to him?" She says her friends tell her she should leave. "There must be a reason I stay; can you help me figure it out? I cannot move to another relationship without understanding what is going on in this one."

Zelda

She is a successful saleswoman and comes into the office with the complaint that she and her husband are having problems. On direct questioning, she affirms that that two do engage in direct fighting that gets physical at times. She says she often initiates the violence. She wants to stay with her husband and says they both want to make a go of things. They want to come into couples therapy and work on improving their relationship. But they fear that if they do go to a therapist together, as soon as she says there is violence in their relationship, she will be refused treatment.

Different cases, different approaches

Belkis benefits from treatment that focuses on support, education about domestic violence, and help with developing a safety plan. She wants to leave but needs the help and structure to do so.

Melanie enters individual therapy, and comes to understand that in her relationship with her husband, she is reenacting the relationship she had as a child with her parents. As a child, she felt like she was there only to help her mother clean and care for her sibling and that her needs and desires did not matter.

She felt that her elder brother was the favorite and that she had to support him as he pursued his studies. In her current relationship, she strives to "matter as a person" and not be seen as someone to do the cooking and the chores. She speaks back to her husband and challenges him when he demeans her. When she understands that the dynamic that binds her to her husband is the same dynamic that she experienced growing up, she feels relieved. "Now I can begin to think about taking care of myself and setting my own goals for my life. Now I can leave my past behind," she said.

Zelda and her husband want couples therapy. Both are committed to the relationship and stopping the violence as well as learning how to solve problems, communicate better, and meet each other’s needs by asking and negotiating. Before entering couples therapy, they agree to stop any violence while in treatment. The therapist teaches them skills to "take a time out" when conflict arises. As I’ve written previously, if patients are unable to discuss the issue calmly, they bring it to therapy (Adv. Psychiatric Treat. 2007;13:376-83).

How common is IPV?

Violence against women was not viewed as a serious issue until the second wave of feminism increased awareness, pushed for legislation, and increased resources.

How should we understand IPV? This phenomenon is often bidirectional, where each partner is both an aggressor and a victim, although women remain much more likely to be injured by partner violence than are men (Am. J. Public Health 2007;97:941-7).

In an outpatient sample of couples seeking marital therapy, 64% of wives and 61% of husbands were classified as aggressive (Violence Vict. 1994;9:107-24). In 272 engaged couples, 44% of women and 31% of men reported physical violence toward their partners (J. Consult. Clin. Psychol. 1989;57:263-8). As illustrated by the three cases above, IPV occurs across a range, from the classic male perpetrator and female victim, to the couple that engages in mutual violence.

Why do women stay?

Researchers such as Virginia Goldner, Ph.D., of the Ackerman Institute for the Family in New York, have contributed significantly to the understanding of why women stay in violent relationships. Dr. Goldner describes a generational imperative that is passed from mothers to daughters (Fam. Process 1990;29:343-64). This often includes the view that the role of women is to preserve the family, regardless of either the personal cost or the presence of abuse or violence.

Daughters raised in a highly patriarchal family might suffer existential neglect and be undervalued except in their capacity as caregiver to others in the family. Therefore, staying in a relationship protects the woman against guilt that she might feel if she gives up her caretaking role. These daughters may grow up with the belief that "being loved" is contingent upon denial of their self, being selfless. They may see the opposite as "being selfish" and not compatible with their self-image. Melanie certainly identified this guilt and had difficulty thinking about meeting her own needs.

Asking women about their mothers and the internalized view of themselves as independent agents can expose this dilemma. These daughters may see their mothers as powerless, devalued, and depressed. Being loyal to their mothers means accepting a subjugated role, while allying with their fathers means betraying their mothers and their own sense of themselves, as a woman.

If you decide to take a couple into therapy, it is important to interview each member of the couple individually before starting couples therapy. The information you glean from these interviews also will help determine when to offer and when not to offer couples therapy.

Factors that should encourage you not to proceed with couples therapy include the uncontrolled, continuous use of alcohol or drugs; fear of serious injury from the patient’s partner; severe violence that has resulted in the victim requiring medical attention; conviction for a violent crime or violation of a restraining order; prior use of a weapon against the partner; prior threat to kill the partner; stalking or other partner-focused obsessional behavior; and bizarre forms of violence, such as sadistic violence.

Here are a few guidelines for assessing intimate partner violence:

• Ask about relationship violence. Consider use of a questionnaire.

• If present, determine severity and ask about fear of partner.

• Identify risk factors for the potentially lethal relationship.

• If substance misuse is present, recommend abstinence and refer for treatment.

• If the couple wishes to stay together and to resolve the intimate partner violence, refer for conjoint treatment with a specialized family therapist.

• Assess and treat common comorbidities such as major depressive disorder and post-traumatic stress disorder.

Belkis, Melanie, and Zelda are three different women in abusive relationships who require three different solutions. Each patient requires a treatment based on their unique history and goals. Make sure that you are a family psychiatrist who understands the differences between your patients – and that you are able to provide a solution tailored to teach patient’s needs.

Elements of a safety plan

Encourage patients who in the midst of intimate partner violence to take the following steps to keep them and their families safe:

• Memorize phone numbers of people to call in emergency.

• Teach older children important phone numbers and when to dial 911.

• Keep information about domestic violence shelters in a safe place where you can get it quickly when you need it.

• Buy a cell phone that the abuser does not know about.

• Try to open your own bank account.

• Stay in touch with friends and neighbors. Do not cut yourself off from people.

• Rehearse your escape plan until you know it by heart.

• Leave a set of car keys, extra money, a change of clothes, and copies of important documents with a trusted friend or relative.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Tailored therapy needed to conquer IPV