Issues in the treatment of domestic violence
based on article published in The Renfrew Perspective, 1996
As a number of recent court cases and homicides make clear, domestic violence is not confined to any one socio-economic or ethnic segment of this nation. However, middle class women may be reluctant to bring up battering experiences in therapy. The aim of this article is to give an overview of treatment as it has developed in the last decades and to suggest some ways to surface the problem in the course of psychotherapy and, once surfaced, what to do with it.
First a word about the gender of DV victims. While one NYC shelter averages about one male resident per year, DV is overwhelmingly a crime against women. As times change, we may see more males (straight as well as gay) reporting abuse but as of now it is a problem that needs to be viewed through a feminist psychological lens. And for sake of simplicity, I will be referring to all batterers as male(even though women do batter female partners in lesbian relationships, and I will refer to all victims as female.
It seems evident that, without the second wave of feminism, an accurate view of battering would not have been possible. This is true of many other "women's problems" ,such as eating disorders, but in DV the entire beginning of effective treatment occurred within a political movement. And because women's lives were being lost with the unwitting collusion of a blaming mental health system, early DV advocates were distrustful of therapists or of psychologizing the dynamics of battering.
Battered women were being diagnosed with masochistic or dependent personality disorders, and female relational capacities and self-definitions were not yet recognized, nor were the effects of chronic trauma on the personality and on object choice.
It can be said that there is an ongoing tension between the "movement" and the "clinicians". In my work, I try to integrate the invaluable political insights of the "movement" with what I find valuable in relational psychology and in PTSD theory. This combination of the didactic and the therapeutic is what makes work with this population challenging and, to me, very satisfying. I hope that more therapists can become comfortable with this work or at least more aware of how to identify these women and refer them to specialized resources.
RECOGNITION OF DV IN THE CLINICAL SETTING
Apart from the obvious physical signs, therapists need to think
of DV as a possibility in women evidencing some or all of the
following: chronic depression, sexual problems, avoidance of discussing
their intimate relationships, somatic complaints, pervasive helplessness,
fear of leaving someone they no longer love, little trust of others
despite high social functioning or along with social isolation
(few female friends, little contact with family of origin). Obviously
this is not an exhaustive list of signs and its breadth is another
way of saying that battering happens to all types of women, with
or without all the other coexisting problems that may bring them
Bit its worth mentioning the frequent coexistence of eating disorders, sexual abuse histories (and asthma) with DV.
(Although the focus of this article is on battered women, its worth noting that the battered man may exhibit all the above characteristics. Also therapists treating men can be alert to signs of possible batterers, including extreme jealousy, low stress tolerance, poor impulse control, severe mood swings, acceptance of violence for problem-solving, philosophy of patriarchy and control.)
When working with a couple in which one or both spouses show DV signs, the therapist needs to find a way to broach the subject (without endangering the victim). It is my experience that it is a great relief to be recognized as such a victim. At the same time, it may be experienced as humiliating initially by the woman and so must be approached gently. Adjuncts such as support groups or reading may be the places she first can identify herself but she must of course feel that this is a subject for individual therapy as well. The well-meaning referral to a hotline or support group can feel like the therapist wants someone else to handle the patient's pain and ambivalence.
As we have learned with sexual abuse and eating disorders, if we don't ask they don't tell- or don't tell for a long time. Some therapists integrate a question about violence into initial interviews, with individuals or couples (e.g "How do you handle disagreements in your relationship? Is violence or threat ever used?"). Sometimes this uncovers a pattern of mutual abuse that should not be ignored in favor of seeing only female victimization.
On the other hand, men sometimes mislabel a woman's self-defense by calling it mutual abuse.
What Do I Do After Uncovering the Violence?
Both therapist and patient would do well to read GETTING FREE by Ginny NiCarthy (1986) for basic information and support. Just as rape is about power and not sex, abuse is about control and not love -- although in both cases the sexual organs are involved and in DV, emotions are usually intertwined. It is my observation that the abusive man may in fact love as well as need to control his "woman" and that both he (and often she) confuse the two. Other abusers have little concept of love but have learned to cloak their control needs in appealing words. Some victims have no more ability to love than do their abusers, and are merely dependent emotionally and very often financially. Untangling this is the work of therapy. What housing and financial resources and legal help will be available, once a woman is ready to leave, is another story and one that varies by locale. Sometimes the therapist will be surprised at the resources that do exist locally, despite hearing from the depressed patient that there is nothing.
Even when resources are available, the patient has to work through feelings about being identified as a battered woman, and about perhaps going to a shelter setting with its loss of privacy and unfortunate association with poverty. Or she will have to depend on family with all the ambivalence that may exist therein. All too often she will hear "I told you so" or be blamed for not being a better wife.
Sometimes the therapist empathizes a bit with the abuser while sitting with a highly provocative client. While the client will ultimately need to learn new ways of relating, the time for that focus is later. When she blames herself for inciting violence, the cardinal reminder I use is the movement slogan "Whatever he says you did, he has no right to hit you."
This also applies to his having no right to threaten, belittle, humiliate or dominate her and her activities or loved ones. Such behavior constitutes emotional abuse. See GETTING FREE for a helpful checklist for identifying such abuse. While not considered a crime, this kind of abuse can be more damaging in the long run, and also usually accompanies physical violence or occurs between physical episodes. It is rare for physical violence to occur without emotional abuse preceding it.
But to get to the point of leaving, both therapist and client will have to understand a great deal about the abuser's psychology, the dynamics of the abusive relationship, ideas about gender roles, and the nature of the patient's attachments.
The abuser's psychology: This is a tricky area therapeutically because most battered women already spend too much time focused on figuring him out, trying to fix him, maneuvering around him. What has to be made clear is that understanding how he ticks is for the purpose of freeing herself, not for learning how to endure. In the "Safety First Model", the emphasis is on recognizing the triggers for her mate's violence and on making herself as safe as possible as long as she stays under the same roof.
This is a good place to note that, for some women, this will be the end goal, or the only goal they are willing to contract on at the beginning of treatment. The therapist can work toward her leaving eventually by linking feelings that she has been dissociating or denying, but of course, cannot impose his or her goal on the client. What is tragic is that some women will be in more danger if they do leave, at least under our present system of permitting stalking. So a sober evaluation of the facts and resources should take place between therapist and patient, but the more she understands her particular abuser's psychology, the better equipped she is to stay or go, and protect any children or pets.
Support groups are invaluable in teaching common abuser patterns and for sharing "war stories" that cut through the otherwise chilling isolation and self-blame of these women. A well-run support group fosters enough of this camaraderie to decrease shame and foster trust, but eventually brings the focus back to the women's desires and powers. Of course, some women have severe PTSD from their experiences and need significant attention to their suffering before they can think about empowerment. As with all severely traumatized or chronically traumatized people, basic human trust is impaired and has to be reestablished with the therapist before any other work can occur ( Herman 1994).For the severely dissociated woman, the therapist needs specialized training, as she would with sexual abuse survivors.
The dynamics of domestic violence:
The description of the "Cycle of Violence" has been groundbreaking for the movement and for individual battered women. In this cycle, which seems to hold true for all batterers, tension-building always leads to violence which eventually subsides into a "Honeymoon Stage" which
in turn will unfortunately develop into tension building once again (be it the next day or in five years). Denial fuels this cycle and coercion techniques (such as
"demonstrating omnipotence" or "occasional indulgences"), keep the cycle going. These coercion techniques can be likened to the brainwashing of POWs and not only keep the woman trapped but may cause deep injury to her personality (Russell 1984).
More recently, we speak of the Calm Phase instead of
the Honeymoon Phase because many abusers do not apologize or ply their victims with flowers and gifts. Whatever the abuser's behavior in that phase however, the combination of relief and denial she feels makes it hard for the woman to believe that there will be a "next time"; the exhaustion she feels from the Crisis Phase makes it hard for her to think of planning an escape. The sensitive therapist will understand this and not expect immediate action. At the same time, when she eventually may be ready to leave, the Calm Phase is the time to act. There is a sort of comfort in knowing that there will always be another Calm Phase, as long as neither she nor the therapist are lulled into believing that the cycle is over and will not keep repeating.
What About Couple Therapy?
For many years the prevailing wisdom was firmly against couple therapy as a DV intervention because of the rate of increased battering that was reported following sessions that had impactful content. However, certain approaches appear to benefit at least certain couples. For five years, the Ackerman Institute for Family Treatment in new York City ran a Gender and Violence Project that attempted to deconstruct the violent moment and undo the gender-based constructs that lock couples into "problem-maintaining relationships" (see Goldner, 1990). Narrative Therapy (e.g. White 1995) similarly seeks to "rewrite" the narratives of batterers so that love doesn't equal weakness, or in an Ericksonian-type "utilization technique", it reframes the man's desire for control. He learns that control over violent impulses is appropriate, as opposed to exerting this control over "his" woman and children. Or he relearns his concept of masculinity as a protective role, including protecting his family from parts of himself! ( Braverman, 1996).
Finally, Rhea Almeida and the Institute for Family Services (Somerset, NJ) report promising results from treating violent families within a structured program that includes gender-based groups, and mentoring for each spouse, as well as couple therapy once the violence has ceased. The mandatory arrest law in New Jersey facilitates this model; its harder to imagine in a state where stalking is still a misdemeanor and police are powerless to help women who are too afraid to press charges.
In Ontario, Canada, the Windsor Family Forum uses a model that is similar to Almeida's with good success. When a man is unwilling to acknowledge that battering is wrong, his partner is helped to enter a shelter.
As noted earlier, there is no prevalence of DV associated with ethnicity or class, but cultural groups do interpret the phenomenon in various ways. I have noted that low income women from all cultures are less shocked by abuse; their middle and upper class "sisters" are more surprised but this is not because of a lower incidence of the problem among them. Rather, it seems due to the experience of more shame and isolation. Some social scientists of color have attributed DV to the general oppression their men live under, but most women of color with whom I've worked demand that "their men" take more personal responsibility for their actions.
What is particularly challenging is working with women from very insular communities such as Muslim, Orthodox Jewish and some Asian groups. The family and community pressure, the religious support for patriarchy, the relative seclusion of these women (and sometimes language barriers) makes their breaking away all the more difficult. It is essential that the therapist have contacts who can answer questions about culturally-mediated behavior and, better yet, intercede with religious authorities.
Some headway is being made in New York's Orthodox Jewish community by rabbis reinterpreting the Torah's call for "Peace in the Home" ("Shalom Bayis") as an injunction against male violence; previously it was an injunction against the wife's leaving!
The Relational Glue
In a workshop at the 1995 Renfrew Conference, I suggested that "The Missing Piece in the Clinical Picture of Domestic Violence" was the "Connection to the Abuser". I talked about adding a relational perspective to the political/systems perspective, on the one hand, and substituting attachment theory for the psychology of masochism or brainwashing. I did not mean that women's relational needs make then victims but rather that connectedness can have be a "gluey" quality that is actually part of female strength (be it biological in origin for childrearing purposes, or culturally constructed, or both).
I had found that until this was understood in therapy, women remained stuck despite receiving excellent consciousness-raising about the cycle of violence. This makes fairly obvious clinical sense; we would not work on separation issues with any patient in a purely didactic way.
However, some in my audience thought my title referred to the therapist's connection to the abuser. In fact, I think we need to consider both directions of connection. In order to understand the victim's connection the abuser, I would argue that we have to understand our own countertransferential "connection" to the abuser. That is to say, the therapist must resonate with the woman's relationship to her mate, in all its vicissitudes. Empathy with the victim's suffering needs to be joined by a feeling for her positive connections, however few or inadequate asthey may seem to the therapist.
In my experience, the therapist needs to feel the patient's love for,- as well as rage at, fear of, pain from, - the abuser. In so doing, we experience our own vulnerabilities, longing for powerful authorities, linking of sexuality and pain, willingness or refusal to compromise to be loved, and other personal dynamics that can be painful to revisit or discover.
It could be argued that the battering relationship represents an extreme form of the dominance dynamic underlying all love relationships (starting with infant-mother).It has been argued that the dominance dynamic undergirds all heterosexual relationships or all love ties in a patriarchal culture where even gay couples learn roles.(Benjamin 1984).
From this viewpoint, even therapists in very equalitarian relationships may identify with some of either the batterer's vying for power and. or his fear of dependence/abandonment. Or we may recognize some version of the victim's trading of oppression for security as all too familiar.
To summarize, the treatment of battered women is complex but
in the midst of all its other features if we retain the notion
of some positive attachments we leave the woman "with a sense
of dignity, which may make it possible for her to choose, eventually,
to leave, or to stay on very different terms" (Goldner 1990,
Benjamin, J. (1984). The Bonds of Love.
Braverman, J. (1996). Book Review. NYSEPH Newsletter, Feb. 1996,
Goldner, V. (1990). "Love and Violence: Gender Paradoxes in Volatile Attachments. Family Process, 29, 343-364.
Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.
NiCarthy, G. (1986). Getting Free: You Can End Abuse and Take Back Your Life. Seattle: Seal Press.
Russell, D. (1984). Sexual Exploitation. Beverly Hills, Sage.
Walker, L. (1979) The Battered Woman. New York: Harper and Row.
Walker. L. (1994).The Abused Woman and Survivor Therapy. Washington,
DC: American Psychological Association.
White, M. (1995). Re-Authoring Our Lives: Interviews and Essays. Adelaide, South Australia:Dulwich Center Publications.
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