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December 15, 2011

Guidelines for Mental Health Professionals

This article goes into detail on the best practices for screening for Domestic Violence, how to respond to a disclosure of violence, counseling and safety planning when needed.

Best Practices in Domestic Violence Cases
A note on language: Because domestic violence is mostly committed by men against female partners, this section refers to abusers as ‘he’ and victims as ‘she.’ However, the information should be understood as referring to all victims and abusers, regardless of the gender of either partner.
Best Practices in Domestic Violence Cases
Screen for domestic violence at intake, or as soon as possible thereafter.
Do not work with victims and abusers together in couple or family counseling, mediation, or multi-family groups. No one should have to engage in therapy with someone who has committed a crime against them.
Evaluate all interventions ahead of time for their potential to endanger the victim or reinforce her partner’s power over her.
Do not attribute abusiveness to personality disorders, chemical dependency, anger, trauma or culture. None of these factors explains the choice to act abusively.
Do not attempt to treat abusers for their abusiveness, individually or in groups, including anger management groups. Do not refer abusers to abuser groups, unless the local domestic violence service provider sees a given abuser program as accountable to victims and their advocates. Be guided by their judgment.
If a court mandates individual treatment for the victim (unless she herself wishes it) or abuser, or any form of joint counseling, refer the case back to the judge, explaining why the referral is inappropriate.
Do not advocate for abusers in custody and visitation matters.
Screening for Domestic Violence
Safe delivery of mental health services depends on early identification of victims and abusers through careful, routine screening.
Clinicians should routinely screen for domestic violence whenever:
  • A woman requests services (regardless of her age, economic status, sexual orientation or presenting problem).
  • A couple requests couple counseling, family therapy or mediation.
  • A woman is referred because she has been arrested as a “batterer.”
  • A male client shows physical, emotional, or behavioral signs of abuse.
Women clients – new and ongoing – should be asked again about DV whenever:
  • They begin or end relationships.
  • They are in the middle a struggle over child custody and visitation.
  • They are pregnant.
  • They have visible physical injuries.
  • They appear to have suffered a traumatic brain injury.
  • They express concern about their partner’s alcoholism or drug use, “bad temper,” or mistreatment of the children (or you suspect child abuse).
  • They show any of the common mental health sequelae of domestic violence, especially PTSD, depression, or chemical dependency.
  • Their partners want to attend their sessions.
Screen in private, out of sight and hearing of the client’s partner and anyone accompanying her, including children, to reduce the danger of her partner’s retaliating against her for disclosing his abuse. (Postpone screening if you can’t speak with her privately, or if a needed interpreter is not available. Never use anyone accompanying the client as an interpreter, including children.)
Stress the routine nature of the screening, and put it in context; e.g., “Because abuse in relationships is so common, we ask about it routinely.”
Ask direct, behavioral questions about hitting, hurting, fear, threats, intimidation, sexual and emotional abuse, and economic controls, not just, “Are you a victim of domestic violence?” Use the Power and Control Wheel as a tool for asking about different tactics of abuse.
Use inclusive language. Avoid gender-specific pronouns and say ‘partner’ until you know how the client refers to their partner. DV is not just a heterosexual phenomenon. Lesbian, gay, transgender and bisexual (LGTB) clients may also be abused, and will more easily disclose if they perceive you as accepting of their sexual orientation. Never attribute DV to the client’s sexual orientation or gender identity.
Responding to Disclosures
If a client discloses being abused:
  • Listen to her story in detail and validate her experience.
  • Acknowledge her fear, and the risk she takes in speaking with you.
  • Recognize and label abusive behavior.
  • Treat her feelings of fear, anger, love and hope as legitimate.
  • Assume that her choices are rational ones; don’t assume that having been abused means she needs psychotherapy.
  • Keep strict confidentiality.
  • Leave her in control of decisions that affect her.
  • Make her safety your top priority.
Assess danger.
  • Start from the assumption that an abuser is dangerous. If he has used weapons or tried to kill her in the past, he is likely to do so again.
  • Try to help his partner identify the circumstances under which he typically becomes violent.
  • NEVER make statements, to the victim or anyone else, that minimize his potential to inflict serious injury, or indicate that he is no longer dangerous, even if his past offenses have been relatively low-level.
  • Also pay attention to factors that indicate a higher statistical risk of domestic homicide. The absence of these risk factors does not indicate absence of risk, but their presence means the danger must be taken very seriously. The main risk factors are not psychological variables, but concrete behavioral ones:
  • Separation (especially if recent).
  • Stalking.
  • Escalation of abuse.
  • Threats (to kill partner, children or self; to take children).
  • Guns available to abuser.
  • Drug and alcohol use by the abuser.
  • Abuser is depressed.
  • Victim is isolated from sources of assistance and support.
Couple and Family Counseling
Joint counseling in any form – couple counseling, family therapy, mediation – is contraindicated in DV cases, even when the victim insists on it. (Her willingness to participate is likely to spring, at least partly, from blaming herself for how her partner treats her.)
Joint counseling should be avoided because it is:
  • Dangerous.
    • Abusers often retaliate against their partners for what they say in couple sessions.
  • Unfair.
    • Victims should not have to attend therapy with someone who abused or committed a crime against them, just because that person is their partner.
    • Victims should not have to give up their other legitimate needs in return for safety. Refraining from violence should never be treated as negotiable.
  • Ineffective.
    • An abuser can skillfully counter any attempts to get him to change, making the clinician unlikely to look deeply into his behavior.
    • A victim’s fear makes her unlikely to speak freely about the real issues.
    • Resolving conflicts – the main goal of joint counseling - doesn’t stop abuse. Conflict happens between people; abuse is something one person does to another. Abusers manipulate their partners – and clinicians – into believing that conflict is the real issue.
Avoid contracting for joint counseling in DV cases.
  • Screen all couples for domestic abuse before agreeing to joint counseling.
  • Tell all new clients that you agree to joint counseling only after making a thorough assessment, which includes private interviews with each partner.
  • Refuse joint counseling if there is ongoing violence or intimidation.
  • If only the victim discloses DV, do not report this to her partner, but find some other basis for refusing joing counseling.
  • Offer each party other services if needed and appropriate.
End joint therapy immediately if:
  • Abuse is disclosed after joint counseling has already begun.
  • There are new incidents of abuse or the victim feels unsafe at any time.
If past domestic violence is disclosed, do a careful assessment and refuse joint counseling if any of the following are true:
  • The abuser is currently suing for custody or visitation.
  • There is an active Order of Protection or the victim is still afraid.
  • The abuser has ever committed felony-level assaults on his partner.
  • He does not take full responsibility for having been abusive. (He may give lip service to responsibility yet continue his abusive behavior).
Safety Planning
In working with abused clients, remember to
  • Collaborate with them on safety planning; don’t try to be the expert.
  • Work on safety plans during periods of relative calm, not just during crises.
  • Evaluate all referrals and interventions for safety, before proceeding. Plan with clients how your own interventions can be handled most safely.
  • Always consider the children’s safety as well as the adult victim’s. Pay attention to the abuser’s use of tactics that target the client’s specific vulnerabilities (care-taking responsibilities, disability, economic situation, sexual orientation, etc.).
Try to help abused clients to:
  • See individual incidents as part of a larger pattern of abusive behavior
  • Focus on the long term, not just the current crisis.
  • Understand that abusers seldom stop just because they promise to.
  • Identify high-risk situations and make specific plans for each one.
  • Identify signals of impending danger as far ahead of the actual violence as possible, to increase their chances of escaping.
  • Identify potential ways to avoid violence or reduce injury.
  • Identify helpful community resources, especially DV service providers.
  • Assess the safety implications of interventions by others (e.g., a court imposes a mutual order of protection or mandates couple counseling).
  • Assess the potential costs and benefits of calling police, getting an Order of Protection, seeking help from DV service providers, or disclosing abuse to friends, family, or members of their community.
  • Rehearse their safety plans, imagine how they could backfire (violence could escalate, danger could increase, there could be legal ramifications), and make contingency plans.
  • Periodically assess how well their plans are working.
(Many of these ideas are from Davies, J. (1998). Safety Planning with Battered Women. Thousand Oaks, CA: Sage.)
Original Article

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