What about couples who present in an outpatient setting requesting help with intimate partner violence? Both sex-specific treatment and conjoint 14-week group treatment have been shown to be effective for outpatient couples with husband-to-wife repeated acts of physical aggression.32 In this study, both treatment groups followed a cognitive-behavioral program that focused on psychoeducation, anger-control techniques, and communication skills. Both groups reported a reduction of physical violence posttreatment and at 1-year follow-up, although only 25% of husbands remained violence- free. The only difference found between groups was that husbands in conjoint treatment had improved marital satisfaction.

Several untested treatments of intimate partner violence exist. Virginia Goldner,33 at the Ackerman Institute for Family Therapy in New York, has used attachment and feminist theory, especially the work of Jessica Benjamin, and views the work of the family therapist as inserting a moral perspective. Goldner highlights clinical multiplicity, with abuse and coercion coexisting alongside intense love and genuine friendship. Goldner believes that the mutative factor in any therapy includes “bearing witness and helping the abuser accept responsibility for his actions” and describes the role of the therapist as helping “clients develop a rich psychological understanding of the abuse” without blame or shame and without letting the perpetrators avoid responsibility for their actions.

Jory and Anderson34 practice couples therapy based on “accountability and a theory of intimate justice.” They simultaneously engage the victim of abuse and the abuser by creating 2 therapeutic environments: one affirming the victim and one challenging the abuser. Lastly, solution-focused treatment for domestic violence offenders offers a “strengths perspective, a solution-focused approach, holding a person accountable for solutions instead of focusing on problems.”35

When should couples therapy be considered? The essential components of safe couples treatment includes adequate screening of couples at risk for severe intimate partner violence.36 The aim for the general psychiatrist is to exclude severe intimate partner violence or partner abusive with impactful assaults from couples therapy (Table 2).
Table 2 Factors that preclude couples therapy
  • Uncontrolled, continuous use of alcohol or substances
  • Fear of serious injury from partner
  • Severe violence that has resulted in medical attention
  • Conviction for a violent crime or violation of a restraining order
  • Use of a weapon against the partner
  • Threat to kill the partner
  • Stalking or other partner-focused obsessional behavior
  • Bizarre forms of violence, eg, sadistic violence

To exclude intimate partner violence, the following factors must be assessed: uncontrolled continuous use of alcohol or substances, fear of serious injury from the partner, severe violence that has resulted in the victim requiring medical attention, conviction for a violent crime or violation of a restraining order, previous use of a weapon against the partner, previous threat to kill the partner, stalking or other partner-focused obsessional behavior, and any bizarre forms of violence, such as sadistic violence. If any of these factors are present, couples treatment is not recommended. If severe intimate partner violence is present, safety planning should be discussed with the individual at risk. This should include education about how to maintain the safety of the patient and of his or her dependents and specifically how to access services in the community.

For couples with partner abusive with non-impactful assaults who wish to enter couples therapy, it is nevertheless important to ensure safety. The key components to safe conjoint treatment include the signing of a “no violence” contract, the use of a negotiated time-out tool, and strategies to manage anger. Treatment of comorbidity is important, and in addition to alcohol screening, patients and their partners should be assessed for depressive disorders and PTSD.

Significant reduction in intimate partner violence can occur when comorbid alcoholism is successfully treated.37 Couples can enter couples treatment when the alcohol abuse/dependence is under control.38 Greater treatment involvement is associated with greater reduction in violence. Couples treatment consists of a sobriety contract, behavioral assignments, and relapse prevention.39 The behavioral assignments are aimed at increasing positive feelings, shared activities, and constructive criticism. At the end of treatment, each couple completes a continued recovery plan that is reviewed quarterly for 2 years. The reduction in intimate partner violence is mediated by reduced problem drinking and enhanced relationship functioning.

Summary

Intimate partner violence has been found to exist in 2 separate forms, severe with significant risk to the victim and mild or reciprocal with low risk of injury. It is unknown whether these 2 types of intimate partner violence are clinically distinct or whether they represent the extremes of a spectrum. Further research is needed to clarify whether these are distinct or whether one type can evolve into the other.

Physicians should make the effort to discuss intimate partner violence with their patients, both male and female, and to distinguish the 2 types of violence. For couples with partner abusive with non-impactful assaults or reciprocal violence, couples therapy may be indicated. To treat a couple engaged in intimate partner violence with couples therapy, guidelines to exclude those who are experiencing severe violence should be followed, and the couple should be screened for comorbid substance abuse/dependence, depressive disorders, and PTSD. The patient and partner should be fully assessed and informed about the treatment options available. In the field of intimate partner violence assessment and treatment, continued research is needed to provide psychiatrists with clear directions for diagnosis and treatment.

 
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