Category: Assessment

Mark and Julie were in their late thirties, and had been married for seven years after living together for three. During their initial session with me, they expressed concern that they had been drifting apart over the past year. They were both under considerable stress. Julie’s planned six-month leave of absence from her job following the birth of their son Brandon had now lasted four years. Brandon required lots of Julie’s time: he was highly impulsive, displayed frequent temper tantrums, and recently bit another child at daycare. Mark supported the family as a salesman for a medical equipment firm, but getting along without Julie’s income meant longer hours and more frequent travel.

“We hardly ever have time for each other anymore,” said Mark. “And I’m out of town so often these days that it’s hard for us to readjust when I get home. Julie is always preoccupied, either with Brandon or something else, and our relationship isn’t a priority for her the way it used to be.”

“We don’t communicate well,” added Julie. “We argue about parenting Brandon, about my housekeeping, about Mark’s being gone so much of the time . . .”

“There’s an example of one of our problems,” Mark interrupted. “ I don’t feel like she appreciates how hard I work to support us. Traveling on business is no picnic, I can tell you. I miss being home with my wife and kid.”

To most outward appearances, this was a couple caught in the typical dilemmas of our age: how to balance work and home life, how to be both parents and intimate partners, how to get one’s own needs met while meeting the needs of the other.

Mark and Julie had been in conjoint therapy twice before; each stint had lasted about one and a half years. Their first therapist, they told me, helped them understand how their relationship replicated themes from childhood. A couple of years later, when their arguments grew more frequent, they decided to try a new therapist. Mark liked their new therapist’s pragmatic approach and appreciated learning how to make “I statements” and practicing reflective listening. Mark felt that he had finally gotten through to Julie about his concerns. Julie agreed that the therapy had been helpful, but wasn’t willing to continue because there was too much focus on Mark’s concerns and not enough on hers.

When I asked Mark and Julie how they argued, they reported that Mark frequently raised issues in an angry way. Julie would withdraw, and Mark would press for resolution. She sometimes burst into tears during these encounters, and he saw this as her way to avoid addressing his concerns. Yet they both reported that their arguments “never get physical.”

Over the next few sessions, I gave Mark and Julie typical homework assignments. We discussed taking time-outs when their interactions grew too heated. We reviewed and practiced reflective listening skills. They voiced an appreciation about each other every day. And despite difficulty finding a babysitter who could handle Brandon, they managed to schedule two “date nights” over the next two weeks.

I did not yet realize it yet, but I was making the same error as their two previous therapists: I was attempting to do couples therapy with an abusive relationship.

Obligation to Assess

Many therapists, including those of us with extensive clinical experience, frequently plunge into doing therapy before we have adequately assessed whom and what we are treating. It is in the nature of the therapist-client relationship that we cannot know the whole story from the outset. Our clients may be lost, confused, withholding, or in denial. They aren’t ready to divulge everything at a first session (and if they were, we would probably wonder why). In the cause of establishing a working alliance, we leave avenues of assessment unexplored until a more opportune moment. Assessment and treatment necessarily walk hand in hand as the ongoing process of discovery and healing unfolds.

However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. “Sometimes we collude with our clients’ denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment.” Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.

One error I encounter with troubling frequency is the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation—or the threat to use any of those methods—to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently, they are also more effective at controlling, hurting, or frightening another, and they can be more emotionally damaging in the long run.

I have met with couples whose seasoned therapists, over the course of several years’ treatment, missed the extent and severity of the physical and emotional abuse taking place at home. We might be tempted to believe that clients bear some responsibility for staying silent on the issue (whether out of fear or outright denial), but the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe bringing up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting separately with one member of a couple they are treating jointly.

Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. “Suffering” is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile, clients incur a sizable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.

Common Misconceptions

Several common misconceptions hamper or prevent an adequate assessment of partner abuse.

“The couple report that they yell at each other, so they both contribute to the problem.”
Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, one of them probably contributes disproportionately to the abuse.

“I spoke to them about partner abuse and they deny it is going on.”
As therapists, we know better than to accept clients’ analyses of their difficulties and to probe more deeply. “If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?”

“It is my policy never to meet individually with clients I see in couples therapy.”
Adequate assessment for abuse cannot be accomplished with both partners in the room. Asking directly about abuse in a conjoint session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.

“I have a ‘no secrets’ policy, so clients know that anything they share with me individually will be brought into the couples session.”
In my view, such a policy is designed to relieve the therapist’s anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.

“Even if there is undiagnosed partner abuse, I’m helping them resolve the underlying relationship dynamic.”
By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner’s hands.

“I can teach them better communication skills until they trust me enough to disclose the issues they are withholding.”
Abusive partners easily subvert communication skills at home. “I” statements are meaningless if the intent is to hurt, control, or manipulate.

“I’m not taking a stand on the issue because I’m afraid the abusive partner will bolt from treatment.”
Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.

An Abusive Dynamic

At their next session, Mark and Julie reported that their second planned date night had started out well. They ate dinner at a quiet restaurant, reminisced affectionately about the first time they met, and held hands as they shared a frozen yogurt. Brandon was asleep when they got home, even though it was still relatively early. When they went to bed, Mark anticipated they would make love; Julie was tired and just wanted to curl up and go to sleep. Mark persisted, saying that this was the only chance they’d had for sex in a while so they’d better take advantage of it. Julie said she was tired of his “guilt trips.” He said she was frigid and accused her of withholding sex to punish him.

They had carried on late into the night as the argument broadened to include many other areas of disagreement. The conflict continued in my office the next evening.

” . . . And I appreciate how hard he works to support us,” Julie was saying. “But when he gets back from a business trip, he’s constantly finding fault with the way I keep the house, the things I wasn’t able to get to. He thinks I’m too soft with Brandon and that’s why he’s been acting up at daycare. It’s true that I could do a lot better job of housecleaning, and I paid the credit card late last month. My hands are so full with Brandon that everything else seems to take second place. I know I need to get better at setting priorities, like Mark says, but I feel like I’m doing the best I can and I wish he appreciated how hard my job is.”

Mark was restless but listened quietly while Julie spoke. When it was his turn, he spoke quickly, with increasing agitation and volume.

“She talks about not being appreciated. Well, she doesn’t do a very good job of appreciating me. I work really hard to support us at this level, and you’d think I could at least come home to a house that didn’t look like a bomb hit it. And Brandon is out of control because she doesn’t know how to set limits with him. He never acts up with me the way he does with her. Plus, she has the entire day to spend at home and take care of the things I can’t get to because I’m out of town. Brandon’s in daycare now, and she has so much free time to get together with her girlfriends for coffee . . .”

“Now, wait just a minute!” said Julie angrily. “That only started a couple of weeks ago!”

“No, you wait a minute!” replied Mark in a louder voice. “I don’t appreciate your angry tone, and I didn’t interrupt you when you were talking. I’d appreciate it if you could show me the same respect!”

“It’s hard to sit still while you misrepresent things,” she said petulantly, slumping in her chair.

“There you go again. When I give my point of view, I’m misrepresenting things. “ He turned to me. “You see how this goes. She never seems to respect my opinion. Everything I say, she counters it.” He raised his voice. “She treats me like she doesn’t even like me anymore! Ever since Brandon came along, our sex life has gone out the window. She always has something else on her mind, or she’s too tired, or I don’t know what.”

“Maybe if you treated me with more respect, I’d feel more like getting close to you,” Julie replied softly.

“See, there you go again. It’s always my fault!” said Mark. “We disagree on so many things, I’m really not sure what’s keeping us together anymore!”

There was a pause. Mark’s face grew darker and his brow furrowed as he spoke. The skin around Julie’s temples grew taut and her shoulders sagged.

“Tell me, is this kind of how things go at home?” I asked. “You start to talk about an issue, and things escalate? Mark, you seem angry and frustrated, and Julie, you seem angry and resigned. I can see that there are a number of issues on the table. But I’m wondering if I’m getting to see how your efforts at communication get off track. Is this how things go when they don’t go well?”

They answered simultaneously. “Pretty much,” said Mark. “This is mild by comparison,” said Julie.

“So what would typically happen at this point?” I asked.

“Mark usually kicks something, then leaves the room,” said Julie, hands crossed over her chest.

“Oh, really? What about you turning on the water works, then giving me the cold shoulder and playing the Ice Queen for three days?” said Mark, pointing his finger at her. “You left that part out. As usual!”

“OK, hold on a moment, both of you,” I said. With ten minutes left in the session, I felt the need to intervene, based on the growing escalation, the content and tone of the communication, and Mark’s increasing impulsiveness. I also feared that their disagreements were severe enough that continuing to talk about them would result in yet another argument as they left my office.

“There’s been a lot of heat expressed in this office today, and I’d like you both to cool off before you leave. I want you both to take a few nice deep breaths, s-l-o-w-l-y. Good. I want you to drop this argument, and I want you to agree not to talk anymore about these issues today.” We spent a few minutes addressing the difficulties they might experience in keeping to this agreement.

It was now clear to me that this couple was caught in an abusive dynamic. Mark had initially given the impression that he was listening to Julie, but he shifted restlessly as she spoke; when she finished, he responded quickly with an increasingly angry and critical tone. He blamed her for their problems and employed various strategies—such as exaggeration, distortion, and counterattack—to deflect any suggestion that he might also bear some responsibility for their difficulties. When Julie attempted to correct his misrepresentation of her coffee dates, he turned the tables by attacking her for the interruption and accused her of having less respect for him than he had for her. Mark felt free to express his anger but could not tolerate Julie expressing hers. He accused her of employing the very tactics he used (for example, “Everything I say, she counters it”). Mark demeaned Julie for the upset feelings she experienced following his angry outbursts and her subsequent need to pull away.

By contrast, Julie recognized some of her contributions and validated many of Mark’s concerns. Her brief efforts to defend herself were quickly overwhelmed by Mark’s responses. Her petulant tone and slumped posture were signs of defeat.

Indicators of Partner Abuse

Like Mark and Julie, clients in abusive relationships present with typical complaints: “We don’t know how to communicate with each other.” “We’ve been arguing a lot.” “We’re both under a lot of stress.” “We’ve needed counseling for a long time and he/she finally agreed.” “We disagree about disciplining the children.” Usually, their level of intimacy has declined.

More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. “There may be a marked difference in the way and the degree to which each partner participates in the session.” The abusive partner may always start the session or, alternatively, always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly—or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.

They may disagree on basic facts and have widely divergent views of the same events. Frequently, both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.

Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.

Assessment Protocol

When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.

Alternatively, a couple like Mark and Julie may come to see me because they’re having difficulties and have decided to try therapy, and I might not begin to suspect partner abuse until they have seen me a few times. When I recognized the abusive dynamic in Mark and Julie’s relationship, I said to them:

“I think it would be helpful for me to set up an individual appointment with each of you so that you can share your concerns without having to worry about the other person’s reactions. I frequently do this in couples therapy, and given the volatility of today’s session, now seems like a good time.”

With an even more highly volatile couple, I might say something as innocuous as:

“During the last several sessions, I’ve had a chance to see how you interact with each other. As part of our work together, and in order to get to know you better, I’d like to schedule an individual appointment with each of you. I want to find out more about you, your childhood, family history—that sort of thing.”

I wait until the individual sessions to address the issue of confidentiality and “secrets.” With Mark and Julie, I began their separate sessions this way:

“This is a rare opportunity to get together with you, and I’m wondering if there’s anything you’d like me to know that you’re not comfortable saying with your partner in the room? If it’s something you want to tell me in confidence, I can keep it to myself. If it’s something I think would be helpful to discuss in a joint session, I’ll let you know that today, but I won’t disclose anything you don’t want me to.”

I also tell each partner that I would like to ask a series of questions about the kinds of behaviors that have occurred in their relationship. With the abusive partner, I am especially interested to learn whether similar behavior has occurred in any previous relationships, because it counters the common belief that the current partner is in some way responsible for the abuse. For this purpose, I use my own Abusive Behavior Inventory, an abridged version of which is included at the end of this article. I frequently supplement the specific questions on the inventory by inquiring about the first, last, and worst conflicts the couple has had.

Choice of Assessment Tools

To develop the Abusive Behavior Inventory, I spent one dreary weekend reflecting on all the variations of spousal abuse I had encountered during several years’ clinical experience and incorporated them with similar questionnaires employed at two agencies where I worked. I also referred to Patricia Evans’s The Verbally Abusive Relationship: How to Recognize It and How to Respond (Bob Adams, Inc., 1992) and Ann Jones and Susan Schechter’s When Love Goes Wrong: What to Do When You Can’t Do Anything Right (Harper Collins, 1992). An instrument similar to mine is R. M. Tolman’s Psychological Maltreatment Inventory (see “The development of a measure of psychological maltreatment of women by their male partners,” Violence and Victims 4 (3): 159B177, 1989).

I do not employ the self-administered Conflict Tactics Scale, developed and revised by noted researchers Murray Straus, Richard Gelles, and Susan Steinmetz. Despite broad acceptance as a research tool, it has numerous shortcomings in a clinical setting. For example, it measures violence only during the preceding 12 months, even though just one violent incident from many years ago may still be casting a shadow over the relationship. It does not ask whether the violence occurred in self-defense. And it equates acts that are inherently unequal due to men’s generally greater physical size and strength and women’s generally greater level of fear that men’s anger will erupt into abuse.

Using the Abusive Behavior Inventory in the individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information—factual, psychological, and emotional—than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.

Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other’s answers generally exhibit greater awareness of problems in their relationships and are more often motivated to do something about them.

Suspicions Confirmed

As I suspected, my individual meetings with Mark and Julie revealed a long-standing pattern of moderate partner abuse. Despite their earlier contention that their arguments “never get physical,” on several occasions Mark had prevented Julie from leaving the room during an argument by standing in the doorway. Once or twice, he had slapped her shoulder as she walked away. He had grabbed her wrist a few times, in one instance hard enough to leave a bruise. He had also thrown several television remote controls and a cell phone when angry, and he frequently punched walls and slammed doors.

Mark sometimes used what he had learned in couples therapy against Julie: for example, by couching frequent critical and demeaning comments using a distorted version of an “I” statement, or by asserting that she was projecting her father onto him. When Julie raised a sensitive subject, Mark frequently got angry, yelled in her face, declared a time-out, stomped out of the room, and never returned to the issue.

Julie reported that her self-confidence had plummeted over the past few years, and she was feeling helpless and hopeless about her marriage. She said Mark had little sympathy for the chilling effect his behavior had on her libido and often criticized her for her infrequent interest in making love.

Recommendations for Treatment

When Mark, Julie, and I came together following my individual sessions with each of them, my recommendations went something like this:

“I have some thoughts about your therapy and where we go from here. We’ve discussed the issues and difficulties you experience together. For example, neither of you feels adequately appreciated, and you both report difficulty getting the other person to recognize and meet your needs. You’re both pretty good about identifying each other’s shortcomings but not so good about identifying your own. And it’s hard for you, even with me in the room, to discuss sensitive issues without getting into a heated argument.

“I think it’s clear to all of us that the two of you need couples therapy. But I think it’s premature at this point. It’s really just a matter of timing. You’re going to be spinning your wheels until you both have a chance to address your own issues. Then you’ll be able to take advantage of what couples therapy has to offer.”

In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I cite only the behavior I observed or heard about in meeting with the two of them together when explaining my recommendation. If the abusive partner has acknowledged any abusive behavior—and it is extremely rare for the Abusive Behavior Inventory to bring no abusive behavior to light—I will refer to that as well.

In his individual session, Mark confessed that he had grabbed Julie’s arm once and frequently got so angry that he hit things. He also expressed remorse about it and a desire to change. So I added:

“And I appreciate your forthrightness, Mark, in acknowledging that you grabbed Julie’s arm and you don’t like the way you act when you get angry. That’s definitely something I can help you with.”

In the typical abusive heterosexual relationship, I generally refer the man to a men’s group with a focus on partner abuse (one of my own groups, or a colleague’s). I refer his partner to a group for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse, and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.

It is important to be resolute about my recommendations prior to the final assessment session so that I keep to them, whether or not the couple finds them acceptable. One or both partners will sometimes attempt to mount a persuasive argument for being seen together, and occasionally one of them will insist on having therapy together or not at all. My express purpose is to send a clear and unwavering message at this stage of treatment that couples therapy is premature—just as I would regarding family therapy with a parent who currently abused the children or who was an active alcoholic.

Arguments for and against conjoint treatment in cases of partner abuse are often heated and polarized among treatment professionals, in a process that runs parallel to the typical dynamics in an abusive relationship. By training and experience, I believe in the paramount importance of holding the abusive partner (or partners) accountable for his or her actions, regardless of what the other partner says or does. In abusive relationships, couples therapy undermines this goal by communicating, either overtly or by implication, that both partners bear some responsibility for the abuse.

There are practical considerations as well. Abusive couples who leave a session with unresolved issues are more likely to erupt afterwards. (I know, because many years ago I heard them yelling outside my office or pealing out in separate cars!) Additionally, conjoint therapy is generally not productive when control issues distort the therapeutic process or when either party fears serious repercussions for speaking the truth.

When is Couples Therapy Indicated?

Before I would consider treating an abusive couple together, they would have to meet several conditions.

1. Their answers to the Abusive Behavior Inventory match closely.
2. Past abuse was moderate to mild; currently, abuse is extremely mild or entirely absent.
3. The couple can adhere to a contract of no further abuse.
4. The abused partner is safe, unafraid, and able to mobilize resources if needed.
5. Both partners are motivated for treatment out of a sincere desire to grow and change.
6. Both partners are willing to be accountable for their behavior, without blaming the other.
7. The couple can use basic communication skills in a non-manipulative manner.

In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.

I presented Mark and Julie with two choices. They could each seek treatment with other professionals and keep me in reserve as their couples therapist at some future date. Or I could take Mark into one of my men’s groups, refer Julie to another therapist, and help them find a new couples therapist when Julie’s therapist and I thought they were ready. Mark’s reluctance to join a group, much less one led by a different therapist, led us to conclude that the second option was preferable.

Over the next three years, Mark and Julie both participated in group therapy supplemented by short bouts of individual work. I consulted regularly with Julie’s therapist to coordinate our treatment efforts, and we met together with the two of them from time to time to coach the couple through especially difficult logjams. Once Mark had achieved more than six months of abuse-free behavior, he and Julie began working with a seasoned marriage therapist who understood the dynamics of abuse. Julie ended her group work, but Mark remained for another six months because he had discovered that being accountable to other men helped ensure his continued recovery.

Conclusion

Treating partner abuse is a specialized field. Trainings in recognizing and treating the problem are helpful, but the only way to develop real expertise is through direct experience. To that end, I recommend that you become familiar with an assessment tool like the Abusive Behavior Inventory and practice administering it to a few colleagues. As with any new tool you add to your clinical repertoire, the greater your comfort in using it, the more at ease your clients will be.

Then, the next time you suspect partner abuse, you’ll be ready to assess for it. When you do, share your findings with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to the danger of leaving partner abuse undiagnosed and untreated.

In many ways, Mark and Julie experienced an ideal outcome. Their commitment to each other and to the process of change allowed them to leave their abusive dynamic behind. Mark was able to give up his sense of entitlement and develop greater empathy for Julie. Although some emotional scars remained, the damage was not so severe that Julie was unable to reclaim the genuine affection she had once felt for Mark.

But they were lucky: without any of these factors, a divorce was likely. And without appropriate intervention, the probable outcome would have been an uninterrupted, escalating pattern of abusive behavior, accompanied by additional years of unnecessary pain and suffering and the possible transmission of abuse to the next generation.