Category: Domestic Violence

Reflecting on Domestic Violence: How One Therapist Made a Difference

Posted on by Psychotherapy.net Team

I loved my work in community mental health, but I hated office politics—the best way to avoid them was to spend as much time outside the building as possible. I accomplished this for over 10 years by providing in-home services.

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Making a Mental Health Impact in the Community

My very favorite program under the in-home umbrella was referred to as “Mother House.” It was a joint program between a Christian based church that wanted to make a difference in the community and the child & family team of the community mental health center (CMHC) where I worked.

The church owned and maintained a four plex, two-bedroom apartment building, the purpose of which was to provide safe shelter for women with children leaving domestic violence relationships. To qualify for the housing, they required the mother and a child to have a diagnosable mental illness and to be receiving treatment for that illness. They asked the CMHC and particularly the child/family services program to provide mental health treatment.

The CMHC where I worked was very traditional in their orientation to service programs; separating adult services from services for children. An adult parent needing mental health services was seen in the adult division, while the child was seen in children’s services. Never the two should meet. “It can’t be done” they said. “One therapist cannot work with both adult and child service programs at the same time.”

By that point in my career, I had worked in every type of mental health program you could imagine—inpatient, outpatient, day treatment, rehab, adult and child case management, and crisis intervention. By then I was the senior clinician in the agency. I was a perfect fit and said, “Watch how it can be done.”  

Making a Domestic Violence Shelter Work

Over the course of the project, I had anywhere from four mothers, and 8 to 11 children of all ages in treatment under one roof at any time. Mothers were occasionally asked to leave the program when they could not honor the rules. One parent and one child in treatment and no men were permitted to live in the building. I had the independence to do whatever I needed to do keep them functioning; grocery shopping, bill paying, doctor’s appointments, school meetings, and therapy.

I loved the constant challenge and the variety of individual, family, or group therapy. I loved the unplanned picnics, holidays, water balloon fights, family feuds, wars with the neighbors, and the continual challenges of keeping men from moving in on the women. I did not care for the police calls. When the police did come, they sent four squad cars and for hours they screwed up what I could have settled in 30 minutes. Things ran far more smoothly when I was in the building.

One of my first families was a mother with a severe mental illness who had lost or given up custody of her four children. The first to come home was her 13-year-old daughter, Wendy. She came home angry, defiant, and rebellious. She had a lot to be angry about and a right to be angry. She was not a bad child, just an angry one. I did not think therapy was successful for her, but she had her anger to keep her going.   

The mother had to leave the program after the fourth child came home because the apartment was not big enough. We lost touch clinically but through sources in the system, I continued to hear of what was happening in the mother’s life and those of her children.

Fast forward to 2021. The picture of a young woman came through my Facebook page, and although the last name was different than I remembered it when working with the mother and four children, I knew it was Wendy. That 13-year-old girl, now in her thirties, was married, a mother, and looking to connect. I responded to her, and she replied. While she had created that post over two years before, we decided to meet at a local restaurant—she, her mother, and me.

When I arrived, she greeted me as soon as I walked through the door, jumping up from the table to wrap me in a big warm hug before I could even sit down. She did not bring her mother because she wanted to let me know personally and privately that she was sorry for the horrible way she treated me while they were living in the apartment. “I was so angry.” I respond, “You were, but you had a lot to be angry about.”

Wendy shared her story, and what a story it was! She had experienced her share of struggles and challenges, several of which I had heard through my mental health grapevine. She was happily married to a good man and together they had a huge family of “his, mine, and ours.” She had turned out to be a wonderful mother, and a loving and caring daughter to her mother.

***

I subsequently reconnected with Wendy’s mother with whom I met occasionally for lunch. Surprisingly, she recalled that her time at Mother House with her four children, and when she later came home with them, was one of the best times of her life. She said, “We were all like family in that building and you were part of the Family!”

Questions for Reflection and Discussion

What are your impressions of the Mother House project?

What challenges might you experience working with this population?

How might you have worked differently with Wendy under similar circumstances?    

Helping Domestic Abuse Victims During Quarantine

Posted on by Psychotherapy.net Team

In a time when most Americans have been asked to stay home in an attempt to control the spread of the novel coronavirus, many domestic abuse victims are finding themselves trapped with their emotional, sexual, financial or physical abusers. Distance is the primary strategy for many victims of domestic violence. For them, shelter-at-home means no shelter at all. They cannot leave home to go to jobs, to work out at gyms, visit friends or family, attend regular therapy sessions or join support groups.

During this pandemic, most therapists are adjusting to online therapy and all the challenges it presents. Many client populations lend themselves well to telehealth options. One that doesn’t is victims who are stuck at home in abusive relationships. Confidentiality and privacy are challenging when someone lives with an abuser. But services for those stuck at home in volatile environments are essential. Finding a private place at home or in their car to participate in online therapy is only one of the many difficulties in providing help to those isolated with their abusers.

Clinical Challenges in Domestic Violence

As a therapist, one of the most challenging populations for me to work with has been victims of domestic violence. I still remember the client I treated in a psychiatric hospital 37 years ago. She’d agreed to inpatient treatment for her depression and severe PTSD and to an escape plan, only to leave the hospital AMA and be picked up curbside by her abuser.

I was young and idealistic. I could not understand how this was possible after all our work together.

I now know that domestic abuse is an extremely complicated dynamic. One complication is that those close to a victim, as well as the victim themselves, often minimize the abuse and blame the victim for what is happening. Their friends and family are unlikely to know the extent of the abuse, and the few who may are so tired of hearing the same old story that they begin to blame the victim for not leaving. “If you’re not going to do anything about it, quit talking about it,” I often hear victims report their friends and family having said to them. This only adds to the guilt and feelings of worthlessness. Victims then feel more alone and emotionally dependent on their abuser. Worse still, it can lead to a victim’s not talking about the abuse all together.

Another challenging aspect of domestic violence is that the abuser often holds a past mistake or shortcoming over the victim’s head. This past error or genetic weakness (i.e., “Your family is full of deadbeats”) is often embarrassing and leads the victim to doubt their own worthiness. Often, an abuser will convince a victim that no one else will ever love them and life with the abuser, however painful, is as good as the victim can hope for or deserves. If the victim feels guilty or indebted, escape is even more unlikely.

Many abuse victims have been raised in abusive childhood homes where belonging, food, clothing and shelter were inextricably interwoven with emotional, verbal, sexual and physical abuse. Many of these childhood norms and assumptions retreat to the unconscious. They may never have been revisited, questioned or replaced with more healthy internal models of "family.” If an abuse victim was told repeatedly throughout their childhood, “I do this because I love you,” the confusion of that message may not even be in their awareness. Part of effective therapy with abuse victims is examining these toxic, yet impactful, childhood messages.

Victims of abuse who have children at home are truly in a double bind. Staying in the volatile environment is damaging to children, but leaving often presents even scarier situations. If they leave and divorce, the odds are, with a couple parenting classes, an anger management course, a few monitored visitations and an expensive attorney, their children will be spending half the time with the abuser without supervision. Just the thought of their children being unprotected with an abusive parent can keep many victims immobilized. Supportive education and legal representation can help mitigate some of these terrifying possibilities.

Another disturbed and disturbing aspect of these toxic relationships that keeps friends and sometimes therapists and law enforcement from intervening is that after a well-intentioned person assists the victim in getting away, the recently escaped is highly likely to return to the abuser. After this occurs, both the victim and the abuser turn on the helper as a way of re-establishing the bond in the abusive relationship. This can leave those who have sacrificed time, emotions and finances feeling used and resentful. Many friends and family members of abuse victims distance themselves from the person who needs them most, because they are just exhausted and discouraged.

It is important that as therapists, we try to remember that the victim is not staying in the relationship because they like the abuse. They are staying in the relationship for the upside (extended family, the “honeymoon” phase after a fight, the generosity, the flattery, the social community, the hope of a better future and stability for the kids), not for the downside. Many abuse victims are enticed by the kindness shown them after an abusive episode. They believe if the abuser can be nice for a short period, it may be in them to really change and show long-term kindness in the relationship. “Victims often believe they can influence the abuser into this state of kindness permanently”. They hope that if they accommodate enough, provide adequate logic, apologize sufficiently, and anticipate the wants and needs of the abuser, then they will be able to have the emotional safety and generosity they have only experienced periodically. In chasing this idealized fantasy, victims find themselves trying to take responsibility for the actions and emotions of their abusers.

Assisting a client in learning that they can survive, even thrive, without the upside of the abusive relationship will go further than continuously trying to get them to view the painful aspects of their circumstances. They are aware of the pain in the relationship. What they need to know is they can create or replace the good parts of the relationship.

Therapists who are working with abuse victims must focus first on immediate safety. This is not always easy to determine, as abuse victims often know the keywords that would trigger a mandated report. At times, I have called colleagues or even the attorneys through my professional organizations and professional liability company to ask questions about what is reportable and what would be breaking client privilege. These parameters are different in each state, and it is important to stay current with reporting laws. If I must make a report, I always tell a client that I am going to, why I must, and what they might expect from social service and law enforcement.

If the victim is not in immediate danger and nothing has recently happened that a therapist needs to report, the therapeutic focus then needs to be on increasing self-confidence and self-trust and creating a plan of safety for the victim.

While developing self-confidence, a sense of efficacy and self-worth are important parts of treatment, these may take time. “One way for a victim to work on these is to establish relationships with other survivors”. This may include reading others’ stories online or in books, feeling a sense of community by following social media dedicated to domestic violence, or joining web-based support groups for domestic abuse victims. Knowing that they are not alone and that others have found ways out are essential parts of treatment for victims. Reading that others have found ways of forgiving themselves for things that were held over their heads, or have learned that they are not worthless even though their heritage or pasts were not perfect, are emotional doors to freedom.

While building a support system and gathering other victims’ success stories, a therapist can help a victim develop practical plans. Strategizing is an important aspect of leaving, but also of staying safe before they leave. Plans can cover emergency shelter, food, money, and safety for themselves and their children.

Pandemic-Related Challenges

While providing treatment to victims of domestic violence is always challenging, the current pandemic exacerbates treatment issues. Not only are victims trapped in a confined space with their abusers, but financial issues, job loss, social isolation, loss of access to outlets like sports or hobbies, and an unpredictable future can increase the acting out behavior of an abuser who already does not possess good strategies for coping with stress. When important aspects of life are actually out of control, people who blame others for their emotions and behaviors are less equipped to problem-solve in healthy ways. Abusers who feel this loss of control may actually become more volatile and hostile.

“Victims also have fewer options during this pandemic”. They have fewer job choices, fewer treatment options and more financial and social restrictions. They may fear that domestic violence calls will not be a priority for law enforcement and the courts will not issue restraining orders. The choices for alternative residences with children may seem impossible. With so much uncertainty and schools and businesses closed to in-person contact, victims may feel hopeless to change their unsafe situations.

A client whom I am treating during this pandemic (details have been changed) must meet for our video therapy sessions locked in his car to keep his partner from listening through a closed door in the house. He and his partner have been together for five years. When my client’s partner found out the venue and caterer would not refund the money for their upcoming wedding after shelter-in-place orders made the event impossible, the partner became enraged, broke valuables in their home and threatened their dog. The partner blamed my client for the financial hit and took his anger and feelings of loss of control out on my client. My client was raised in a household where he was beaten and eventually thrown out due to his sexual orientation. His fears of abandonment and history of violence added to his tolerance of his current abusive situation. My client quit his job six months ago to help his partner start a new business, a business that is not viable in the current climate. He has tried to leave several times; after the most recent time, his partner promised to change and proposed marriage. Now with no job, all finances gone, isolation from friends, and a family that offers no safe haven, my client feels trapped and hopeless.

The following list contains strategies I use when working with domestic violence victims during the COVID-19 crisis.

Therapeutic Planning

I have found the following to be highly effective when planning with my clients impacted by domestic violence.

1. Seek shelter with someone else. “If possible and safe, find an excuse to stay with another close family member or friend”. Maybe they need help working from home or with their children or pets. Maybe the neighbor’s dog needs to go for a walk. Maybe your kids need a playdate with another child. Maybe you need to take food to someone who cannot cook for themselves. Find a reason to get out, at least for a while.

2. Stay prepared. Hide an extra car key, jacket, credit card and walking shoes. Keep your phone charged. If things escalate, you need a way to leave. Planning is essential because when you are under pressure with adrenaline pumping through your brain, you may not be able to think as clearly.

3. Avoid escalating things with your abuser. Many arguments escalate faster (and may become violent more quickly) when you try to explain yourself. Let your abuser believe false things about you, i.e., “You always…,” “You never…,” “You think that…,” “You didn’t keep your word about…,” “I always give you…” “I do everything for you, you don’t…,” etc. Let them view you incorrectly, at least for the time you are stuck at home. Note: If your abuser has ever been violent, or you think they may become violent, this is not a suggestion to allow or put up with harm. If you are in danger, leave the situation and/or seek help from someone you trust as soon as you judge it safe to do so.

4. Don’t try to resolve this fight. Remember that this won’t be your last fight. Often abusers rope victims into arguments threatening that “this is your last chance, or…” You will most likely have this argument again. If they threaten to leave or divorce, remember they will probably say it again in the future. This will not be the last argument. Allow the tension to not be resolved. Do not chase them to “understand” you or your perspective.

5. Reach out to people you can trust. Tell people who care about you. This is the time to reach out to those who love you. “If you don’t have trusted friends or family, call the National Domestic Violence Hotline” at 1-800-799-7233. If your abuser forbids you to continue therapy with your current provider, there are other therapists offering phone or video sessions during this crisis. Some counselors are even offering discounted therapy sessions during the pandemic. If for any reason you can’t continue therapy with your current provider, search for a trustworthy therapist here. If you feel suicidal or have thoughts of hurting yourself, call the National Suicide Prevention Lifeline at 800-273-8255, call 911, or go to a local emergency department for help.

6. Practice self-care. Take care of your emotions. Switch activities up if your abuser clamps down on one or two. Exercise, listen to music, play video games, go for walks/bike rides, garden, do creative projects, or join online groups. Your feelings are legitimate. You are not overreacting. Pour your emotions into a healthy activity.

7. Avoid being trapped. Try not to be stuck in a car with your abuser. Try to avoid confined places where you cannot leave. Make excuses to get away or take separate cars. Call 911 if you feel in danger.

8. Don’t let your abuser pull you back into an argument. When you stop responding in an argument, don’t get pulled back in by “See, you don’t care, you’re just walking away,” “There you go giving up on us,” “Come back here, I’m not done talking to you,” or “See, you’re not interested in resolving this!” Walk away anyway. Don’t explain why. Remember that you can tell your therapist about this in your next session. You don’t have to process it with your abuser.

9. Remember the abuse is not your fault. Remember that “an abuser isn’t abusive because they don’t understand you or the facts, they are abusive because of who they are”. And no matter what you do or don’t do, say or don’t say, you can’t change them. This is extremely difficult; it may seem like you caused their anger and are responsible for it, but you didn’t and you aren’t.

10. Get help if you feel threatened. Go to a neighbor’s home or call 911 if you feel threatened. There are many domestic violence safe houses that can pick you up and keep you safe from your abuser and help you with legal issues like restraining orders. Many have accommodations for children as well.

***
 

Let your clients know they deserve to be compassionate to themselves even if they feel they are not making progress fast enough. Remind them that they did not cause anyone to treat them in an abusive way. They are never to blame for someone else’s behavior. They deserve respect, no matter how they have reacted in the past. As their counselor, you can model this and help build their sense of self-worth in therapy.

As a therapist, you have a unique role. In that role, you may be able to demonstrate compassion and kindness the victim has never experienced before. Even if you feel disappointed that the victim has once again returned to their abuser, demonstrate that you believe they will eventually leave and that you are there to support them on their journey. Don’t be discouraged. The seeds you plant may grow to fruition long after your client has discontinued therapy with you.
 

Howard Kassinove on Anger Management

Posted on by Psychotherapy.net Team

“I can see your bald head”

Christian Conte: Dr. Howard Kassinove, how did anger management became a central focus for you?
Howard Kassinove: When I went to graduate school, the central focus seemed to be anxiety, and the physiological or biophysical aspects of emotion. So we studied heart rate, sweating, pupillary response to light—but all with regard to anxiety. I then went out to study with Joseph Wolpe and of course his major area was anxiety. But he really put me in touch with this notion of approach versus avoidance behaviors—moving towards, moving against, or moving away from. I was also trained by Albert Ellis and he was very interested in emotionality in general.
But with that background, once I went into private practice what I discovered was that lots of my patients were angry at each other. Husbands angry at wives, parents angry at children, adolescents angry at their parents, and I had been ill trained. I really didn’t know much about it, because anxiety was the major focus of my training. So I began to study and read and my practice moved along. But then in about 1992, I really decided I had to get some kind of a handle on this. So with my then Ph.D. graduate student Christopher Eckhardt, now a professor at Purdue, he and I just started cold calling people in the field of anger: Charlie Spielberger, Jerry Deffenbacher and a range of figures. We put together an edited book, which included all aspects of anger from Spielberger’s measurement to Sergei Tsytsarev and Junko Tanaka-Matsumi’s cross-cultural perspective, and this was the beginning of me becoming centrally involved.
Then I started doing more cross-cultural research—in India, Russia, Romania and many other countries. We collected data on anger in all these other countries and I did a number of doctoral dissertations on anger. One of the most important was with my colleague Chip Tafrate, who of course is doing books with me and did the video released this month by psychotherapy.net. He did a very interesting study in which we would try to insult people—“I can see your bald head!”—and Chip would ask people to respond in different ways. One was, “How could you say that to me? That’s terrible. I can’t stand it!” And the other was, “It’s unpleasant that you’re saying that. I wish you weren’t saying it, but I can tolerate it.”
CC: The old Albert Ellis stuff.
HK: Albert Ellis, exactly. We even had a controlled condition where I would kind of insult you like that, and you would say things like, “A stitch in time saves nine.” What we found was that both the Ellis rational ideas and the distracting statements led to anger reduction.
CC: So for you it centers on cognitive behavioral techniques—on changing the thoughts around and having people learn different forms of self-talk.
HK: Yes, but my original training was at Adelphi University, which is a very psychodynamic place. One of my great heroes always was Karen Horney, because she spoke about the tyranny of the shoulds well before Ellis did. She spoke about moving against, moving away from, and moving towards people. So I also have that background.

What Exactly is Anger Management?

CC: Obviously anger has been around as long as there were human beings, but in the news over the last several years it seems like anger management in particular is getting more attention than it has in the past. From your perspective, what exactly constitutes anger management?
HK: Let’s go back to the beginning of modern anger management—Ray Novaco’s 1975 book, Anger Control. Prior to that we were not really dealing much with anger management. Ray came on the scene and became a major figure, but the word “control” has kind of disappeared and now we talk about “anger management.”
I think of it as developing less intense disruptive responses to aversive stimuli. The fact is that we live in a world where there are lots of aversive stimuli:
People take our parking spots, students tell us we’re lousy teachers, our wives and husbands tell us that we didn’t mow the lawn correctly. We are kind of bombarded with this aversive stimulation environment. Lots of good things occur in the environment, of course, but the bombardment with the aversive stuff leads us either to be angry—”How dare you say that to me?! You know you don’t have any right! You should treat me with more respect!”—and it can also lead to anxiety, when we’re being threatened by someone in authority or someone with a knife or gun.
CC: Sure.
HK: So I think that anger management in a broader sense is emotion management or emotion regulation. I try to live my life in the most mellow way possible. Most of the time these days I succeed. But it’s not only anger or annoyance I want to bring under control; I also want to bring anxiety under control. This is where Rational Emotive Behavior Therapy (REBT) has played such a central focus in my own life. Lots of abrasive events occur in life that are overwhelmingly unpleasant. These days I try and leave them there—whether it’s difficulties with my own children or difficulties with my students or my car or whatever. So in the broader sense, it’s emotion management.
CC: That’s exactly the word I use: emotional management. You’ve developed what you call the “anger episode model.” Can you talk a little bit about the evolution of that?
HK: As the years were going by, I found myself becoming kind of disgusted with the notion that kids are lazy, people are stupid—this kind of broad overarching condemnation of people. Instead, because I became more and more of a behaviorist as time went along, I wanted to speak about how people behave in particular situations. You might become angry at your wife, let’s say, when she does something wrong, and you might yell at her and maybe even demean her verbally in some way. But I bet you wouldn’t do that if you were at a state dinner with President Obama, because in that environment you’re going to behave very differently.
So I found myself moving away from the notion of “he’s an angry person,” “she’s such an angry woman,” to the idea of—how can we deal with individual situations? We started to develop the notion that people have “anger episodes” and that led to the anger episode model. The more episodes we can help them bring under control, the more likely it is they will become more generally controlled.
It’s kind of like an incremental model. I don’t think we can really change broad-spectrum personality. If I define personality as the cross-situational stability of behavior, then what I’m trying to do is change behaviors in a number of situations with the hope that eventually through generalization people become less angry.
CC: That’s fantastic.
HK: We needed a very specific and relatively simple model that we could teach to our patients.

Triggers

CC: I really identify with what you’re saying. You put people in different situations, they respond in different ways. I say to people all the time, “If I gave you a million dollars, would you respond in the same way?” They say, “Well, I don’t know if I’d be that angry if somebody cut me off in traffic if I knew I was getting a million dollars.” So we really get at the heart of those thoughts.
You talk about triggers, and I wondered does it always, from your perspective, take an outside trigger to set someone off into an anger episode?
HK: I wouldn’t necessarily say it takes an outside trigger. Something has to initiate the sequence, but it can be an inside trigger. It can be a memory of what you did to me yesterday, how you treated me as a colleague or as a student or as a professor yesterday. I remember when you gave me the mid-term examination and you were unfair then. I’m quite sure you’re going to be unfair now. That’s an inside memory. But most of the time, I still see anger as a social, interpersonal process.
Most of the time, I’m going to become angry at a person or a group of people because of something that I perceive they did wrong. Let’s face it—I’m looking around in your office right now; I bet you don’t get angry at your bookcase.
You don’t get angry at your doorknob. You don’t get angry at your carpet. But you might get angry at your wife or your children or something like that. It’s always the social, interpersonal process. But it could be what the kids are doing today, or it could be you’re lying in bed and remembering what they did yesterday.
CC: That’s so powerful. I’ve specialized in working with people convicted of violent crimes and people are always really fascinated by the intense experiences I’ve had. I wonder if you could recall for us memorable and intense situation you encountered throughout your years in anger management.
HK: That’s an interesting question. I run an anger management program at Hofstra, and it’s housed in a generic building that has little children who are learning how to read, people who are having marital problems, and kids who are there all day as part of a child care center. So we’re always worried—is there going to be an intense anger problem? I’m always worried about my students, who are upstairs behind closed doors with anger patients, many of whom come from the probation department, and they’ve been convicted of anything from pushing and shoving to murder. They have histories. I’m always concerned. But I have to tell you that in the last nine years, we have had zero intense anger problems.
CC: Many new therapists are intimidated whenever it comes to working with angry patients. They’re scared of dealing with angry people, so I have my own approach to orienting them to the work. What’s something that you teach new therapists to do if they find themselves intimidated by the anger of their clients?
HK: Well, look at how I approached you, Christian, before we started this interview. I even made fun of your bald head.
CC: Yes, you did.
HK: Right? This is really important. The interpersonal therapeutic relationship, for me, is critical. You have to know how to not make every interaction into the most serious problem in the world. Most people, I find, are willing to kid around with me. They’re willing to take my barbs, my probes, my jabs, and that’s really what I say to students. Let your clients know that you’re in their corner. You know, “I understand you have been sent by your wife, sent by your husband, sent by the judge, from the probation department, and I’m going to be as respectful of you as I can, but I’m also going to jab you a little bit.” Then I ask, “Christian, would it be okay if I jabbed you a little bit? Can we play together like that?”
I think the only way people really get better is if we engage in reinforced practice in the office. So if I’m going to consider you as my patient for a moment, I might say things like, “Well, Christian, we’ve learned a bit about your life. You’re married and you have two children, and I know that you’re having troubles with your wife, who sometimes calls you lazy. Would it be okay if I called you lazy?”

The Comeback

HK: I’d talk to you a bit about that, and then I’d say, “Well let’s start off with some deep muscle relaxation.” I would make sure that you and I are on the same page, but then I would think about some kind of a hierarchy of insults. I’d start off with, “Well, Christian, take a deep breath. Just let your body relax. Consider what a nice day it is. I can see the sunshine behind you there. It’s really a nice day. Are you ready?”
CC: Yes.
HK: Here it comes. “You know, Christian, you seem very immature today. Take a deep breath in, and out.” So that was very mild.
CC: Very, yes.
HK: As the weeks go along, it’s going to escalate to, “Christian, you’re damned immature. Do you know that?” Then I’m going to go up to, “Christian, what the hell is wrong with you? How could a man of your age be so goddamned immature?”
CC: That’s awesome.
HK: And we’ll do two things. One, I’m going teach you to engage in those cognitive coping responses. So for example, say it to me.
CC: All right. Howard, you seem awfully immature.
HK: I understand what you’re saying. Thanks for sharing it with me.
CC: So you’re kind of putting me off there. That’s a sure sign of immaturity. You seem really immature.
HK: You have a real firm impression. It’s unpleasant to hear it, but I do want to thank you for sharing with me. It shows we have an honest relationship. Thank you.
CC: That’s great. That was a good comeback.
HK: What I’m trying to do is teach the patient a way of responding that, first of all, does not inflame, because—actually come at me again.
CC: Howard, you seem awfully immature.
HK: What about you? I mean, look at that shirt that you’re wearing. It’s like something I would wear around the supermarket or something, and here we are being interviewed! There’s that come back. Or, I could teach you another comeback—try it again.
CC: Boy, Howard, you really are immature.
HK: Yes, Christian. I bought a new hard drive for my computer yesterday.
You don’t know what to do with that, right?
CC: No, that totally threw me off.
HK: In my therapy, I try to, first of all, focus in on in your particular family or life, what are the adverse verbalizations that you might be receiving? That’s what I want to hone in on. I try to teach you either to relax deeply and not respond, to say something that’s really totally silly like, “I got a new hard drive,” to thank you for being honest, to say, “It’s unpleasant. I don’t like to hear it, but I can tolerate it.” So I’m teaching a variety of responses, you know?
CC: That’s great. It’s fantastic. I love the immediacy of the role-play right there in the moment.
HK: It works pretty well. Not all the time, obviously. I’m so interested about your work in the criminal justice system. Some of those people are kind of tough cookies.
CC: Yeah. Some of them are tough to crack, but overall, even though we’ve never met before this interview, there are so many things that you’re saying that I’m putting into practice. It’s so fun to be even in a role-play on the other end of that for even just a moment. It’s just great.
Tell me about your co-author. How did you get involved with Raymond Chip Tafrate?
HK: That’s kind of a funny story. Chip was originally my PhD student, and he was just going to become a practitioner and open up a mental health center. But then when he and I did this dissertation together on anger, we started to form this close bond. He went on to become a professor in a criminology and criminal justice department in Connecticut. We just bonded. He’s a wonderful man. If there is one thing I’ve learned—I’m sure you’ve been a professor also—there are just lots of things I don’t think about. We are both experts in the field, but you and I can really learn from each other.
And I thought I could learn from Chip. He’s thoughtful. He’s grounded. He comes out of a literature base now in criminology, that’s a little bit different from mine. Even though I taught him originally about REBT or relaxation training, he also studied with Ellis and he taught me about motivational interviewing. He really turned me on to that. So it’s just been a synergistic relationship.
CC: Well the book you wrote together, Anger Management: The Complete Treatment Guidebook for Practitioners, is extremely well done.
What’s something that you know now that you wish you could go back and tell yourself as a new therapist?
HK: I think I’d tell myself to be happy with small gains. If I can just teach that person not to rebel when the boss says, “I’d like you to stay an extra two hours tonight,” and not to flip off the boss, I’m happy with that these days.
CC: I think that’s so deep for people to get and really understand. Those little things, when people have been thinking one way their entire lives and all of a sudden now they can go that extra two hours and look at it differently, I think that’s big. I think learning to appreciate that is really big.
HK: I’m kind of unhappy when I go to some of the professional meetings these days. I hear about one-session or three-session or five-session treatments for Disorder X. I think we have a lifetime of learning. We have all kinds of reinforcements and punishments and incentives that are with us all day long. You really need time, and that’s something I didn’t understand as a young person.
Many times the judges here will mandate people to come see us for twelve sessions, twenty-four sessions. It’s not enough.

CC: I totally agree.

HK: I have a cousin who is a family court judge in California, and she says she recommends people for fifty-two sessions. I said, “I’m praying for that.”
CC: I just moved back to Pittsburgh, Pennsylvania, a year-and-a-half ago, but I was a professor at the University of Nevada before that. I co-founded a center for violent offenders in South Lake Tahoe, California. So in California, if they commit a violent crime, they are sentenced to fifty-two weeks of anger management. That’s standard. But in Nevada, just on the other side of state line, if they get in trouble there they were only sentenced to twenty-six weeks. I found in my own research that people did not make the kind of changes in twenty-six weeks, not even close, to the ones who were sentenced to fifty-two weeks. So I am a big proponent of a long treatment. Here in Pennsylvania, I’ve have judges say, “If they need a session or two.” A session or two to change a lifetime of anger? That’s just funny.
HK: Sometimes we ask patients, “How much anger management did the judge tell you you need?” “Today, just today.”
CC: “I just need to come to this one class.”
HK: If there’s anything I’ve also learned it’s that change comes about not from a class, not from education, but from practice. I teach my students practice makes better. We have to get these people into our offices and practice better behaviors with them. I even had one case, one of my students, where we started to transition from kind of barbing him and insulting in the office and frustrating him in the office, to out in the real world. So this patient happened to have worked as a shoe salesman, and what my student did is he went to the shoe store and without the patient seeing, pushed over a whole batch of shoes. This guy used to respond with great anger, but we wanted to see if we had done anything. Indeed, he responded very well. So I think practice makes better, starting in the office, going to the natural environment. That’s one thing I’ve learned that I really didn’t fully understand as a beginning therapist.
CC: I wholeheartedly and really sincerely appreciate this interview and this time with you because it’s tremendous to listen and hear and say I agree. I mean, two people practicing in totally different parts of the country and our experiences sound so similar. To me, that’s grounded in truth. There’s an essence to that change that obviously is just there regardless of words.
HK: Thank you.

The Tao of Anger Management: A Yield Theory Approach

Posted on by rezendevknowfully.com

“The gentlest thing in the world overcomes the hardest thing in the world.” —Lao Tzu

Brian had been incarcerated for taking a baseball bat to his girlfriend’s truck with her inside of it; he then pulled her out and beat her unconscious. He was out of prison and in my anger management group for two weeks when he reported, “What I did may have been too much, but she deserved it because she stole my money.” He claimed that he shouldn’t have gotten in that much trouble because it was “my truck anyway,” and besides, she “slipped and hit her head on the ice.” Brian was still in the precontemplation stage of change: he didn’t think he had a problem.

Things got worse before they got better. The following week Brian was furious when he came to group, complaining that he had been called in by his probation officer two days in a row to be drug-tested. The only reason for this, he claimed, was that his ex was “sleeping with a cop.” In a state of rage, his face flushed, his fists and feet pounding wildly, he shouted about police corruption and denounced his ex-girlfriend, the “whore” who was just out to get him. 

Instead of asking him to calm down, take a breath, or do anything other than be where he was in the moment, I simply validated him. I imagined what the world would look like from Brian’s perspective as I said, “Man, that’s just plain messed up.” I knew that Brian didn’t know anything other than what he knew in that moment, and he needed someone to see what he saw, so I went with him further: “You know, it sucks that you work so hard to be sober, and then people go and pull this shit, and test you even more.” I paused briefly, made a projection about what he might be thinking and added, “I mean, they tested you literally, but they’re also testing your limits too. It’s like they’re trying to set you back.”

He responded emphatically, “Exactly! They’re pushing me!”

“You know what?” I said, “this was kind of messed up, so I’m not even going to ask you to calm down right now.” I paused, shook my head, and waited for a moment before continuing. “In fact, even if this is supposed to be anger management, it would be stupid for someone to think you need to learn from this right now, because you have a right to be pissed off.”

He nodded his head in agreement, and he was visibly calmer, so I went on.

“I’m not going to tell you to learn anything from this right now, but let’s say this was tomorrow at this time, what do you think you might say about this experience?”

“I don’t know.” He paused. I waited. “I guess I would say that I probably overreacted.”

I then said, “I’m not going to say that you overreacted because it was really messed up, but, I don’t know—I wonder if this was like a week later… I wonder what you’d say about this experience then?”

 “I don’t know,” he said. “I guess I’d say that probation has a right to test me two days in a row in case I’m using or something.” He was calming down more, and moving more and more into his frontal lobes.

So I said finally, “Look, I know you’re pissed off, and I see you’re hurting about this, and we don’t need to talk about this tonight—but if this were a month from now, I wonder what you might say about this whole night?”

Almost completely calm now, Brian replied, “I guess if this were a month from now, I would probably look back on this night and see that I was still doing the same thing I always did: blaming her for me not wanting to be drug tested.” 

The shift occurred. The door was open to future work. 

Behind the Mask

"Treat the people as trustworthy, and they will be trustworthy." —Lao Tzu


When Brian came in furious and outraged, it could have elicited fear in me—he was, after all, an imposing figure—but I knew that Brian wasn’t angry at the world or at me; he was angry at having to take responsibility for something unpleasant. When that happens, people are usually blinded with rage, but not likely to hurt someone they don’t know. Brian was scared to face the world without what he had come to depend on: drugs to alter his state of mind. He was not ready in that moment to genuinely be accountable for what he did—so that was not the time to get on a soapbox and criticize his actions. 

More importantly, Brian didn’t scare me because I am armed with the knowledge that anger masks fear. Just as you wouldn’t walk into a costume party and believe that goblins and monsters are suddenly alive and dancing with each other because you would know it was people dressed in costumes, so too do I see that when people are angry, they are wearing a mask to hide what is really going on inside them. It was important for me to trust the deepest part of Brian’s essence: the part that is, in my view, inherently good. 

As a therapist, my goal is to facilitate people’s journey through the depths of their undiscovered psyches in a way that helps them move beyond the battle of the ego/true-self dynamic so that they can find, hold, and live in expanded consciousness. My working assumption is that the essence of people is much deeper than what we can see on the surface. This assumption helps me view people as vastly greater than their actions, and infinitely more than any pain and suffering they have caused or experienced. 

I specialize in working with people who have been convicted of violent crimes: murder, rape, and the abuse of others. The work is not easy, but it is some of the most rewarding work that I have ever done, due in part to the amazing transformations that I’ve witnessed throughout the years. I’ve watched gang members gain awareness and perspective enough to walk away from their gangs; I’ve seen people who train as fighters walk away from street fights; I’ve seen people who have spent their lives believing that life is about getting “respect,” make incredible changes and learn to more deeply respect themselves and the world around them. 

“No one sets out to be defined by his or her worst moment in life, yet almost every violent offender is judged, convicted, and defined by his or her worst moment.” Just imagine if everyone in your life defined you by your worst moment, that this moment accompanied you like a badge of shame throughout your life, limiting all future possibilities, including your hopes and dreams. It would seem terribly unjust; and yet this is what we do with violent offenders. They carry the burden of our shadow projections and are left believing that they are terrible people because they have done terrible things. And because they lose hope about the possibility of breaking free from these deeply internalized expectations, they live up to their self-fulfilling prophecies by continuing to do terrible things. 

The startling recidivism rates in our country (close to 70% of violent offenders return to a life of crime after imprisonment) should be all the evidence we need to understand that our system of rehabilitation-by-incarceration alone simply doesn’t work, but it’s not. The “more shame, more guilt, and more punishment” approach—though it has a long history among treatment of violent offenders—has led to 7 out of 10 people returning to lock-up. It’s clear that it is time for a new approach to this problem, and it requires a change in consciousness, not only among violent offenders, but also among the population at large. 

Yield Theory

“Knowing how to yield is strength.” —Lao Tzu


My approach to working with clients who have committed the most heinous of crimes is grounded in what I call “Yield Theory,” a powerful and compassionate approach to communication that essentially boils down to radical empathy delivered with intentionality. Taoism is a spiritual tradition—the core of which is seeing beyond the black and white world of either/or, good/bad, and recognizing balance through the single essence of everything. Founded by the legendary Lao Tzu more than 2,500 years ago, “Tao” means the way. For me, the journey that clients take to personal growth is the same as what we all undertake along the way in life.

Yield Theory differs from radical empathy in that in addition to attempting to think and feel entirely from clients’ perspectives, therapists also go with or literally yield to what clients are saying in the moment, with the intention of guiding them to new insight on situations. This approach involves more than simply understanding that multiple factors contribute to violent interactions—you must cultivate the ability to not resist even the angriest outbursts. Yielding entails both joining with the essence of who clients are, and “going with” clients to circumambulate their fight-or-flight responses so they will be more open to the possibility of healthier options.

The underlying assumption of Yield Theory is this: If we lived every day as another human being—not just walked a metaphorical mile in that person’s shoes, but actually had the exact same cognitive functioning, affective range, and life experiences—then we would make every single decision that that person has ever made. Every single decision. This goes beyond simple empathy: it is the capacity to truly recognize the essence of others, and non-judgmentally accept who people are, regardless of their choices and actions—including violence. 

By yielding with others and genuinely trying to understand why they have done what they’ve done rather than judging them, I have found that people are more than just willing to open up and talk—they are also much more open to the possibility of change. I have found that by accepting the essence of people, I have an easier time approaching violence with compassion. The Yield Theory framework has allowed me to rid myself of judgment and do the job I was intended to do: assess people accurately and help them change and lead lives directed by their true selves (their essence), rather than by their egos (introjected identities). 

My anger management program is predicated on respecting all human beings who enter treatment, regardless of their actions, and strives to meet every person where he or she actually is. I call it, “conscious education rooted in compassion.” Even the most resistant clients who ardently deny any accountability for significantly harming others are accepted as readily as those who are actively seeking change. Everyone has a story, and people’s cognitive functioning, ability to process emotions, and life experiences shape and continually influence them.

“Though many therapists and counselors may claim to “accept all people,” in practice, most struggle in their work with people who have violent tendencies.” It could be that the natural fight-or-flight response triggers their survival fears and causes them to write off violent offenders as incapable of change, dangerous, and hence deserving of judgment; but it could also be because human beings tend to value their own standards of living, beliefs, and ideas over those of others and in subtle and often unconscious ways judge people who are different—particularly when those differences appear threatening. 

It is hard for most people to grasp that fully accepting a person who commits a violent crime has absolutely nothing to do with condoning that person’s actions. Truly understanding this, however, makes all the difference in our work with those who are pushed the margins of society. 

Components of Yield Theory

Vulnerability takes courage—especially amongst people who define themselves by how “tough” they are—and yet I have found in my anger management groups (which are open, so there always new people coming in) that people share with the same level of vulnerability and honesty as any therapy group I’ve ever witnessed. I believe this is due to the key components of Yield Theory that I apply in my groups: acceptance, the elimination of shame, mindfulness, creativity, conscious education, non-attachment and authenticity.

Acceptance
The potential for everything great and everything terrible resides inside all human beings. If a human being has performed an act, then it is accurate to say that it is “human nature.” If we can accept the nature of human beings (that we will at times be loving and kind, at other times hurtful and cruel, and everything in between and beyond), then we can evaluate others, as well as ourselves, in terms of trying to simply understand human behavior. Furthermore, if we accept the premise that we cannot do one single thing to change the past, and we merely have the ability to impact the present to shape the future, then we can see that pejorative, judgmental approaches do little to impact the present or future in positive ways; whereas acceptance of what is, along with acceptance of the essence of people, can set the stage for conscious learning and change.

With Brian, it was important to accept him for the essence of who he is, and from there to accept where he was cognitively and emotionally in that moment. From his perspective, after all, things were unjust and unfair, so acknowledging that was an important first step.
 
Shame
Years of studying people who commit violent crimes has led me to the conclusion that people who live in shame act out of shame.Eliminating shame, therefore, has become central to my work. At first glance, it may seem difficult to swallow the idea of not shaming someone who has committed a violent act; however, as David Hawkins (2002) suggested in his “map of consciousness,” shame is the lowest form of consciousness that human beings experience. What I have learned is that it is difficult for human beings to make highly conscious choices from low levels of consciousness, so helping people have expanded consciousness becomes paramount to changing their actions.

It would have shamed Brian to try to get him to see what he did wrong while he was in a state of fear and anger. It was not the time to have him acknowledge responsibility or even awareness of anything he did that was hurtful. Instead, it was important to work with what was available for him cognitively and emotionally in the present moment.

Mindfulness
Mindfulness was first described in the Dhammapada as a way that the Buddha taught others to observe and keep constant watch over their thoughts. Engaging in “right mindfulness” entails expanding the awareness that we have not only for ourselves, but also for the world around us. The more mindful we can be in every moment, the more likely we are to consider alternative ways of interacting with others. Mindfulness begins with self-awareness, but it also extends to an awareness of the environment and what is going on inside other people as well. As a group leader, I both practice and teach mindfulness. Though it is fairly easy for therapists to learn how to teach or simply read a basic mindfulness exercise in a group setting, it is the role modeling of mindfulness (i.e., the therapist’s constant awareness of present moment intra and interpersonal experiences) that seems to make the biggest impact on clients. As many people who teach mindfulness would explain: mindfulness must be lived to be understood. 

It was important for me to be mindful and aware of my own thoughts when Brian began railing against his parole officer and his ex, and to be careful not to get caught up by them. I tried to be as aware as possible about what might be going on inside of him, based on what I was seeing in him and my own internal reactions, but ultimately the best we can do as therapists is project what we imagine others are thinking, and then check those projections. In this instance, my projection appeared to be accurate. But mindfulness goes much deeper than just awareness of my thoughts and his; it is also an awareness of the environment in the moment, and a willingness to stay present with whatever unfolds without reverting into a reactive or defensive posture.

Creativity
In my experience, having the ability to genuinely meet a diverse group of clients where they are separates average therapists from very good ones. If we are charged with meeting people where they are, then we must consider that people have varied learning styles, and forcing clients to only get information in the way that we think works is, in my view, irresponsible. To implement creativity in therapy is to constantly evaluate one’s own communication style, and to be open to adjusting it accordingly to what people need. I believe the onus of communicating effectively rests with the therapist, so when clients are not getting what we are communicating, I believe it is our responsibility to find creative ways to meet them where they are. Creativity can come in the form of analogies, metaphors, techniques, or even just in the openness to develop new ways to say things in ways clients can fully hear. 

In the heated moment with Brian, I chose to use a future-self technique with him. I have found that in working with a largely angry population, being able to think quickly and creatively is not only a bonus, but a necessity. 

Conscious Education

“What is a good man, but a bad man’s teacher? What is a bad man, but a good man’s job?” —Lao Tzu

In my view, it is the responsibility of therapists to offer something more than just listening to their clients. Teaching skills is essential to helping people who are struggling with anger. We cannot expect people to respond differently to the world until we teach them different options. For counselors to implement conscious education, they must be willing to teach concepts patiently and compassionately until clients understand the ideas. This is quite different than simply relating concepts and assuming that clients understand them. In conscious education, therapists do not assume their clients should already have specific information; instead, they make the effort to teach in compassionate ways that meet diverse learners where they are.

As a former tenured professor, I know all too well how lengthy the discussions can be over the semantics of what does and does not constitute teaching. Outside of the world of academia, however, I would argue that we are always teaching others—even if the lesson is about how we are likely to respond in a given situation. I know from further interactions with Brian that he learned that day how to implement the future-self technique. He subsequently reported using it several times and even taught it to another group member during an anger management session.

Non-attachment
The idea of non-attachment is at the foundation of healthy learning. Whereas it is fairly easy for most Westerners to understand the idea of attachment to material goods through identification (“I’m a homeowner” or “This is my car” or “I am a good person because I have a high-paying job”), the notion that we are equally attached to our ideas seems far less widespread. “As long as our ideas are a part of who we are, we become defensive when people disagree with us.” When we can separate ourselves from our things, as well as from our very ideas, we are engaged in the process of non-attachment. As therapists model this concept, they create a safe path for clients to learn to express themselves openly, knowing they will not offend their therapist in any way. 

As a caution to those becoming too attached to the idea of non-attachment, Zen practitioners offer the concept of the “soap of the teachings.” Consider that to clean a shirt, it is necessary to use soap; but if the suds are not rinsed out, the garment will not truly be clean. In this same way, non-attachment to the idea of non-attachment becomes central to practicing the concept. 

In the case of Brian, I was not attached to his response, and would have been content with being off base had he told me that was the case. I was also not attached to the technique I was using with him; had it not helped, I was ready to readjust my technique to something more useful. 

Authenticity
People can spot disingenuousness easily. Mirror neurons are not only the root of vicarious learning, but are also the key part of our neurology that helps us identify when people are being authentic with us or not. It is well known in our field that clients will use the inauthenticity of their therapists as a reason they cannot or should not have to change. On the other hand, when people experience authenticity and know that we sincerely have their best interest at heart, they are much more open to learning about themselves.

The most pragmatic way therapists can convey authenticity is to regularly practice the ideas that they are teaching in their personal lives. It is paramount to practice what we preach. We do not have all the answers, nor should we purport to. We make mistakes as equally as our clients: not better or worse mistakes, just different mistakes, and we are all in this process of experiencing what it is like to be fully human. 

Conclusion

“Can you love the people and lead them without imposing your will?” —Lao Tzu

To understand people’s stories is, in a sense, to journey with them to the depths of their psyches. As a modern journeyman, I like to use vehicles as an analogy for journeying. Here’s my analogy for using Yield Theory to work with clients: Imagine that you are riding in a car and you come to a merge point (a yield sign). You merge with another car until you are side-by-side. Suspend what you know about reality, and imagine that as you travel beside the car long enough, the other driver sees that you are going in the same direction, so he invites you into his car. 

As a passenger now in this person’s metaphorical car, you have a better opportunity to see the road as he sees it, through his windshield. As the trip goes on, perhaps the driver gets tired and is ready to rest for a bit. You are now trusted enough to take the wheel. When you do, you can help steer the car down a more effective path. 

Lao Tzu said, “What is painted on these scrolls today will appear in different forms in many generations to come.” Similarly, the words of all therapies emerge at different times and come in different forms, but they are always essentially the same. For Yield Theorists, accepting the core of who people are, finding creative ways to communicate so that we are actually heard, teaching in some form, modeling openness, facilitating awareness and being authentic are therapeutic concepts that are simultaneously a way of life. 

The first practice of the Tao is something called undiscriminating virtue. It means taking care of those who are deserving and also—and equally—taking care of those who are not. When therapists practice Yield Theory, they are practicing undiscriminating virtue by immersing themselves into the psyches of others—regardless of anything they have done up to that point. Violence as a human construct probably cannot be eliminated; however, people—even those with the most violent backgrounds and intense struggles with anger—can learn a different way. 

We can continue to stand on our soapboxes and preach against violence and against the people who perpetrate it, but violence will always exist and shaming people simply doesn’t work. If we truly want to help people overcome their violent tendencies, we must work from a place of consciousness, choose to merge with others—see the world as they see it, attempt to understand what they understand, and help support them in their journey to new levels of awareness and peace. 

“To the highly evolved being, there is no such thing as tolerance, because there is no such thing as other.” —Lao Tzu



 

Assessing Partner Abuse in Couples Therapy

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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.