Considerations of Conjoint Couples Therapy in Cases of Intimate Partner Violence

Abstract

This article reviews the current literature on the implementation of conjoint couples counseling in cases of intimate partner violence (IPV). As maintained by feminist theorists, due to the possibility of perpetuating or increasing violent behaviors within a couple, a conjoint treatment for IPV is generally contraindicated. However, multiple studies have shown that conjoint approaches do not increase the risk of harm to the victim. Following a thorough assessment of the dynamics of violence within a relationship, individual personality patterns, and adequate counselor training in IPV, a conjoint approach may be beneficial to reduce violent behaviors while increasing communication, problem-solving skills, and overall relationship satisfaction.

Keywords

partner violence couples counseling spouse abuse

Intimate partner violence (IPV) is a common public health problem in the United States. IPV encompasses physical violence in addition to emotional violence, including verbal abuse, gaslighting (i.e., a form of victim blaming involving psychological manipulation leading someone to question their own sanity), coercion, manipulation, and threats of physical violence (Black et al., 2011). In 2011, the Centers for Disease Control (CDC) reported 47.1% of women in the United States experienced some kind of psychological aggression in their lifetime, and 37.3% of women experienced sexual/physical violence or stalking in their lifetime (Black et al., 2011). IPV is often treated as a women’s issue, although men also suffer from partner abuse at rates comparable to women: 47.3% reported some kind of psychological abuse and 30.9% reported sexual/physical violence or stalking in their lifetime (Black et al., 2011). Thus, addressing IPV represents a significant public health crisis in the United States.

The Duluth Model: A Unidirectional Approach to IPV

Traditionally, legislation aimed at solving the problem of IPV has been based on the Duluth model of intervention developed in the 1980s in Duluth, MN, in response to an increase in IPV-related arrests (Pence & Paymar, 1993). This model assumes that violent perpetrators are traditionally men who commit violence against women. Thus, the treatment for IPV is traditionally separated by gender; male perpetrators attend batterer intervention programs while victims receive separate advocacy and resources. The Duluth model, based on feminist theory, posits that IPV is perpetuated by the patriarchal system of power and control (Pence & Paymar, 1993). Batterer intervention programs aim to help perpetrators abandon patriarchal use of dominance and power, male privilege, manipulation, isolation, and victim blaming in favor of a more egalitarian view of relationships and gender roles. Sessions are typically psychoeducational in nature and are designed to help men modify their approach to violence as a control and problem-solving mechanism.

Unfortunately, research has found that this model of predominately men’s groups leads to minimal reductions in violence, with some studies showing just a 5% reduction in IPV (Babcock, Green, & Robbie, 2004). Some have argued that adding cognitive-behavioral elements to the model improves treatment outcomes (LaTaillade, Epstein, & Werlinich, 2006; Murphy & Eckhardt, 2005); however, the format of the intervention itself may be counterproductive. A group setting may become a place for perpetrators with lower levels of violence to implement more severe forms of violence learned from other group members (Stith & McCollum, 2011). Additionally, as noted in the Duluth “power and control wheel,” perpetrators are often adept at manipulation and control and may appear to improve in treatment while continuing violent behaviors outside the intervention setting (Stith & McCollum, 2011).

The Duluth model assumes that all perpetrators use violence for similar reasons and takes a one-size-fits-all approach to treatment. This feminist approach suggests that the majority of violence is perpetrated by men; however, multiple studies have shown that bidirectional couple violence occurs in 50–60% of couples (Langhinrichsen-Rohling, Misra, Selwyn, & Rohling, 2012; Whitaker, Haileyesus, Swahn, & Saltzman, 2007). Treatment approaches that assume unilateral, male-to-female violence may not fully address a large portion of problematic behaviors that couples present. The Duluth model has become the dominate treatment modality in large part because of the potentially harmful and fatal risks of treating the violent perpetrator and victim together.

Conjoint Approaches to IPV

Despite controversy surrounding the appropriateness of conjoint treatment of IPV, there are a variety of reasons for implementing couple’s therapy for domestic violence. First, research consistently shows that male batterers are a heterogeneous group. Kelly and Johnson (2008) provide two IPV perpetration subtypes: “coercive controlling violence” and “situational couple violence.” Coercive controlling violence involves violence with the goal of controlling one’s partner and is often sustained by positive attitudes about violence overall. This type of violence has also been termed “characterological violence” (Antunes-Alves & Stefano, 2014). The second type of violence, “situational,” describes mild to moderate violent behaviors such as slapping, pushing, or grabbing. This type of violence is not motivated by underlying goals to dominate or control one’s partner but is instead a result of situational stressors addressed using violence as a problem-solving technique. In the context of situational violence, conflicts are escalated to the point where both partners may become both the perpetrator and the victim of violence.

Holtzworth-Munroe and Stuart (1994) explored the literature on batterer intervention programs and developed three descriptive dimensions of IPV (i.e., severity of marital violence, generality of violence [toward the partner or toward others], and presence of psychopathology/personality disorders) which have consistently been found to distinguish subtypes of batterers. They suggest that three subtypes of batterers exist (i.e., family only, dysphoric/borderline, and generally violent/antisocial) and that tailoring treatment to each subtype of violent men might improve treatment outcome. Advocates of conjoint approaches suggest that a couple’s approach should be limited to one subtype of batterer (the family-only batterer without apparent psychopathy), who is most likely to benefit from couple therapy (Stuart & Holtzworth-Munroe, 1995).

In addition to treating subgroups of batterers differently, there is reason to include female partners in treatment. Research has found that women initiate and carry out physical assaults on their partners as often as do men (Black et al., 2011; Stith & Straus, 1995). In cases of bidirectional violence, separation of genders without providing treatment for women in unlikely to stop the violence. Studies show that cessation of partner violence by one partner is highly dependent on whether the other partner also ceases violent behaviors (Feld & Straus, 1989; Gelles & Straus, 1988). Thus, addressing both sources of violence is the most productive form of treatment in these cases.

Although men’s treatment groups address men’s role in intimate partner violence, they do not address underlying relationship dynamics that may affect each partner’s decision to remain in the violent relationship despite the violence, or dynamics that contribute to maintenance of violent behaviors (Stith & McCollum, 2011). In a study involving the prediction of mild and severe husband-to-wife physical aggression with 11,870 randomly selected military personnel, Pan, Neidig, and O’Leary (1994) found that marital discord was the most accurate predictor of physical aggression against a partner. For every 20% increase in marital discord, the odds of mild spouse abuse increased by 102%, and the odds of severe spouse abuse increased by 183%. Because marital discord is a strong predictor of physical aggression toward a partner, it would seem that failure to address marital problems during treatment of men and/or women would make it likely that the abuse would recur.

Recurring bidirectional violence is typically sustained by dyadic rather than individual factors. From a systems perspective, this type of violence is treated as a relational problem, rather than an individual problem; violence is perpetrated through relationship patterns that both partners engage in, and cannot be attributed to a single perpetrator (Stith, McCollum, Amanor-Boadu, & Smith, 2012). Contrastingly, feminist theory is concerned that a systems approach implies the victim is equally responsible for violent behavior and has an equal responsibility in ending it (Tomsich, Tunstall, & Gover, 2016). However, as noted above, a significant portion of violent relationships involves bidirectional violence in which both partners are perpetrators and victims and are equally responsible for the continuation and cessation of violent behaviors. Feminist theory and feminist concerns apply to a portion of IPV cases in which the perpetrator is motivated by power dynamics and control, but it does not address other forms of IPV relationships.

Studies of Approaches

The first study examining couples therapy in a court-mandated sample recruited 49 couples experiencing male-to-female abuse (Brannen & Rubin, 1996). Couples were assigned to a conjoint group treatment for 14 weeks, while men in the control group received a gender-specific cognitive-behavioral treatment (CBT) for 14 weeks. Although no differences in violence recidivism rates between groups were found, the overall rate of violence cessation was 92%. They also found that women in the couples treatment modality did not experience increased danger after treatment compared to the gender-specific treatment (GST) group, refuting feminist claims that a conjoint approach is potentially more dangerous for the victim. Authors of this study concluded that a conjoint approach can be used safely in the presence of close monitoring by probation officers.

Another study using the same treatment protocol as Brannen and Rubin (1996) compared GST for both men and women to a conjoint approach, which both occurred for 14 weeks (O’Leary, Heyman, & Neidig, 1999). The men’s GST focused on decreasing aggressive behavior, educating men about the cycle of violence and anger, and increasing the use of effective communication. The women’s GST addressed recognition of abusive patterns in relationships, emotional regulation in negative situations, and consideration of advantages and disadvantages of staying in a violent relationship. The conjoint treatment condition involved working to reduce physical and psychological violence, coping with anger, communicating effectively, and working toward mutual respect. At 1-year follow-up, the researchers found a 50% reduction in men’s psychological aggression and overall improvement in marital satisfaction across both treatment types. There was also a significant reduction in physical violence across treatments; 8% of male partners were not physically violent in the 14 weeks prior to treatment while 39% were not physically violent during the 14 weeks of treatment.

Dunford (2000) conducted an experimental study in which he randomly assigned 861 Navy couples to one of four treatment conditions: a 26-week cognitive-behavioral men’s group followed by 6 monthly sessions, a 26-week multicouple group followed by 6 monthly sessions, a “rigorously monitored” group, and a “no treatment” control group. The rigorously monitored group involved monthly individual counseling meetings between case managers and perpetrators for 12 months. Every 6 weeks a record search was completed to document and arrests or court referrals, and perpetrators wives were asked to report on any abuse (only if doing so would not place them in danger) on a monthly basis. At the completion of treatment, case managers sent progress reports to perpetrators and their commanding officers. The men’s CBT group and multicouple groups were organized to include didactic and process activities, although the multicouple group gave victims the chance to witness their partners being held accountable for their abusive behaviors and to be included in the training of conflict resolution techniques. Results revealed that 83% of men who completed treatment (men’s group, conjoint, and rigorous monitoring) did not engage in violence during a 1-year follow-up period, with no differences between treatment modalities.

Such findings provide little evidence of the effectiveness of conjoint treatments in relation to GST modalities; however, they do provide evidence that conjoint treatments do not increase the risk to victims as the feminist-informed Duluth model would suggest. Evaluation of conjoint treatment models in voluntary and court-ordered samples has been historically limited because of the assumption that conjoint models blame the victim and increase victimization (Stith & McCollum, 2011). Courts have been reluctant to order conjoint treatments for these reasons, despite research refuting these claims. These studies provide encouragement for the implementation and evaluation of other conjoint treatment models that have been empirically untested (e.g., The Ackerman Institute Model from Goldner, Peen, Sheinberg, and Walker [1990], The Cultural Context Model from Almeida and Durkin [1999], and the Solution-Focused Domestic Violence Couples Treatment from Lipchik and Kubicki [1996]).

Other Approaches

Since the development of the Duluth model and the lack of evidence demonstrating its effectiveness, additions to GST have been made in order to encompass a wider range of perpetrators using violence for a variety of reasons (Armenti & Babcock, 2016). CBT approaches are designed to actively address maladaptive beliefs about women and learned violent behaviors in a therapeutic manner, rather than a psychoeducational manner (Armenti & Babcock, 2016). One CBT approach, Couples Abuse Prevention Program (CAPP), was found to increase relationship satisfaction in males, decrease partner hostile withdrawal in males and females, and elicit no change in threats of physical aggression (LaTaillade et al., 2006). There were no significant differences in outcomes between the CAPP treatment and conjoint treatment. CBT-oriented GST may be appropriate and effective in reducing abusive behaviors in couples displaying psychological and/or mild to moderate physical abuse (LaTaillade et al., 2006). More research comparing the Duluth psychoeducational model to modified CBT approaches to GST is warranted.

Another conjoint approach, The Physical Aggression Couples Treatment (PACT) program (Heyman & Neidig, 1997; Heyman & Neidig, 1999; Heyman & Schlee, 2003; O’Leary et al., 1999), is delivered to groups of couples who are experiencing psychological/physical aggression but not severe violence. PACT is a CBT approach that focuses on reducing current aggressive behavior and preventing future violence. Treatment goals include psychoeducation about the patterns of violence in close relationships and alternatives to IPV, increasing personal responsibility for the use of violence, reducing and ultimately eliminating IPV through anger management and conflict resolution skill training, and increasing relationship satisfaction and positive couple interactions through communication and problem-solving skill training.

PACT was compared to GST in a longitudinal investigation of its efficacy in reducing and eliminating IPV (O’Leary et al., 1999). At posttreatment, husbands and wives reported significantly higher marital adjustment scores than at pretreatment. In addition, husbands scored lower on measures of both psychological and physical aggression at posttreatment. Furthermore, husbands reported significant increases in taking responsibility for their violence, as well as significant decreases in victim blaming. Similarly, wives reported significant decreases in self-blame and taking responsibility for their husbands’ use of aggression. One-year follow-up results indicated that husbands’ reduction in physical/psychological aggression was maintained, according to both husbands’ and wives’ reports. In addition, both husbands and wives reported significant increases in marital satisfaction at the 1-year follow-up. There were no significant differences in outcome measures between PACT and GST. Still it is unclear if conjoint treatment provides violence reductions above and beyond those of GST.

Assessment for IPV Dynamics and Typology

Given the heterogeneity of perpetrators of IPV, couples’ counselors intervening in cases of IPV should conduct a thorough assessment of the individuals and relationship dynamic to determine appropriate treatment modality (Schacht, Dimidjian, George, & Berns, 2009; Stith, Rosen, & McCollum, 2003). Also, many couples therapists are already treating violent couples without knowing it. O’Leary, Vivian, and Malone (1992) found violence rates as high as 67% in couples seeking regular outpatient treatment. Couples therapists should incorporate IPV assessments into treatment even if the couple does not wish to directly address the violence. IPV may be indirectly addressed through interventions designed to improve communication, conflict management, and problem-solving (Dunford, 2000). Assessments should also include multiple modalities (i.e., separate and conjoint interviews in addition to self-report surveys) because individuals may be reluctant to report abuse if safety is an issue, they are ashamed of the violence, or they are unaware of what qualifies as abuse. Interviews should clarify the definition of violence to include physical and psychological abuse; although many couples do not self-identify as IPV victims in cases of mild to moderate physical violence or psychological abuse, these kinds of abuse are still common and maladaptive (Stith & McCollum, 2011).

The most common IPV assessment tool is the Conflict Tactics Scale (Straus, 1979). This 18-item self-report inventory allows both partners to indicate whether they or their partner engaged in any number of physically aggressive behaviors in the last 12 months. Other measures include the Abuse Assessment Screen (Soeken, McFarlane, Parker, & Lominack, 1998), the Assessment of Immediate Safety Screening Questions (Family Violence Prevention Fund, 2002), and the Domestic Violence Initiative Screening Questions (Webster, Stratigos, & Grimes, 2001), which includes a screen for substance use or mental health problems that may compromise the safety of partners and/or modify the treatment plan (Dutton & Corvo, 2007). Such instruments help clinicians clarify the nature and context of the violent behaviors and aid in identifying appropriateness for couples treatment versus individual treatment. As described above, in cases of mild/moderate bidirectional violence absent of comorbid psychopathology, a conjoint approach may be appropriate.

Conclusions

The limited research on conjoint IPV treatments has revealed no significant differences in violence reduction between individual and conjoint treatments. Some studies have demonstrated improvements using couples treatment formats in outcomes associated with violence (e.g., alcohol use, marital satisfaction), and such programs have the added effect of violence reduction. However, it is unclear if conjoint treatment directly addressing IPV is more effective than individual treatment forms (Dunford, 2000; O’Leary et al., 1999).

Under specific circumstances, conjoint couple therapy may be the appropriate intervention for IPV if certain conditions are present, as determined by the clinician. As a general guideline, conjoint couple therapy may be helpful with couples where there is common couple violence and where the violence is mild to moderate in nature (Bagarozzi & Giddings, 1983). There seems to be general consensus that where violence is severe and life-threatening, systems-based interventions are contraindicated, and a more traditional approach of partner separation is warranted (Gelles & Maynard, 1987; Straus & Gelles, 1986). There is also agreement that couples (a) who take responsibility for their aggressive behaviors, (b) are motivated to change, and (c) do not attribute their behavior to external factors, are also good candidates for conjoint work (Bograd & Mederos, 1999; D. G. Dutton, 1986; Holtzworth-Munroe, Bates, Smutzler, & Sandin, 1997). In certain types of violent relationships, a conjoint approach increases accountability, marital satisfaction, and other outcomes in couples experiencing bidirectional violence who wish to stay in the relationship (LaTaillade et al., 2006).

It is strongly recommended that couples counselors conduct thorough IPV assessments using psychometrically sound measures in multiple formats such as interviews and self-report surveys (Schacht et al., 2009). Furthermore, it is recommended that clinician educators should increase in IPV-specific training and coursework for graduate students intending to work with couples (Schacht et al., 2009; Tomsich, Tunstall, & Gover, 2016). Given the high prevalence of IPV, counselors need to improve their awareness and training in this area. Research on conjoint treatment of IPV has been stagnant for decades because of the proliferation of the GST recommendation of the Duluth model, despite little evidence to support its efficacy in violence reduction. Furthermore, research has shown no evidence of increased danger to victims of IPV in conjoint treatments, although practice has not yet caught up to incorporate these findings. More research is needed on the effectiveness of conjoint counseling compared to individual treatment. To date, there have been few randomized clinical trials devoted to couples counseling for IPV, most likely because of the proliferation of the gender-separated Duluth model which discourages courts from requiring conjoint treatment to protect victims. Indeed, recommending conjoint counseling in the context of IPV can have potentially fatal consequences in some cases, which some report as the main barrier to the prevalence and research on conjoint treatment modalities (Tomsich et al., 2016). Certainly, thorough core screening is necessary before couples counseling for IPV is recommended or initiated.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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