The Assessment of Court-Mandated Perpetrators of Domestic Violence
Sonkin, Daniel and Liebert, Douglas (2003). The assessment of court-mandated perpetrators of domestic violence. Journal of Trauma, Aggression, Maltreatment and Trauma. Volume 6 Number 2, pp 3-36.
Correspondence may be sent to Daniel Sonkin, Ph.D., 1505 Bridgeway, Suite 105, Sausalito, CA 94965.
The authors present a comprehensive assessment protocol for court-mandated perpetrators of domestic violence. Because of the inherent risk of harm to others present in the context of domestic violence treatment, the authors present an assessment process with a clear set of goals and expressed expectations. These goals help to set the context of treatment from the onset and serve as a continual frame of reference that both therapist and patient will refer to throughout the treatment process. The authors discuss the following assessment issue: informed consent and disclosure; confidentiality; patient rapport; patient motivation for treatment; patients suitability for treatment; differential diagnosis; the assessment of violence and social history; patients risk for further violence and other acting-out; behavioral interventions for violence control; developing treatment plans.
Keywords: domestic violence, perpetrators, batterers, assessment, risk
The Assessment of Court-Mandated Perpetrators of Domestic Violence
Domestic violence treatment programs have historically been designed for men who have been or are at risk for becoming violent with an intimate partner. With the recent advent of mandatory arrest laws for domestic violence, treatment programs have proliferated around the country in response to the growing need for services of court-mandated patients. Additionally, women who have been arrested for domestic violence are also often referred for mandatory treatment. In most programs, family safety remains a primary and immediate concern. While this goal is often commonly pursued, the approach and underlying rationale may differ significantly from program to program (Sonkin, 1995). The variety of theoretical orientations described in this book are in direct contrast to the currently popular and seemingly politically correct view that education remains the intervention of choice. We believe this to be at best an overly simplistic and naive notion that ignores the rich and evolving literature regarding potential methodologies available for effective clinical intervention. However, regardless of what theoretical orientation a clinician or treatment program utilize when intervening with this population, there remains the simple fact that most domestic violence perpetrators present in treatment with a wide range of underlying psychiatric problems. These at some point must be addressed in the treatment process in order to effectively minimize the potential for future violence. Additionally, even if a licensed mental health professional is using a primarily educational approach, they will inevitably be held to a higher standard than a non-mental health professional should an ensuing civil or licensing action result from a complaint of malpractice or unethical treatment by a patient. This article will describe a comprehensive assessment process or model that clinicians can utilize in pursuit of fulfilling their legal and ethical mandate, as well as set the proper framework for treating perpetrators of domestic violence.
The Assessment Process Goals
Because of the inherent risk of harm to others present in the context of domestic violence treatment, it is critically important that therapists approach the assessment process with a clear set of goals and expressed expectations. These goals help to set the context of treatment from the onset and serve as a continual frame of reference that both therapist and patient will refer to throughout the treatment process. Common goals often found in the assessment process may include: providing informed consent and disclosure of program expectations; procuring appropriate authorizations to release information; developing rapport with the patient; assessing the patients motivation for treatment; assessing the patients suitability for treatment; determining the clinical diagnosis of patient; assessing the patients violence and social history; assessing the patients risk for further violence and other acting-out; providing immediate behavioral interventions for violence control; and developing a treatment plan in cooperation with the patient and other providers. Each of these assessment goals will be addressed in subsequent sections of this article.
Providing Informed Consent and Disclosure of Program Expectations
Technically, treatment begins with the first phone call. How one sets the frame of treatment from the first contact is an important first step in helping patients manage their violent behavior. On a practical level, this is most evident at the first appointment when the therapist discusses with the patient the parameters of treatment. This is done in part through the informed consent process, telling the patient what the realistic limits of treatment are, and the disclosure statement (setting and communicating the expected rules of conduct). It is crucial that each patient understand the informed consent and agree to adhere to the program rules and follow them exactly as they are set forth to assure that they derive the most benefit from the experience.
The informed consent statements to patients and their partners typically include common limits of treatment. Although some studies have indicated a high remission rate of violent behavior while the perpetrator is in treatment and for some time afterwards, many patients do continue to re-offend even while participating in highly effective treatment programs (Rosenberg, 2001). Therefore, a specific statement to both parties will communicate the seriousness of the domestic violence while at the same time present a sobering statement about the real chance that violence will continue and may become more serious over time. Partners are not your patient or clients; therefore, clinicians must be careful about how they communicate with spouses about the risks and benefits of treatment. Your primary duty is to your client and informing him/her of the risks and benefits of treatment.
Some programs and therapists do require that their clients allow the program/therapist to have contact with the client’s significant others. This can be done, and may be advisable in many cases, but it can present some tricky legal and ethical issues. For example, if a program has regular contact with a spouse, does that spouse technically become a client? If so, could conflicts arise that compromise the therapy of the perpetrator or the safety of the spouse? If not, how does the program communicate that fact? If a spouse is not a client, then technically the spouse is not entitled to confidentiality in some cases. In addition, there is no psychotherapist-patient privilege should testimony in court be required. These are complex legal and ethical issues that therapist must address before involving third parties in the treatment of their clients. Some programs get around these issues by having a third party or another program have contact with partners assessing their counseling needs and reporting of additional acts of violence. Whichever method a program utilizes to assess treatment outcome with partners, they should probably procure legal advice in order to address these complicated legal and ethical issues.
The disclosure statement typically describes the expectations of the therapy process. This would include policies about fees, confidentiality, missed appointments, and cancellations (see Sonkin, 2000 for an example of a comprehensive disclosure statement).
Procuring Appropriate Authorizations to Release Information
Clinicians should be aware that working with perpetrators of domestic violence poses a number of important legal and ethical concerns (Rosenbaum, Warnken, & Grudzinskas, in press). Before conducting the first interview, patients must sign an authorization to release information so that the clinician may notify the probation officer of the appointment. Some patients may be reluctant to sign this form prior to meeting with the therapist. This presents an interesting dilemma. On one hand, the patient is mandated to a specific program by the court or probation and therefore really does not have any choice in the matter, other than to have his or her attorney object to the court. On the other hand, some probation departments give the patient the names of multiple programs and allow the patient to choose the program in which he or she would like to participate. In the latter case, it may make sense for the patient to meet with the therapist or program coordinator prior to starting the formal evaluation process to determine if the program philosophy and approach is congruent with his or her needs and values. However, in both cases, the question remains: does the patient have a right to check out the program before agreeing to sign an authorization to release information? Most importantly, it may be difficulty for a patient to speak candidly if he or she believes that the therapist will report information to the probation officer or the court. Here lies one of the conflicts that plagues many court mandated mental health treatment programs across the country. Is the mental health provider’s first duty to create a safe and therapeutic environment for the prospective patient or to help the system enforce the law? These conflicts have been pondered by legal and mental health scholars for many years, and a simple and clearly defined solution does not seem to exist.
The needs of mental health providers and criminal justice personnel working with domestic violence perpetrators may at times be in conflict and, while challenging, the differing needs of the system and the therapist are not irreconcilable. The most important process is that services providers meet with criminal justice personnel and find creative solutions to these and other conflicts. If the professionals cannot work out their conflicts, how can we expect our patients to work out theirs?
The problem of privacy is further complicated by many domestic violence patients tendency to manipulate the system to avoid responsibility and to defend against feelings of defectiveness, insecurity, etc. Some patients may use the issue of the release to avoid dealing with the problems that brought about the referral in the first place. Therefore, therapists need to be careful to avoid being seduced or manipulated by the patient’s acting-out or testing of the clinician in attempting to take control of the treatment relationship from the beginning. Additionally, the patient may be required to sign an authorization to release information so that other professionals may be contacted (e.g., other mental health professionals, medical personal, social worker, religious or spiritual advisors) in order to complete the assessment process.
In general, the patient must be informed of the specific purpose of these contacts via a written authorization to release information form, but it is good practice to tell the patient verbally as well that the clinician is going to make contact with a third party. Most patients cooperate with the completion of these releases, but do not assume that failure to immediately cooperate is a sign of resistance or that complicity is a sign of agreement. Generally, exploring their fears of the disclosure, and what exactly you will be revealing to the other party, may allay concerns or vulnerabilities. Although a patient does ultimately sign an authorization to release information, the therapist can reassure the patient that the therapist will use discretion in their conversations with the outside parties. One can argue that the patient lost their right to confidential treatment when their personal problems involved them in the criminal justice system. However, regardless of this limitation, the patient will retain some element of privacy within the limits provided by the law and sound clinical judgment. Lastly, the patient should also be reminded that even though he or she may not have complete confidentiality (no patient can be guaranteed of this), nevertheless much can be gained from effective therapeutic intervention.
Developing Rapport with the Client
Developing rapport is critical to working with perpetrators of violence, as it is with any type of client. Many domestic violence clients are skeptical of the psychotherapy process in general, and therapists may thus be viewed with low credibility. Therapists should not take for granted the fact that the court-mandated patient is an involuntary consumer of services and therefore the process of developing rapport will be complicated, extremely difficult, or altogether impossible. Although developing rapport may be extremely problematic with this population, therapists can work to develop a therapeutic alliance that will pave the way for successful treatment outcome.
How does one establish rapport with a patient who has extreme distrust of mental health professionals specifically or difficulty viewing attachments with others in general as positive and desirable? The answer to this question falls more into the domain of the art of psychotherapy rather than to the science of psychology. It is critical that persons working with perpetrators approach their patients with compassion and understanding, and with a belief in the process and a conviction in the importance of the goals. Therapists need to examine their own negative attitudes toward people who use violence, or else these feelings and beliefs will be communicated to their patients, either overtly or unconsciously. Just as therapists pick up subtle messages and cues from their patients, the patients will sense whether or not the therapist truly cares and understands or judges. This is not to say that therapists should collude with patients' view that they are victims of circumstance -- but they should realize that many of these individuals have often had horrific family of origin experiences and their violence to a great degree may have been influenced by those experiences. Likewise, many of the people perpetrating violence are also suffering from multiple psychological diagnoses, such as depression, psychoactive substance disorders, and other psycho-physiological illnesses, and therefore need help from a professional who is skilled in treating multiple conditions. However, because of their resistance to addressing psychological issues in general, along with their sensitivity to feeling blamed, weak, or devalued, batterers present strong obstacles to receiving the help that therapists enthusiastically want to provide. So walking that fine line between support, understanding, and empathy on one side and limit-setting on the other, maintaining the treatment goals while remaining willing to confront minimization, denial, and externalization -- this is the greatest challenge for therapists working with perpetrators of violence.
Much of what is defined as necessary for effective treatment by probation departments, state legislatures, and battered women advocates is defined by confrontation, limit-setting, consequences, and self-responsibility. A steady diet of these interventions may be sufficient for some patients with a more healthy psychological personality; however, many of the patients referred by the courts do not fall into this category. According to the research of Dr. Donald Dutton (1995a) and others in the field (Hasting & Hamberger, 1988; Holtzworth-Monroe & Stuart, 1994), there is mounting evidence that many batterers are suffering from attachment or characterlogical disorders. If this is the case, then the clinician needs to consider the differential application of confrontational interventions and the use of interpretation. Confrontation is the intervention of choice when encountering patients who are acting out in self-destructive or other-destructive ways. However, many batterers do not have a fully developed sense of self, which is why they often look outside themselves for definition and control. Therefore a certain amount of interpretation of defensive acting out is necessary, both to help patients better understand themselves and the function their violent behavior serves, and to help clinicians develop a working alliance so that patients feel understood by their therapists. Clinicians who use both interpretation and confrontation with patients (as opposed to primarily confrontation) are more likely to develop a positive therapeutic alliance. When the patient perceives the therapist as being understanding and yet helpful in the change process, they are likely to attach to the therapist while at the same time become significantly invested in their change process.
Therapists may consider helping patients understand the psychological meaning or purpose of the violence. For many patients, defenses of avoidance, hostility, blaming, denial, substance abuse, or attempts to control others, themselves, or their feelings cover up a tremendous sense of emotional vulnerability and psychic pain. Teaching patients to understand the difference between defensive anger or hostility and legitimate emotional expression may also help them to begin the initial process of understanding their violence in a broader psychological perspective.
It is necessary for therapists to show genuine empathy toward patients, in order for the patient to ultimately learn how to be empathic toward others. It is very easy to feel disgusted and exasperated by the patients' acting-out behaviors both outside and inside of the consulting room, but therapists must remind themselves, and their patients, of the difference between the feelings they are trying to avoid, protect, and soothe and the defensive behaviors themselves. Maintaining an empathic and supportive stance in the face of tremendous denial, and sometimes hostile and aggressive behavior, can be challenging to even the most seasoned of therapists.
Lastly, many professionals are drawn to the domestic violence and child abuse fields because of their own experiences as a victim, a perpetrator, or both. Therapists with unresolved feelings about their own history of abuse are likely to either displace anger and hostility upon their patients or to collude with their patients' minimization and denial. Having a personal history of childhood abuse or family violence can certainly be an asset when working with batterers, but when the therapist’s psychological issues are left unchecked those experiences can become a detriment to effective treatment. Obviously, it can be particularly problematic when a therapist has had a recent history of perpetrating violence towards others. Like any experience, this can be an asset or a liability to the treating therapist. Patients who have been victims of abuse in their childhood are likely to project tremendous negative feelings onto the therapist, act out, and look or even pull for negative reactions in the therapist (Schore, 1994). The possibility for projective identification and countertransference is very real for the treating therapist. Because of the inherent complexity of treating violent individuals and the potential for therapists to act out or react to the patient’s material inappropriately, it is recommended that persons who have had experiences of either victimization or perpetration of violence should participate in their own psychotherapy. Therapists need to be open to the obvious need to continue their own treatment as well as pursue on-going consultation with peers or a supervisor while working with this challenging clinical population.
What can clinicians do to develop a positive therapeutic rapport with the court-mandated patient? Freud’s (1958) suggestions, originally made almost ninety years ago, still hold true today. A friendly, sympathetic attitude toward the patient is beneficial for the initial development of the alliance. The patient wants to feel both that the therapist is an authority and at the same time that there is a sense of collaboration in the treatment process. When patients agree with the technical aspects of the treatment process and feel that the therapist is willing to negotiate the treatment goals, they are more likely to view the therapist as both accepting and supportive (Horvath & Luborsky, 1993).
Using the therapeutic relationship is another means toward developing rapport and ultimately effecting change. Patients will bring to the therapeutic encounter dysfunctional interpersonal patterns that are often reactivated during therapy. If the therapist responds in a manner that confirms or plays into these patterns, then these dysfunctional beliefs or expectations are likely to be maintained or exacerbated. However, if the therapist uses the appearance of these maladaptive patterns as an opportunity to help the patient recognize and examine them, it is possible that these patterns will be disrupted and the patient will get a better grasp on his or her interpersonal dynamics. The exploration and discussion of in-therapy interpersonal dynamics may have a greater impact on the therapeutic alliance than the sole discussion of out-of-therapy events. Therapists who are more engaging of patients in this way are also likely to improve the therapeutic relationship.
Assessing the Patient’s Motivation for Treatment
Patients must have some discomfort in their lives in order to produce the required motivation to change. Unfortunately, most court-mandated patients do not feel discomfort about their problematic behaviors. If they feel any discomfort, it is mainly about the fact that they are being forced to go to treatment. The relationship between discomfort and motivation is not linear but curvilinear. When a patient has too little discomfort, this generally results in only a modest amount of curiosity about themselves and the change process. Most persons who lack this curiosity are also not very interested in paying for therapy, especially if they believe it will provide no benefit to them. On the other hand, patients with too much discomfort, and particularly those with too little ego strength, can find therapy so emotionally overwhelming that it may not be able to meet their highly pressing psychological needs for control of emotions or behavioral acting-out. For these patients, pharmacologic intervention and/or hospitalization may be an appropriate initial or collateral intervention. A moderate amount of discomfort may motivate a person to pay the price (both literally and figuratively) that is necessary for successful therapeutic outcome.
Patients who enter into therapy who believe in the therapy process are going to be more motivated to change than those who do not believe in the value of psychotherapy (Yalom, 1994). The popular media (books, movies, television, newspapers, and magazines) have provided the general public with stories (not always positive) involving therapy. Additionally, some patients who have been in therapy in the past may have had positive or negative experiences. Asking patients about their understanding and experiences of therapy can help the clinician address any misconceptions the patient may hold about the therapeutic process.
An important part of the assessment process is for the therapist to help the patient see how they can benefit from psychotherapy. Showing the patient domestic violence treatment outcome statistics can help motivate a potential patient. Additionally, therapists who have evaluated their own work can show the patient those outcome statistics in hopes of increasing belief in the therapy process.
Hearing about other patient’s improvement from the patients themselves can be the most powerful way for a new patient to develop faith in the therapy process. This is why group psychotherapy can be very effective with male batterers, particularly those who do not believe in the value of therapy. Patients who have been in a therapy group for some time can provide the necessary support for new patients who may be skeptical of the therapy process. Lastly, patients who stay in treatment long enough to observe changes in themselves that have directly resulted from their participation in treatment are more likely to increase their faith in the therapeutic process.
Regardless of what experiences or expectations the patient has about psychotherapy, the therapist must ask the patient to take a leap of faith. Sometimes we must put aside our negative expectations and be open to what the experience has to offer. Of course, with the court-mandated patient this leap of faith is desirable, but not necessary. It is more the leap from jail that is the primary motivating factor; hopefully, this changes over time.
The issue of motivation is particularly problematic with male patients. The principles upon which therapy was developed (cooperation, reflection, connection, etc.) are usually not encouraged in male children to the degree that other qualities are emphasized (e.g., competition, independence). As a result, the notion of therapy is often a foreign concept to many men. Therefore, it is necessary for many male patients to make a conceptual leap or a psychological adjustment in order to best utilize the therapeutic processes. The early stages of therapy with men involve their learning the rules, or tricks of the trade as it were. Helping men see the value of therapy can be quite a formidable task for clinicians. Male patients often wonder how talking about their problems can bring about a change in their life situation. Many male patients are often looking for pragmatic answers to their problems. In order for them to see therapy as valuable, these patients must perceive that they have received something from the therapeutic encounter -- something practical or concrete. Typically, the first few sessions of psychotherapy are focused on the therapist-collected information. For the patient who may have a great deal of skepticism about unfamiliar methods of treatment, it is important to help him/her attain some type of meaningful gain right from the onset of psychotherapy.
Most importantly, many perpetrators of violence experienced only abusive, exploitative, indifferent, or unavailable caregivers in childhood. As a result, these patients view authority figures as questionable at a minimum, or as downright dangerous in the extreme. These early childhood experiences will affect how they experience close relationships of all types, including the relationship with the therapist (see Sonkin & Dutton, in press). How can a therapist work with the realities of these developmental issues, so as to reduce resistance and to facilitate the therapeutic process?
The male patients’ motivation can be somewhat improved if the therapist utilizes empathy as the primary means of engaging the patient, rather than focusing exclusively on responsibility and confrontation. Understanding the abuser as a wounded individual, rather than a manipulative person needing consequences, can be an important step in the right direction. In addition, the therapist needs to focus on the collaborative aspect of the therapeutic encounter rather than promoting the mythology that the therapist holds the answers to the patient’s problems (i.e., that the therapist is the authority). It is also important to explore with the patient the meaning behind his behaviors and problems rather than further promoting shame by focusing solely on the problematic aspects themselves. Therapists can take some of the charge out of these issues by exploring with the patient his thoughts and feelings about admitting to having a problem in the first place, or about needing or even being forced to seek assistance from others. It is also imperative that the specific long-term treatment goals are generated by the patient and therapist together, and not by the therapist alone. Therapists can mitigate the amount of resistance to change, acting out, or uncooperative behavior in general by demonstrating greater sensitivity to their patient's gender and cultural issues.
Recent research on treatment of court mandated batterers suggest that the use of motivational interview techniques may increase the batterer’s readiness for change as assessed through a Stages-of-Change Model (Kistenmacher, 2001). Prochaska, DiClemente, and Norcross (1992) introduced the Stages-of-Change Model (also called the Transtheoretical Model) for predicting health-related behavior change. Their theory suggests that individuals who try to overcome problems such as smoking, sedentary living, or being overweight move through a series of stages (precontemplation, contemplation, preparation, action, maintenance, and termination). People must move through early stages in which motivation and commitment are formalized before taking action and changing their behavior. They found that participants who were not in the preparation or action stages early in the program were likely to drop out or fail to progress because the interventions offered were geared toward participants in the later stages of change. There was a mismatch between the type of program offered (action-oriented) and the condition of the population (precontemplators).
Dutton (1995a) has suggested that this model can be applied to working with perpetrators of domestic violence as well. Levesque, Gelles, and Velicer (2000) have developed a stages of change measure for men in batterer treatment. Their research indicates that clients in the most advanced stage clusters (e.g., preparation, action, and maintenance) were most likely to have used strategies to end the violence in the last year. They engaged in less partner blame and valued the Pros and minimized the Cons of changing more than did their counterparts in the earlier stage clusters (e.g., precontemplation or contemplation). The URICA-Domestic Violence (URICA-DV; Levesque, Gelles, & Velicer, 2000) is a 4-dimensional stage measure assessing batterers' readiness to end their violence. This measure has promise to not only assist clinicians in identifying appropriate participants for treatment, but also to guide treatment planning and help the therapist to match clinical interventions with the patient’s readiness for change level. This research suggests that a one-size-fits-all approach to domestic violence treatment is not appropriate.
There are a number of concrete or observable behaviors clinicians may consider to form a hypothesis about the patient’s degree of motivation. These may include behaviors such as attending the scheduled appointments; completing the necessary paperwork; answering questions during the clinical interview; providing the therapist with necessary names for collateral contacts; completing the assigned homework between assessment interviews; expressions of remorse; and perpetrating violence between assessment interviews. There are other indicators of motivation that may not be as obvious. Some clinicians may view motivation as related to the patients' ability to focus on themselves, or their tolerance of self-reflection. Therapists may also view motivation as indicated by patients' curiosity about their own behaviors or their ability to think psychologically; for example, how well are patients able to identify or allow themselves to feel their emotions, or to step back and reflect on themselves? Furthermore, therapists may assess motivation by sensing how genuine or authentic the client presents in session when discussing significant material. These more indirect methods of assessing motivation can be as valid a means to assessing motivation for treatment as those more observable behaviors described earlier.
It is important to mention how relapses in violence or aggressive acting-out relate to the issue of motivation. Continued acts of violence may be an indicator of low motivation. Likewise, the lack of violence may be an indicator of higher motivation. However, lack of violence may also be a sign of compliance, which is not the same as motivation because it is unlikely to sustain a person subsequent to treatment. One presupposition of the approach outlined in this article is that extremely motivated, well-intentioned, and hardworking (in the psychological sense) patients can have relapses. A psychological analysis of domestic violence must include the idea that the patient will experience both progress and setbacks in the process of therapy. The idea that all patients are in complete control of their behavior stems from the socio-political perspective that emphasizes power and control, self-will, and accountability. Although research suggests that a percentage of perpetrators may use violence instrumentally (Holtzworth-Monroe, Meehan, Herron, Rehman, & Stuart, 2000), the vast majority of batterers use violence impulsively and therefore are needing more than the message “use violence, go to jail.” If these patients' behavior were completely under their own control, they really would not need therapy in the first place (which is of course argued by some activists). Interventions would then be primarily geared toward facilitating the clients to decide they are no longer going to be violent, and that would be that. From our perspective, violence is a function of a complex interaction of biological, psychological, and social problems that require equally complex interventions. Change takes time; therefore, relapses must be viewed as opportunities for the patient and the therapist to deepen the work, achieve higher level coping skills, and/or refine the treatment goals or interventions. In this way, treatment can be viewed as a process of both moving forward and moving backward, but with the net result of the patient developing more sophisticated coping mechanisms to the vicissitudes of life.
Many programs evaluate the patient’s progress within the first eight to twelve weeks of treatment so that changes in the treatment plan can be implemented before the patient is firmly entrenched in a negative pattern of engagement (Sonkin, 2000). For example, if by the end of the first evaluation period the patient is still blaming his/her partner for the violence, the therapist may want to first address this issue clinically with the patient. But if, after a specified period of time and a revision of the treatment plan or interventions, there is no change in this area and behavior change is not forthcoming, the therapist may want to reconsider whether or not the patient is motivated for this particular treatment program, or any program for that matter. It is suggested that therapists receive either professional or peer consultation when assessing these difficult and complex situations.
Assess the Patient’s Suitability for Treatment
Determining suitability for treatment relates to assessing who is likely to benefit from your treatment program or group (given the reality of its constraints) as well as determining special patient needs that your program/practice cannot provide for (therefore making collateral referrals necessary). Suitability issues include such factors as dangerousness, medication needs, psychoactive substance use and abuse, developmental disabilities, language and cultural issues, gender, types of violence perpetrated, transportation, and patient work schedules. Suitability relates directly to the clinician's assessment of the patients bio-psycho-social needs (i.e., biological, psychological, family, and social needs) and the development of a treatment plan that addresses each level of need. Many domestic violence patients have a variety of psychosocial needs that few providers can address completely. Therefore, collateral referrals will be necessary for many cases. Therapists should be well aware of the resources in their community in order to facilitate the referral process. Let’s discuss some of the more common suitability issues experienced with domestic violence patients.
Many patients may present with histories of severe and high frequency violence. For this patient, once-a-week outpatient treatment may not be sufficient to help contain the acting-out behaviors. Other support measures, such as medication evaluations or concurrent individual sessions, may be needed to reduce the risk for continued violent acting-out. Untreated psychoactive substance abuse/dependency is another common issue that may interfere with the effectiveness of a batterers intervention program. Many perpetrators with moderate to severe alcohol or drug problems will need inpatient or outpatient chemical dependency treatment either before or while receiving domestic violence treatment. Active and untreated psychiatric disorders, such as depression, anxiety, and post-traumatic stress disorder, can also be contraindication to an outpatient, once-a-week perpetrator group. These clients may need to be referred for a medication evaluation and ongoing psychotherapy to stabilize symptoms. Some patients may even require a period of hospitalization in order to be adequately stabilized.
It has been also suggested by researchers (Holtzworth-Monroe et al., 2000; Saunders, 1996) that certain typologies of batterers may do better in one type of treatment program rather than another. For example, batterers who are diagnosed as anti-social personality disorder may do better in a structured cognitive-behavioral program, whereas batterers who are dependent or have traumatic histories of child abuse may do better in a psychodynamic or process oriented group. The former may need the structure to prevent further acting out and the latter may need to address childhood abuse and resolve trauma symptoms in order to reduce the further risk of acting out. In addition to typology, batterers with severe head injury or other neurological deficits may not be able to keep track of the information or process in either type of the above groups and may need individual therapy that is geared toward addressing violence within the context of their particular neurological impairment.
Not all suitability issues relate to psychiatric diagnosis or level of motivation. Some patients may have difficulty engaging in a particular treatment program for authentic, pragmatic reasons. Developing specific groups or services for monolingual non-English speaking patients, as well as services for individuals with moderate to severe learning difficulties, literacy problems, or physical or developmental disabilities may be necessary in some communities. Likewise, therapists may assess that some patients of a specific gender, ethnicity, or sexual orientation may be able to engage more easily into the treatment process if they were able to participate in a group or with a provider of a similar background. Additionally, there are logistical issues such as work schedule or transportation issues that may affect the match between the patient and a particular treatment program. Although group treatment seems to be the intervention of choice, perhaps we need to explore methods of addressing this problem from an individual, couples, and family perspective as well in order to address the needs of different populations of perpetrators.
Determine the Clinical Diagnosis of Patient
Perpetrators of violence are likely to present with a range of psychiatric diagnoses (Hamberger & Hastings, 1991). Research in domestic violence has indicated that the vast majority of perpetrators suffer from one or more conditions, including affective disorders, personality disorders, neurological disorders, trauma-related disorders, and psychoactive substance disorders (Cohen, Rosenbaum, Kane, Warnken, & Benjamin, 1999; Dutton, 1998; Holtzworth-Munroe et al., 2000).
Affective disorders. Depression, anxiety, or a combination of the two is common in domestic violence perpetrators. Some patients have a long-standing personal and/or family history of affective illness. For others, anxiety and/or depression may be symptoms associated with personality or trauma disorders (Dutton, 1998). Many untreated patients have self-medicated with the use of psychoactive substances meant to either reduce or increase affective symptoms. Typically, when an individual is in the throes of depression they are not likely to act out toward themselves or others simply because of his/her lack of energy in general. But acting-out may either precede a full depressive episode or the patient may act violently upon gaining energy subsequent to a depressive episode. The patient may have learned to use anger, aggression, and violence as a means to mobilize his/her energy. Some younger individuals, as well as older adults, may develop an irritable depression, rather than the classic vegetative symptomology, which can ultimately manifest in aggression or violence. On the other hand, high levels of anxiety can result in violence, aggression, or other acting-out behaviors. Many perpetrators experience extreme affective reactions to criminal proceedings. For those clients suffering from a personality disorder, particularly borderline, extreme depression may be triggered by the potential or actual loss of their partner, such as separation or divorce. It is likely that dysphoric affect is likely to be a function of the personality structure of the patient rather than situational. Many batterers control their partner in an attempt to self-regulate or soothe their own emotional discomfort. When the partner is not available, they are either forced to find some other way to self-regulate, such as using psychoactive substances, or are left to experience the deep sense of loss and emptiness they were avoiding in the first place. Experiencing the breakup of a relationship and family can be a serious blow to anyone and can exacerbate any psychiatric condition. Depression and anxiety can be situational and resolve over a short time, or it can be persistent and last the entire duration of treatment. In either case, the patient may need considerable assistance in achieving stabilization, such as the use of psychoactive medication, increased frequency of sessions, or other social-psychological support systems to be put in place.
Substance abuse and dependency. One of the most common psychiatric disorders in domestic violence perpetrators is psychoactive substance abuse and dependency (Dutton, 1998). Early on, it was thought that violence and chemical dependence were two distinct disorders needing to be addressed separately. Today, there is a proliferation of domestic violence and chemical dependency dual diagnosis treatment programs, where individuals can receive treatment for both disorders in the same treatment groups. It was also thought at one time that the substance abuse problems needed to be treated before the violence problem. Many providers with experience in drug and alcohol treatment held the view that the chemicals caused the undesirable behaviors. Years of experience with domestic violence and substance abuse have taught us that although some perpetrators will stop their violence once they abstain from psychoactive substances, many will continue to be violent while abstinent. Therefore, violence and substance abuse should be thought of as separate but related problems, both needing treatment intervention. Many domestic violence treatment programs require a period of abstinence ranging from days to several months prior to treating an individual with both violence and substance abuse problems. These assumptions, recommendations, and treatment interventions have traditionally been based on the program’s treatment philosophy rather than on empirical research into these issues. Assessment-based treatment dictates that clinicians not use a single approach to understanding psychoactive substance abuse. Instead, clinicians should evaluate each case individually based on the available clinical, corroborative, and historical information.
There are differing philosophies about how to treat the patient who is experiencing domestic violence and who also presents with a psychoactive substance disorder. This patient is commonly referred to as having a dual diagnosis. However, domestic violence remains less of a diagnosis and more of a behavioral descriptor (V-code); therefore, traditional psychiatric diagnosis should include a comprehensive multiaxial understanding of the patient. In these cases, whether there is a single treating clinician or multiple clinicians, each diagnosis must be addressed in the treatment plan.
Childhood maltreatment and post-traumatic stress disorder. Over two thirds of the perpetrators of domestic violence have suffered from some type of child maltreatment in their family of origin (Dutton, 2000; Holtzworth-Munroe et al., 2000). In a significant percentage of these individuals, the abuse may have been severe enough to cause post-traumatic stress disorder (Dutton, 1998). These patients' violence may be understood as a deep and powerful reaction to feelings of powerlessness, not being in control of their lives or the lives of others, or fears that their self-esteem is being attacked. Many persons who experienced child abuse have learned early on in their lives how to avoid the dysphoric affect associated with feeling victimized -- by dissociation, valuing self-control in their lives, and/or by attempting to control their environment. As a child, these traits were not only helpful but may have been the key to survival; however, as the child grows and is expected to respond to more complex situations requiring more sophisticated responses, these adaptive coping mechanisms become extremely maladaptive, particularly in intimate relationships. Nevertheless, individuals continue to utilize these interpersonal strategies in spite of their repeated failure to solve their problems.
Childhood maltreatment and personality disorders. One possible outcome to childhood maltreatment is the development of disorders of attachment, or personality disorders (Sonkin & Dutton, in press). According to the research in domestic violence perpetrators, the rate of personality disorders with perpetrators (Dutton, 1998; Holtzworth-Munroe et al., 2000) is quite high. The most intensely studied personality disorder in the domestic violence literature is the borderline personality disorder.
Recent research in domestic violence from an attachment theory perspective suggests a significant percentage of batterers present with borderline personality organization and a fearful or disorganized attachment style (Dutton, 1994). Dutton also found subgroups of batterers who fell into the other two insecure attachment categories as well. When analyzing attachment styles, the borderline batterers neither have a well-defined sense of self (and look to others for that definition) nor do they trust that others will have benign intentions towards them (which manifests in rageful attacks). Different conceptualizations of attachment theory (Sonkin & Dutton, in press) suggest different attachment dynamics or conceptualization of violent behaviors in this population. But in his most recent studies, Dutton (1998) suggests that all batterers may suffer from an attachment disorder that correlates with a variety of personality disorders (Dozier, Stovall, & Albus, 1999), but what they all have in common is the characteristic dysregulation of intense emotion (Dutton, Saunders, Starzomski, & Bartholomew, 1994; Dutton & Starzomski, 1993).
Although treatment of borderline personality disorder as it relates to domestic violence is addressed elsewhere in greater detail (Dutton, 1998; Waltz, in press), it is important to note that persons suffering from this disorder need structure in order to contain their impulses to act-out their emotions. Hence, it becomes understandable why many domestic violence programs have emphasized the need for structure, limit-setting, and confrontation in treatment of perpetrators. One problem with such a style of treatment intervention is that many persons with personality disorders will feel a deep sense of shame and wounding (that will only exacerbate the acting-out behaviors) if they only experience confrontation. Therefore, clinicians need to interpret the acting-out (through interpretation of the defensive structure) in such a way that the patients experience empathy and understanding from the therapist (Masterson & Klein, 1995). Daniels and Murphy (1997) suggest that clinicians must focus on engaging the patient in the psychotherapeutic process through more gentle techniques such as support, interpretation, and empathy.
One of the most promising areas of inquiry is in the domain of typology. Looking at categories of abusers, rather than thinking of them as one and the same, may ultimately help us develop more effective, assessment-based interventions in treatment. Typology may also help us better understand how to intervene in changing violent reactions to emotional stress. For the most part, the typologies that have been developed to date are primarily oriented to diagnosis. Dutton (1998) has developed a typology categorizing perpetrators into three groups: psychopathic, borderline personality organization, and overcontrolled. He plots these three group across two continuums, control (over-controlled versus under-controlled) and violence expression (instrumental versus impulsive). The psychopathic group uses violence instrumentally and is under-controlled. The borderline group uses violence impulsively and is under-controlled. The over-controlled group uses violence somewhat impulsively and instrumentally, and is over-controlled. His typology is based on psychological personality testing, history of trauma, attachment patterns, and a number of other variables. Similar profiles have been developed by others as well (Gottman et al., 1995; Hamberger, Lohr, Bonge, & Tolin, 1996; Holtzworth-Munroe & Stuart, 1994).
How does knowing a perpetrator’s profile affect our intervention strategies? By understanding the typology of the patient, we can form some hypotheses about how to proceed with treatment. For example, borderline batterers, with their severe histories of childhood abuse, may do better in an approach to treatment where they will address childhood trauma issues earlier in the therapy process and develop skills in emotion containment. On the other hand, the psychopathic batterers may simply need a more confrontational, structured, educational approach that gets across the message that “if you perpetrate more violence you will go to jail.” The over-controlled batterers may do well with a program that emphasizes emotion identification and communication. These typologies once again remind us that the better the psychological understanding we have of our patients, the more likely we will formulate effective interventions that will increase the likelihood of successful treatment outcome.
Recent research suggests that a significant percentage of violent individuals have experienced prior head injury that may have resulted in neurological changes and that may contribute to violent behaviors. Along with injuries stemming from trauma, some individuals may present with other prominent neurological dysfunctions that may respond to appropriate medications (Maiuro & Avery, 1996), including attention deficit disorder, epilepsy, and severe psychiatric and developmental disorders (Lewis, Lovely, Yeager, & Femina, 1989; van der Kolk, 1994).
Rosenbaum and his colleagues have found clinically significant prior head injury in 53% of batterers, 25% of maritally discordant men, and 16% of maritally satisfied men (Rosenbaum & Hoge, 1989). In a recent study, when comparing batterers with non-batterers, Cohen and colleagues (1999) found that 1) batterers had weaker performance on a test that measures cognitive flexibility, which is related to frontal-lobe damage; and 2) batterers had relative impairments on tests that demands focused attention, information processing efficiency, and working and executive control ability. Both of these findings suggest impairments in executive control functioning. They conclude that executive dyscontrol is one of the most significant cognitive problems observed in batterers. Along with these patterns, batterers also exhibited deficits in: 1) learning, particularly for verbal information; 2) memory, particularly for verbal information; 3) verbal ability; and 4) vocabulary knowledge. Batterers also exhibited higher levels of emotional distress than did nonbatterers. This data suggests that high levels of emotional distress in combination with cognitive deficits may be important variables in understanding the etiology of violence. Although there are many more questions than answers at this time, there is mounting evidence that some batterers may be suffering from neurological impairments; therefore, traditional talk psychotherapy may need to be augmented with psycho-pharmacological interventions.
Psychological Assessment and Diagnosis
In any clinical encounter, the patient’s presenting complaint dictates a process, whether formal or informal, commonly described as a “clinical assessment.” Simply put, professional standards dictate that the clinician has a proactive responsibility in their attempt to understand the nature and extent of the patients difficulties and assumes that a basic grasp of the patient’s presentation, history, intellectual functioning, personality characteristics, environmental pressures, and resources can form the requisite understanding necessary for offering effective intervention. The methods available to assist in this understanding have expanded just as our knowledge of psychiatric illness has developed; in addition, the methods and techniques available for intervention have changed.
As noted by Meyer et al. (2001), while unstructured interviews may be time efficient, they have inherent limitations when it comes to conducting an adequate assessment that forms the crucial basis for developing an appropriate treatment plan. For example, unstructured interviews may result in overlooking certain relevant areas; alternatively, when interviews are highly structured, patient responses to specific questions may not be understood within the broader life or diagnostic context, and even under the best of circumstances patients may be poor reporters of their history or biased in their presentation. Formal psychological assessment offers several advantages to minimize the inherent limitations associated with the clinical interview. For example, a carefully crafted psychological assessment can answer or provide hypotheses in response to specific clinical questions as this methodology can measure a broad number of relevant patient characteristics simultaneously. Psychometric testing can provide empirically quantifiable data often resulting in more precise diagnostic precision of the patient then on clinical interview alone. As traditional psychological testing is normed, each patient’s responses or performance on testing can be compared with relevant peer groups. This allows the assessor to make more precise diagnostic inferences about the patient, and research on reliability and validity of formal psychological assessment argues strongly for its inclusion. However, psychological tests carefully chosen by the evaluator in response to the specific questions posed as one component of a comprehensive evaluation can assist in developing an adequate understanding of the individual being assessed and developing an initial working differential diagnosis to assist in treatment planning.
While a thorough review of psychological assessment is beyond the scope of this article, it is worth noting that presently in the domestic violence literature in general, three types of instruments are often utilized when assessing batterer functioning: general psychological tests that measure personality, specific domestic violence assessment scales, and assessment tools that measure specific personality, affect, attitudes, or behavior characteristics. In general, all three types of instruments improve on the inherent problems found in the traditional clinical interview because of the assessment tool’s acceptable reliability and validity.
One of the most commonly utilized psychological tests to identify subcategories of batterers in research has been the Millon Clinical Multiaxial Inventory (MCMI-III; Millon, 1994). This measure is frequently utilized because of its dimensional, rather than categorical, descriptions of personality (Gottman et al., 1995; Hamberger & Hasting., 1991; Holtzworth-Munroe et al., 2000; Tweed & Dutton, 1998). The test takes a relatively short time to complete, consists of 175 questions, and twenty-four scales are derived corresponding to Axis I and Axis II disorders. In spite of its frequency of use in typology research and its potential utility, the vast majority of clinicians treating domestic violence do not rely on this measure or any psychometric data in their assessment process. Perhaps as the standard for intervention moves from education to treatment there will be a greater reliance on psychometric data.
There are a number of clinical and research instruments in use developed specifically to assist in domestic violence assessments, and each has their strengths and limitations that clinicians should consider before utilizing them to augment their assessment protocol (Dutton & Kropp, 2000). The Conflict Tactic Scales (Straus & Gelles, 1990) has been the most widely utilized domestic violence assessment measure by researchers and clinicians to identify the types and frequency of violence within intimate relationships. One of the reasons for this is that is quick to administer and easy to score. The revised version of this scale (CTS2; Straus Hamby, Boney-McCoy, & Sugarman, 1996) lists each behavior twice, asking once what the participant/patient has done to his or her partner and once what the partner has done to the participant/patient. The Spouse Abuse Inventory (Sonkin, 2000) is a more extensive version of the CTS, listing over 70 different acts of physical, sexual and psychological violence and their frequency. The list also includes a checklist of over 100 injuries possible resulting from the acts of violence. The questionnaire also includes a series of open-ended questions about specific acts of violence, the first act of physical violence, the most life threatening act of physical violence, the most frightening act of physical violence, the most humiliating act of physical violence, a typical act of physical violence, and an example of non-physical violence. Another domestic violence-specific measure is the Psychological Maltreatment of Women Inventory (PMWI; Tolman, 1989). Like the CTS, it has been utilized in many research studies to identify patterns of psychological or non-physical violence, and is very easy to administer and score. However, like the MCMI, the PMWI is not often used to augment the clinical assessment process.
Researchers have utilized a number of assessment tools with specific questions in mind. For example, the Hare Psychopathy Self-Report Checklist (Hare, 1991) is often utilized to identify those subtypes of batterers that may be classified as psychopathic or antisocial. In addition, various attachment questionnaires (Bartholomew & Horowitz, 1991; Brennan, Clark, & Shaver, 1998) have also been useful in identifying the three subcategories of batterers based on their attachment style (pre-occupied, dismissing, or fearful). Many batterers present with substance abuse; therefore, the clinician should consider assessment tools that measure psychoactive substance abuse/dependency, such as the Michigan Alcohol Screening Test (MAST; Selzer, 1971) or the Structured Clinical Interview for the DSM-IV (SCID; First, Williams & Spitzer, 1997). In addition, because many perpetrators of domestic violence were abused themselves as children, they are like to present with various forms of post-traumatic stress disorder. Assessment scales such as the Clinician-Administered PTSD Scale (CAOS; Blake et al., 1990), the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993), or the Trauma Symptom Checklist (TSC-33; Briere & Runtz, 1989) would be advisable for all patients.
Given the seriousness of domestic violence, it is our hope that as the standards for treatment evolve, they will include the use of formal assessment so that an accurate diagnosis is assessed and the treatment plan may address the specific psychological needs of the patient.
Assess the Patient’s Violence and Social Histories
Obtaining a thorough description of the physical, sexual, and psychological violence perpetrated by the patient recently as well as in the past is a critical part of any domestic violence assessment interview. Abusers commonly minimize the frequency and severity of their violent behavior even with the best of interviewers; therefore, particular techniques should be employed in order ascertain the most complete history as possible.
Typically, a violence history will begin with the clinician asking the patient to describe the most recent incident of violence. The clinician can be purposely vague when approaching the violence history. This may occur before the clinician provides the patient with a definition of physical, sexual, or psychological violence. The purpose of this procedure is so the clinician can determine from the patient’s point of view what behaviors are problematic or may be considered violence. Typically, there is considerable omission of details due to denial, minimization, shame, or lack of memory due to decreases in higher cognitive processes during highly impulsive, dysphoric states. Whatever the reason, it is important for the therapist to slowly encourage the patient to disclose greater details, so that he/she can begin to examine their violent behavior and the dynamics that led to the problem in the first place.
In some jurisdictions, therapists may receive copies of the police report or a summary of the offense in a probation report prior to interviewing the patient. Having this information ahead of time can allow the therapist to confront the patient on his/her minimization and denial of the violence. However, this level of confrontation could also be problematic when conducted too early in the assessment process. With some patients who are experiencing high levels of shame regarding their violence, this type of confrontation may cost the development of a therapeutic rapport. The patient may experience the therapist as critical and judgmental, and react either by overt hostility or passive avoidance. On the other hand, with patients who can handle a more directive style, the development of trust with the therapist will be predicated on the therapist confronting the patient immediately upon the first signs of minimization or denial. Who can handle and who cannot handle this type of confrontation most often is determined in part by diagnosis (e.g., borderline versus narcissistic), but more often by trial and error.
As the therapist pulls for more details through questioning, and in some cases discussing third party data such as a police report, a more complete picture of the referring incident will become evident. At some point in the interview, the therapist may begin obtaining a violence history through a more structured interview (using one of the scales described above). At this time, the therapist may want to offer the patient a more complete definition of what is meant by physical, sexual, and psychological violence. Having these definitions written for the patient may help him/her recall specific incidents of violence. With these definitions in mind, the patient may be given another opportunity to discuss the referring incident or previous acts of violence in an open-ended manner. The therapist may facilitate this process by asking a number of open-ended questions in order to give the patient an opportunity to provide as many details without prompting. After a while, therapists may want to encourage the patient to be more specific by asking for clarification. The therapist is encouraged to take detailed notes in the patient’s own words, describing the specific incidents of violence. During this part of the interview it is also important to elicit the patients thoughts and feelings about their violence.
Another important element to completing the comprehensive assessment is conducting a social history of the patient. This can be quite valuable in that it helps the clinician understand the patient’s violence in a larger life context. It also helps the patient to appreciate their psychological complexity and even possibly develop insights into the etiology of their violent behaviors. The social history (education, employment, childhood/family, medical, marital/relationship, etc.) also helps the patient become more comfortable with the process of self-disclosure that will be an integral element of the therapy experience.
Assess the Patient’s Risk for Further Violence
Prediction of violence remains a controversial concept in the field of psychology (Monahan, 1993). Although some theoreticians say that violence prediction or lethality risk is an immeasurable concept in clinical practice and that professionals should refrain from making such predictions, others suggest that abandoning the attempt to make accurate predictions is somewhat premature at this time. Research has indicated that we are likely to be wrong as often as we are right about predicting violent behavior in the general clinical and criminal population. However, studies looking at factors that predict violence have consistently shown that the best predictor of future behavior is past behavior. Therefore, we can extrapolate from this data that a person who has established patterns of physical, sexual, or psychological violence towards his spouse is likely to continue that pattern unless there is some intervention that is directed to changing these behavior patterns, such as psychological treatment and/or criminal justice intervention (and even then, the violent behaviors can reoccur).
The reader may ask, why is risk assessment important, especially since there are no proven methods of predicting future behavior in the first place? There are several reasons why a discussion on risk assessment is necessary with domestic violence patients. First, we are often asked (whether we like it or not) directly or indirectly by probation officers and the court to render opinions about future dangerousness of perpetrators. In addition, patients, and partners in particular, often want to know about prognosis and the possibilities of future violence. Also, when a lethal incident does occur and a liability suit arises, the clinician is often asked to explain how he/she took measures to reduce the risk of future violence. Although laws mandating reports of threats of violence may be fairly clear about reporting thresholds, such as in Tarasoff reporting (Sonkin, 1986: Sonkin & Ellison, 1986), there exists some expectation that therapists will provide the necessary treatment interventions when a patient presents a high risk for violence, but has not made a specific threat against an identifiable person.
In addition, research suggests that a significant number of batterers do re-offend while in treatment (Rosenberg, 2001). So given this fact, how does one differentiate who is at higher and lower risk of commiting violence while in treatment? As mentioned earlier, the generally accepted rule has been past behavior is the best predictor of future behavior. This turns out to be somewhat true, but even that rule may not be that simple. Multiple factors need to be considered when making predictions about future behavior. Mulvey and Lidz (1995) proposed a conditional model of violence prediction, where context plays an important role in the manifestation of violence. Rather than viewing a patient as violent or non-violent, the clinician may see a patient as possibly doing some type of act if certain situations or factors persist or present themselves.
For example, a person diagnosed with manic-depression may have an increased risk of future violence towards a person if he does not comply with medication orders, uses psychoactive substances, and has a history of property violence. Or a person with borderline personality disorder has an increased risk of violence if using psychoactive substances and has a partner who wants a divorce. A person with a history of domestic violence and who is in recovering from drug abuse may have an increased risk of violence if they continue to associate with their drug abusing partner who is also physically or psychological abusive. Even when a person suffers from a severe psychiatric condition, their risk for violence may only increase when there is a presence of symptoms. The types of symptoms are also important; for example, hallucinations or delusions of physical harm, hallucinations or delusions of feeling threatened, beliefs of mind or body control, and extreme anxiety or fear of loss may all increase the risk for violence towards others.
After psychiatric deterioration, alcohol use is the second most common condition related to violence (Swanson, Borum, Swartz, & Hiday, 1999). The combination of psychoactive substance use and the above psychiatric factors increases the risk of violence significantly (Skeem, Mulvey, & Lidz, 2000). Substance abuse and psychiatric illness are two factors that are quite common with domestic violence patients; therefore, clinicians are in the position to intervene with these conditions (e.g., via medication and/or collateral referrals to substance abuse treatment programs) so as to reduce the risk for further violence.
Other situational factors not directly related to the patient or family members may increase the risk of violence; for example, peer group support for violence, unemployment; socioeconomic status, community factors (such as crowding, community violence, etc.), unavailability of support resources, and other psychosocial stressors. Mulvey and Lidz (1995) suggest that clinicians need to consider risk from these broader contextual factors – the patient is likely to commit violence towards this person under these conditions. To complicate matters more, dangerousness is not a static issue, but will change over the course of treatment. Factors not present at the beginning of treatment may over time increase a patient’s risk potential. On the other hand, patients assessed as high risk at the onset of treatment may participate in the necessary interventions that considerably reduce risk over time. The bottom line is that treatment programs must have a structured procedure for collecting clinical data necessary to assess risk at the onset of treatment, as well as procedures to continually respond to changes in individual patient’s status over time. Most importantly, therapists should always seek peer or professional consultation in assessing risk as well as developing the most effective response to a patient’s level of dangerous throughout the treatment process.
Dutton and Kropp (2000) reviewed a number of structured risk assessments that clinicians may utilize to structure their risk assessment protocol. One of the most commonly utilized measures is the Spouse Assault Risk Assessment (SARA; Kropp, Hart, Webster, & Eaves, 1998). The SARA was designed as a clinical checklist of risk factors for spousal assault, based on risk factors identified in the empirical and clinical literatures. The SARA is not a psychological test, but can be used as an assessment guide to ensure that pertinent information is considered and weighed. Risk factors are rated absent, sub-threshold, or present in the following domains: criminal history, psychosocial adjustment, spousal assault history, and current offense. Summary risk ratings (imminent risk of violence towards partner and imminent risk of violence towards others) are rated low, moderate, or high. Summary scores include the sum of items comprising the four categories and the sum of the risk ratings. While not a psychological test per se, the SARA remains a promising clinical checklist of risk factors, and while additional research needs to be conducted to demonstrate adequate validity and reliability, most clinicians should find this instrument particularly useful and intuitively helpful.
Sonkin (2000) developed the Risk Checklist, a structured interview that guides the clinician in the assessment process. This checklist consists of sixteen multiple choice questions based on psychosocial factors, many of which have been empirically associated with risk that the clinician should consider when developing a comprehensive assessment and treatment plan. Sonkin outlines preliminary factors that discriminate risk derived on the basis of factors that generated lethal responses by battered women in the Browne (1987) study: the man’s frequency of violence, severity of violence, frequency of intoxication, drug use, threats to kill, and forced/threatened sexual acts, and woman’s suicide threats. Although not empirically tested, Sonkin notes that the Risk Checklist is not meant to be a psychometric test, but rather a structure for conducting a risk assessment consisting of clinical data and collateral information, and made in consultation with colleagues.
Meloy (2000) advocates a biopsychosocial model for violence risk assessment. While not specifically focused on the issue of domestic violence per se, Meloy identifies a number of specific risk factors for violence towards others. He suggests that a comprehensive risk assessment consider not only each individual factor identified but also the potential synergy between them.
While each of these instruments do not claim to predict violence, and all have methodological limitations, they do help clinicians to organize their assessment process to one degree or another, and some, such as the SARA, can potentially provide some objective measure of risk. Most importantly, no instrument will ultimately replace the implicit knowledge that many experienced clinicians utilize that tells them to intervene when “red flags” in the clinical material triggers an intuitive sense of danger. It is the combination of good clinical sense and objective measures that will ultimately help our assessment of risk become more reliable.
Treatment Planning and Collateral Contacts
One of the last goals of the assessment process is to engage the patient in the treatment process such that they are in agreement that their behavior needs to change. This is why extending the assessment process beyond one or two sessions is preferable. This allows the client to get on board prior to attending their first group session. When patients help develop and endorse the treatment goals, they are more likely to feel motivated for treatment (Yalom, 1994). Therefore, if the client does demonstrate some motivation for treatment, it is important that he/she take part in the treatment planning process. This can be as simple as agreeing with the primary goal of treatment (stopping violence), or the patient can be directly involved in negotiating the methods utilized to achieve that goal. In addition, many clients will have secondary goals either directly related to the violence or indirectly related, such as addressing childhood abuse, psychoactive substance abuse, and other psychosocial problems. The reader is referred to Sonkin and Durphy (1997) for a detailed description of common available techniques for achieving specific behavioral goals, and Sonkin (2000) for a comprehensive description of a domestic violence treatment plan and the evaluation of achieving specified goals. The treatment plan is an example of a treatment plan that addresses the specific behavior of violence only – a bare minimum for domestic violence patients. It does not address the complete etiology of the patient’s violence as well as other myriad of biological, psychological, family, cultural, or social issues that patients typically present with.
Treatment plans ideally need to address a wide variety of issues so that we can give the patient the greatest possibility of treatment success. Most programs and clinicians are not able to be all things to all people. Therefore making referrals for collateral issues will be necessary for many domestic violence patients. It is critical that providers be intimately familiar with resources in the community such as substance abuse programs, psychiatric services, neuro/psychological testing services, disability resources, employment development programs, and other social services. Many poor, court-mandated patients may already be involved with a variety of social services in their community. These patients often experience the tug and pull of one agency working against the goals of another agency. Therefore, it is critical that treatment providers initiate contact and work closely with other service providers during both the assessment process and throughout the treatment experience. Other providers may possess important psychological or social data that will be critical to the assessment or treatment process.
Conducting a thorough and comprehensive domestic violence assessment is necessary for successful treatment outcome. In order to complete the assessment the clinician must take sufficient time. The authors recommend a minimum of four to six clinical interviews and collateral psychometric methods. The purpose of the assessment is not only to assess for motivation, suitability, diagnosis, etc., but also to slowly begin the treatment process so that clients who enter individual or group treatment at a later date will already have some skills and insight about the etiology and solutions to their violent behaviors. Because of the risk inherent in domestic violence, treatment will be a process of on-going assessment. Patients will reveal new information about themselves or evidence certain dynamics in group or individual therapy, and therapists may revise their psychiatric diagnosis or understanding of the patient. In addition, new or re-occurring psychosocial stressors and crises will emerge during the course of treatment necessitating particular interventions geared toward reducing the risk of acting out. By conducting a thorough initial assessment and linking treatment interventions with those findings, we increase the likelihood of a positive treatment outcome, which thereby better serves the needs of our patient, their families, and the criminal justice system.
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