Psychotherapy 101: Don’t blame the victim – The case of intimate partner abuse survivors
There is surprisingly little research that has surveyed clients about their experiences of therapy. One exception is Leedomet and colleagues (2019) who surveyed 101 clients who were survivors of intimate partner abuse and had received psychotherapy. The goal of the study was to find out what these people found helpful and unhelpful about therapy.
The methodology is a little unusual for psychological research. The authors used a coding system to divide participants into 5 groups based on their qualitative responses to open-ended questions. The first group were characterised by acknowledging that there were benefits to being held accountable for their choices about their relationship. The second group indicated that their therapists had either said or implied that they had chosen to remain in an abusive relationship. The third group’s clinicians had interpreted that their abusive relationships were due to co-dependence between the client and her partner. The fourth group were defined by having therapists that explained the abusive relationship as being due to the client being especially vulnerable due to childhood trauma. The fifth group was the smallest and was characterised by having clinicians who attributed the occurrence of the abusive relationship due to the client having another unspecified vulnerability.
There were significant differences in the working alliances and client satisfaction with therapy, between these groups. Clients who acknowledged benefits to being held accountable for their relationship decisions, rated their therapeutic alliances as significantly higher than those of groups 2 and 3. Therapists of these clients were described as using questioning, being nonjudgmental, affirming and validating. They exhibited the motivational interviewing spirit of evocation. Effective therapists also warned clients when there was evidence that they weren’t safe, and provided education about personality disorders and abuse.
On the other hand, clients whose therapists said or implied that they chose to be in the abusive relationship, felt blamed, misunderstood, invalidated and gave the lowest working alliance ratings. They saw their therapists as naïve and ignorant of how manipulative, deceptive and dangerous abusive partners can be. Although clients whose therapists attributed the occurrence of their abusive relationship to the client’s childhood trauma reported adequate working alliances, some of these clients also reported wishing that their clinician had done more to inform them of how dangerous their partner was and discouraged them from reasoning or maintaining the relationship.
The authors provide a range of excellent practical recommendations which I have listed below in the clinical implications section. Theoretically, results were consistent with the idea that traumatic bonding is probably responsible for the majority of abusive relationships. Traumatic bonding occurs where a power imbalance and intermittent good-bad treatment promotes an attachment pattern that elicits a “tend-and-befriend” response in the recipient, who seeks proximity to the abuser (the phenomenon has been observed in dogs and nonhuman primates too). Although there is an elevated risk of getting into abusive relationships among people with PTSD, formulating the abusive relationship through this lens was not the optimal way to engage and help this client group. Finally the authors do the helping community a great service by reiterating that there is no scientific support for the concept of co-dependent relationships, other than that it is a schema some counsellors hold that adversely affects their practice!
Clinical implications
It is more common for survivors of intimate partner violence to not have first suffered childhood trauma or to have developed a personality disorder. Therapists should validate reports that the client was deceived or manipulated into the relationship.
Therapists should educate clients that people with antisocial personality disorder/psychopathy exist, and describe their characteristics and tactics. Abuse should be attributed to these perpetrator characteristics. This can help reduce client self-blame and make sense of their experience.
When assessing clients, elicit and highlight changes in thinking, feeling and behaviour before and after the relationship to reinforce attributions of disability to the impact of the perpetrator.
Use motivational interviewing skills: open-ended questions, reflections, affirmation and validation
Assess for PTSD and Depressive Disorder symptoms and treat where present
Don’t blame the survivor
If survivors feel blamed, therapists can thank the client for letting them know and work on repairing the alliance, through apologising, making corrective statements, and asking clarifying questions until the client accepts the apology and feels understood and accepted.
If the therapist is inexperienced with intimate partner violence, they should honestly declare this and express willingness for the client to educate them.
Therapists should consider routine screening for intimate partner violence
Click here for the full article: https://onlinelibrary.wiley.com/doi/full/10.1002/jcad.12285
Reference
Leedom,L.J., Andersen, D., Glynn, M.A., & Barone, M.L. (2019). Counseling intimate partner abuse survivors: Effective and ineffective interventions. Journal of Counseling and Development, 87: 364-375.