How should we understand IPV? This phenomenon is often bidirectional, where each partner is both an aggressor and a victim, although women remain much more likely to be injured by partner violence than are men (Am. J. Public Health 2007;97:941-7).
In an outpatient sample of couples seeking marital therapy, 64% of wives and 61% of husbands were classified as aggressive (Violence Vict. 1994;9:107-24). In 272 engaged couples, 44% of women and 31% of men reported physical violence toward their partners (J. Consult. Clin. Psychol. 1989;57:263-8). As illustrated by the three cases above, IPV occurs across a range, from the classic male perpetrator and female victim, to the couple that engages in mutual violence.
Why do women stay?
Researchers such as Virginia Goldner, Ph.D., of the Ackerman Institute for the Family in New York, have contributed significantly to the understanding of why women stay in violent relationships. Dr. Goldner describes a generational imperative that is passed from mothers to daughters (Fam. Process 1990;29:343-64). This often includes the view that the role of women is to preserve the family, regardless of either the personal cost or the presence of abuse or violence.
Daughters raised in a highly patriarchal family might suffer existential neglect and be undervalued except in their capacity as caregiver to others in the family. Therefore, staying in a relationship protects the woman against guilt that she might feel if she gives up her caretaking role. These daughters may grow up with the belief that "being loved" is contingent upon denial of their self, being selfless. They may see the opposite as "being selfish" and not compatible with their self-image. Melanie certainly identified this guilt and had difficulty thinking about meeting her own needs.
Asking women about their mothers and the internalized view of themselves as independent agents can expose this dilemma. These daughters may see their mothers as powerless, devalued, and depressed. Being loyal to their mothers means accepting a subjugated role, while allying with their fathers means betraying their mothers and their own sense of themselves, as a woman.
If you decide to take a couple into therapy, it is important to interview each member of the couple individually before starting couples therapy. The information you glean from these interviews also will help determine when to offer and when not to offer couples therapy.
Factors that should encourage you not to proceed with couples therapy include the uncontrolled, continuous use of alcohol or drugs; fear of serious injury from the patient’s partner; severe violence that has resulted in the victim requiring medical attention; conviction for a violent crime or violation of a restraining order; prior use of a weapon against the partner; prior threat to kill the partner; stalking or other partner-focused obsessional behavior; and bizarre forms of violence, such as sadistic violence.
Here are a few guidelines for assessing intimate partner violence:
• Ask about relationship violence. Consider use of a questionnaire.
• If present, determine severity and ask about fear of partner.
• Identify risk factors for the potentially lethal relationship.
• If substance misuse is present, recommend abstinence and refer for treatment.
• If the couple wishes to stay together and to resolve the intimate partner violence, refer for conjoint treatment with a specialized family therapist.
• Assess and treat common comorbidities such as major depressive disorder and post-traumatic stress disorder.
Belkis, Melanie, and Zelda are three different women in abusive relationships who require three different solutions. Each patient requires a treatment based on their unique history and goals. Make sure that you are a family psychiatrist who understands the differences between your patients – and that you are able to provide a solution tailored to teach patient’s needs.
Elements of a safety plan
Encourage patients who in the midst of intimate partner violence to take the following steps to keep them and their families safe:
• Memorize phone numbers of people to call in emergency.
• Teach older children important phone numbers and when to dial 911.
• Keep information about domestic violence shelters in a safe place where you can get it quickly when you need it.
• Buy a cell phone that the abuser does not know about.
• Try to open your own bank account.
• Stay in touch with friends and neighbors. Do not cut yourself off from people.
• Rehearse your escape plan until you know it by heart.
• Leave a set of car keys, extra money, a change of clothes, and copies of important documents with a trusted friend or relative.