Daniel Carlat, MD. Vice Chair, Community and Public Sector Psychiatry, Tufts University School of Medicine. Publisher, Carlat Publishing.
Dr. Carlat has no financial relationships with companies related to this material.
1. Understand the importance of proactive screening for intimate partner violence (IPV) and creating a safe environment for disclosure.
2. Recognize the significance of using appropriate language and assessment tools when working with domestic violence (DV) survivors.
3. Identify the key risk factors and safety planning considerations for DV survivors.
Tailoring psychotherapy to the individual needs of domestic violence (DV) survivors is crucial in ensuring their safety and well-being and avoiding potentially fatal mistakes.
This is especially true in DV where our urge to spirit the abused person away from their partner may feel like a good idea to us, but not reflect a client’s best interests, and could even endanger them. Here are six recommendations that should enable therapists to avoid the serious, and sometimes fatal, mistakes clinicians make when working with victims of intimate partner violence (IPV).
1. Don’t expect your client to bring up the subject or volunteer information.
Identifying IPV can be hard because survivors may try to hide their predicament out of shame, fear of retribution from the offender, love of the perpetrator, or other reasons. Therefore, you need to :
• Pick up on red flags, such as frequent calls from your client’s partner to cancel appointments, or injuries for which your client offers vague, unrealistic, or inconsistent explanations—and then proactively screen for IPV.
• Use framing statements, such as, “Since domestic violence is so common, I always ask my clients . . .” or “I routinely talk about . . .” These statements provide a context that makes it easier for a client to acknowledge a problem. Remember, it is your responsibility to create an environment and a supportive relationship that enable the client to feel safe enough to talk.
• Follow framing statements with behaviorally specific questions, such as, “Has your partner ever hurt you physically?”
• If a client takes offense at a question, say, “I’m sorry. I often see people in this sort of situation, and they are usually afraid or embarrassed to tell me what is going on, unless I ask.”
2. Don’t neglect to use a standard assessment tool if appropriate and use language to fit the situation.
A variety of validated screening tools are available at the Agency for Healthcare Research and Quality (here). When screening for or assessing IPV, choose the most inclusive terms possible, such as “partner,” rather than boyfriend/girlfriend, husband/wife, or date, until more specific terms are indicated. Avoid using potentially loaded terms, such as “perpetrator,” “abuser,” or “criminal,” unless the client thinks in those terms. One quick and simple screener with high reliability is the HITS (Iverson KM et al, J Traumatic Stress 2015;28(1):79–82).
3. Don’t forget to assess and address the possibility of imminent harm.
Ask direct questions about major risk factors. For example, does your client intend to leave their partner, and do they know of the victim’s intentions? The risk of serious harm, including murder, increases by a factor of nine if an abuser threatens to harm the children if an IPV survivor leaves, or fails to return to, the relationship. The risk doubles if a partner follows the survivor around outside the home or spies on them. Other serious risk factors include batterer-associated violence outside the home or against the children; threats of homicide or suicide; escalating threats; substance use; access to weapons; and job loss (Messing JT et al, J Interpers Violence 2013;28(7):1537-1558
The presence of stepchildren in the family increases the risk of harm to the IPV survivor. Greater violence is also associated with pregnancy, and the months after delivery, perhaps because the demands of a baby may be disruptive and take a woman’s solicitous attention away from her partner (Taliaferro EH and Surprenant ZJ. Respond to Intimate Partner Violence: 10 Action Steps You Can Take to Help Your Patients and Your Practice. Tucson, AZ: Medical Directions, Inc; 2003).
When these factors are present, you may need to talk about safety planning. If the partner becomes violent, can the client call the police from a cellphone? Do the children know what to do in an emergency? Would the client like an order of protection? Does the client have adequate and immediate access to money? How has the client coped successfully in the past with violence, and how would they cope in the future, if the need arose?
Importantly, IPV can include verbal, emotional, psychological, or sexual harm (including stalking behavior), in addition to physical abuse. The astute clinician considers these various forms of IPV, which can be similarly dangerous, in their assessment and treatment of clients.
4. Don’t sanitize your progress notes or use words that raise doubts about your client’s veracity.
Don’t write, “The client alleged her partner was physically abusive.” Instead, record what the client said: “The client reported her partner grabbed her by the hair and banged her head against the window until the glass shattered.” Using the phrase "the client alleged" suggests that the therapist doubts the client's report of abuse, and it could potentially harm the client's case in legal proceedings. Instead, therapists should use the client's own words to describe what happened. This not only shows support and validation for the client but also creates a more accurate and detailed record of the abuse.
In cases of domestic violence, it is essential to document specific details of the abuse, including the nature, frequency, and severity of the incidents. This information can be used to develop safety plans and inform legal action if necessary, as indicated above.
Overall, the goal of therapy for domestic violence survivors is to provide a safe and supportive environment for clients to process their experiences and heal from the trauma. Accurate and thorough documentation is a critical aspect of this process, as it helps to ensure that clients receive the support and protection they need.
5. Don’t be afraid to refer the client to other professionals and resources.
Could they benefit from a support group, legal and advocacy services, or a DV shelter? Is there a victim services agency that reimburses medical expenses incurred from IPV? Can the victim access services for their children? Do they have friends or relatives who could be supportive? If the survivor is a student, does their school have resources they can use? Is their primary care physician documenting signs of physical abuse? Helping your client may be a collaborative effort.
6. Don't rush your client into leaving the relationship.
If you feel a need to remove your battered client from home, think about whether this urge reflects your client’s agenda and interests. Survivors need to make their own decisions, even if you find them frustrating—and leaving increases the risk of murder and other serious harm. Instead, help your clients decide what they want to do, using standard therapeutic frameworks, such as the James Prochaska and Carlo DiClemente “Stages of Change” model (Prochaska JO and DiClemente CC Prog Behav Modif. 1992;28:183-218). This model makes it easy to tailor your messages to the client’s level of readiness to change, and to help them prepare for change (Raihan N, Cogburn M. Stages of Change Theory. [Updated 2023 Mar 6]. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023). Such preparation is essential in intimate partner violence.
Editor’s note: This article was originally published in the April 2012 issue of The Carlat Behavioral Health Report under the title Six Critical Mistakes to Avoid When Treating Survivors of Intimate Partner Violence by Elizabeth Saenger, MD. The article has since been updated.
Best Practices for Working With Survivors of Domestic Violence
Identify red flags and proactively screen for IPV using framing statements and behaviorally specific questions
Expect the client to bring up the subject or volunteer information
Use language to fit the situation and choose inclusive terms when screening for IPV.
Neglect to use a standard assessment tool if appropriate
Ask direct questions about major risk factors and talk about safety planning if necessary.
Forget to assess and address the possibility of imminent harm.
Record what the client says and avoid using words that raise doubts about their veracity.
Sanitize your progress notes.
Offer resources and services that could benefit the client, such as support groups, legal and advocacy services, and victim services agencies.
Be afraid to refer the client to other professionals and resources.
Use standard therapeutic frameworks to help the client prepare for change and make their own decisions.
Rush your client into leaving the relationship.
References in order of appearance in this article
Iverson, K. M., King, M. W., Gerber, M. R., Resick, P. A., Kimerling, R., Street, A. E., & Vogt, D. (2015). Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension. Journal of traumatic stress, 28(1), 79–82. https://doi.org/10.1002/jts.21985
Messing, J. T., & Thaller, J. (2013). The average predictive validity of intimate partner violence risk assessment instruments. Journal of Interpersonal Violence, 28(7), 1537-1558. doi: 10.1177/0886260512468250
Taliaferro, E. H., & Surprenant, Z. J. (2006). Respond to Intimate Partner Violence: 10 Action Steps You Can Take to Help Your Patients and Your Practice. Tucson, AZ: Medical Directions, Inc.
Prochaska, J. O., & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in behavior modification, 28, 183–218.
Raihan N, Cogburn M. Stages of Change Theory. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556005/
PO Box 626, Newburyport MA 01950