Clinical Guidelines When Addressing Abuse over Telemental Health

Abstract

Providing therapy services via Telemental Health (TMH), or teletherapy, has exponentially increased since the COVID-19 pandemic. Although previous research demonstrates that TMH is as effective as in-person therapy, there is a dearth of research on how therapists should address technology-perpetrated abuse and intimate partner violence (IPV) over TMH. This is extremely problematic given the frequency in which violence occurs in romantic relationships. This manuscript aims to address this gap by providing concrete clinical guidelines based on existing literature and professional experience with engaging in TMH services. The authors review literature on technology-perpetrated abuse and discuss innovative ways to assess and treat IPV over TMH by adapting protocols from Domestic Violence-Focused Couple’s Therapy. Within this, the authors integrate research on high-conflict couples to provide new suggestions on how to manage couples who escalate quickly and who are prone to violence. The manuscript will conclude with future directions for research.

Introduction

Providing therapy services over videoconferencing, or Telemental Health (TMH)/teletherapy, is becoming an increasingly popular treatment delivery modality, especially since the COVID-19 pandemic (Chen et al., 2020). Previous researchers have found that TMH is equally as effective as in-person services for both individual and relational cases (Berryhill et al., 2019; Backhaus et al., 2012; de Boer et al., 2021). Although TMH has been found to be an effective delivery method, there is a significant absence of research on managing risk issues over TMH, including intimate partner violence (IPV; de Boer et al., 2021). The lack of research on TMH services with IPV is further complicated by the limited research on related topics such as technology-perpetrated abuse and high-conflict couples. With limited guidance on how to address IPV in TMH services, it raises concerns about the widespread integration of TMH services, especially since over 50% of couples who present to couple’s therapy have a history of violent incidents in their relationships (Greene & Bogo, 2002). The purpose of this manuscript is to provide therapists with innovative, practical considerations, and suggestions for assessing and working with violent couples over TMH. Specifically, the authors will discuss how IPV can be perpetrated via technology, the similarities between high-conflict and violent couples that therapists may confront over TMH, and IPV screening procedures and treatment considerations from Domestic Violence-Focused Couple’s Therapy (Stith et al., 2011) with a focus on adaptations to TMH. The paper will conclude with recommendations for future research.

Technology-Perpetrated Abuse

According to the World Health Organization, IPV occurs when there is physical, sexual and/or psychological harm being perpetrated by one or both partners in a relationship (2012). A more recent type of IPV includes technology-perpetrated abuse. Technology-perpetrated abuse is the use of technology to perpetrate harm, violence, and/or to control someone else to “instill fear in the victim” (Markwick et al., 2019, p. 144). There are numerous ways in which one could perpetrate technological abuse, such as cyber-stalking, cyber-monitoring, and/or cyber-harassment, with the following methods originating from Freed and colleagues (2017), the Safety Net Project (2018), Woodlock (2017), and from previous clients’ reports. One method includes having physical access to the victim’s device, through which they could install spyware. Spyware can allow the perpetrator to access the victim’s home security system and the camera or the screen of the device itself. Physical access to a device also allows perpetrators to log into and monitor social media accounts, place tracking devices on vehicles, and view search histories (e.g., texts, Google searches). Additionally, if the perpetrator has physical access to the victim’s residence, they could install hidden cameras. A second method includes phishing, in which the perpetrator could send (e.g., email, text) the victim a link that when clicked would download spyware onto the device, allowing the perpetrator to engage in similar behaviors outlined when having physical access to a device. A third method includes online harassment, in which the perpetrator could leave threatening texts and voicemails, post threatening comments on the victim’s social media accounts, track victim’s locations through their social media accounts (or their friend’s and children’s accounts), disclose sensitive information about the victim online (e.g., outing their sexual orientation), and threaten revenge pornography. A fourth method includes the perpetrator and victim having shared accounts, which can include bank accounts and social media accounts. Of additional concern is that some forms of technology-perpetrated abuse are hard to detect, and an individual may be unaware of these behaviors occurring.

Technology-perpetrated abuse has become exceedingly more common as technology has advanced (Freed et al., 2017). For example, one study found that 50% of participants were either perpetrators or victims of technological abuse, with some engaging in sending harassing instant messages and using hidden cameras and GPS trackers (Burke et al., 2011). Also, Picard (2007) found that 10% of participants experienced a partner sharing an explicit photo of them without consent. With the increase in use of technology to perpetrate violence, it requires that therapists know to assess for this form of violence and to consider how teletherapy services may risk safety to a victim of abuse if their device is being used to monitor them. It is also important to note that as technology advances, perpetrators may find new ways to commit technological abuse (e.g., Apple’s AirTag technology being used to track partners whereabouts; Kelly, 2022), and the authors recognize other forms of technological abuse may exist. Thus, it is crucial for therapists to continually educate themselves on new methods that may require assessment. The authors will provide specific suggestions for assessment in the assessment section.

High-Conflict Couples

Along with concerns over technology-perpetrated abuse, high conflict couples also raise anxiety for therapists hoping to provide teletherapy services. High-conflict couples have both pervasive negative patterns of interaction and a hostile environment. Couples with pervasive negative patterns of interaction can be identified by defensiveness, aggression, negative views of each other, and quick escalation (Anderson et al., 2010). Couples with a hostile environment are in an emotional environment characterized by “strong negative affect, emotional reactivity, lack of safety, triangulation, and mutual distrust” (Anderson et al., 2010, p. 16). In high-conflict couples, there is a propensity for situational couple violence, in which there are occasional instances of minor violence between partners (Anderson et al., 2010; Johnson, 1995).

Therapists have expressed concerns over how to interrupt and de-escalate high conflict couples with TMH, citing unease over the lack of control over the clients’ environment and use of common in the room de-escalation techniques that may not translate to TMH. For example, therapists cannot move closer to clients, stand up to create a larger presence, and physically move the clients’ chairs to create separation in the same manner over teletherapy in which they would be able to do in-person. In general, the concern is that the lack of a physical presence would reduce therapists’ ability to directly control the environment, raising the concern that conflict could escalate to unsafe levels with limited ability to de-escalate by the therapist. Suggestions on how to address this concern are provided in the treatment section.

Situationally Violent Couples

In the 1990s, Michael Johnson began developing typologies of violence, including situational couple violence (SCV; Johnson & Ferraro, 2000). In SCV, both partners perpetrate violence. The motivation for violence does not encompass an overall desire to control one’s partner. Instead, violence typically occurs within specific conflicts and is more representative of poor conflict and problem resolution skills. Also, violence tends to be less frequent and encompasses milder acts of violence compared to when the motivation is to control (Johnson & Ferraro, 2000; Kelly & Johnson, 2008). This form of violence is in contrast to intimate partner terrorism (IPT), where violence is unilateral and represents coercive control (Johnson, 2005).

Researchers have found that over 50% of couples who enter therapy have a history of abuse in their relationships (Greene & Bogo, 2002). The type of IPV that is present in therapy most often is SCV (Johnson & Leone, 2005). Although violent couples where control is present can also be present in couple’s therapy, it is much less common. This is likely because a perpetrator who is controlling their partner would not allow them to enter therapy at all.

SCV has been identified as a form of violence that can be treated in couple’s therapy because it occurs in relationships in which the abuse is not intended to control or intimidate and is representative of poor conflict and problem resolution skills (Kelly & Johnson, 2008), which can be addressed in couple’s therapy (Stith et al., 2012). However, when control is the motivation (not congruent with SCV), the perpetrator is unlikely to allow the victim to be honest about the violence and other relationship issues. Also, the victim is likely to have been coerced into therapy, and treatment cannot be effective when one person is involuntarily attending due to force or threats of harm. Thus, these couples are not appropriate for conjoint treatment.

Assessing the Appropriateness of Conjoint Therapy

With typology of violence impacting the appropriateness of conjoint treatment, it requires therapists to identify what is occurring when presented with IPV. The authors recommend adhering to the inclusion criteria established in Domestic Violence Focused Couple’s Therapy (DVFCT; Stith et al., 2011) when assessing the appropriateness of conjoint treatment. The inclusion criteria include that all partners must: (1) want the violence to end and be committed to ending it, (2) not fear discussing difficult topics conjointly, (3) must sign a no-violence contract and a safety plan that is constructed with the therapist. Also, the perpetrator(s) must take responsibility for the violence. Finally, the authors suggest that therapists should not provide conjoint couple’s therapy when there is a history of severe control over the other partner(s) or when coercion (i.e., IPT) is present. Including couples in which at least one partner exhibits traits of IPT is unadvisable as the victim(s) would not be able to be honest about the violence and other relational problems, and the victims would likely have been coerced into therapy. Further, perpetrators whose intent is to control are not likely to take responsibility for their violence as they often blame the victim, and, thus, will not likely see the need to end it. DVFCT was developed for in-person services and has not been tested with TMH services to date. However, DVFCT has strong empirical support and provides therapists with a theoretical and research-based protocol for assessing IPV. The authors present an extension of DVFCT to TMH practice, including a screening procedure and treatment applications found in the treatment section.

Assessing IPV over TMH

Prior to starting TMH services and before therapists begin assessing IPV, there are two plans that should be developed with the client, a technology failure plan, and a safety plan. The technology failure plan describes the steps that will be taken in case of technology failure during session (i.e., a secondary method of contacting the client; Caldwell et al., 2017). The TMH safety plan moves beyond the traditional safety plan for in-person services and considers safety issues related to the therapist and client(s) being in separate locations (e.g., medical crisis, active harm to self or others, and risk of harm to client from a third party). In the safety plan, emergency contacts must be included, which encompass both community resources (i.e., local hospital, local emergency number in client’s location, mental health resources) and close people in the client’s life. Also, therapists must document the physical location of the client at the start of each session in case any emergency occurred. This not only allows the therapist to verify that the client(s) are within the jurisdiction the therapist is licensed to practice, but also provides requisite information on where the client is should emergency responders need to get to the client’s location.

After completing these plans, therapists can transition to assessing IPV. All couples should be assessed for IPV, not just in situations where therapists may suspect it. Thus, the following suggested guidelines apply to all couples. Using recommendations from DVFCT, screening must include written and verbal assessments (Stith et al., 2011). As many therapists have clients complete intake paperwork online, the same can be done with teletherapy clients. This can be done before the intake session or, if therapists want to ensure privacy, therapists can have clients complete the intake assessments during the individual, verbal assessments. This is one method to try to ensure all partners have a safe space to complete the assessments without other partners watching. Once written assessments are completed, separate interviews with all partners occur next (Stith et al., 2011). The verbal assessment requires therapists to consider multiple adaptations when screening IPV via teletherapy.

The first consideration is that over TMH, the therapist cannot guarantee that during the separate meetings that the partner(s) not being met with at the time is out of ear shot. This reduces both privacy and safety (Simon, 2021). Although it is recommended that the therapist always scans the room by having the client show them the entire room with their camera (Luxton et al., 2016), the other partner could be sitting right outside the door. Also, the perpetrator may force the victim to allow them to be hidden off screen during the scan or could enter the room after the room scan has been conducted. One adaptation is to request that the partner being met with wear headphones, which would limit what the other partner(s) could hear. Another adaptation is to request that the partner(s) not being met with go the farthest away they possibly can in the home, step outside the home, or create background noise (e.g., turning on the television, white noise machine, or playing music). An additional option is to meet with each partner at separate times when the other partner(s) is not at home, or at an alternative location where the partner(s) would not have access to the session (e.g., friend’s house, work office). Another consideration, which requires additional research and the development of innovative solutions, is that technology-perpetrated abuse can include surveillance of a partner’s device, often done without the individual’s knowledge. Therefore, the device being used for TMH services may not be private and the act of accessing therapy or disclosing relationship concerns could unknowingly put the partner’s safety at risk. A final adaptation is to develop a code word with the client at the start of the individual session (Luxton et al., 2016). This code word would tell the therapist that the situation has become unsafe and to stop discussing violence. The therapist could then transition to asking about other client concerns that do not entail violence.

However, therapists must recognize that none of the above suggestions are without limitations. For example, clients may simply give the appearance that they are listening through headphones, but they may not actually sync their headphones or plug them into their electronic device. Further, there is no way to guarantee that the partner(s) is not in the home or may not return home after being requested to step outside. It is common for therapists to have concerns about these realities of teletherapy occurring in clients’ home environments. However, in-person therapy is not as controlled as therapists would like to believe. With in-person services, a partner may still enter a waiting area/listen at a therapist’s door or record the session either by requiring their partner to bring a recording device to session or hide a device in their partner’s belongings (e.g., personal bag). Thus, even certain circumstances are outside the therapist’s control with in-person therapy and require therapists to do as much as possible to ensure safety by assessing all potential risks to the best of their ability and by following current recommendations.

The above adaptations provide methods to establish a safe interview environment. Another consideration is to determine how to go about asking the screening questions. Stith and colleagues (2011) recommend that therapists begin by asking questions such as “How is conflict handled in your relationship?” Questions such as these are the most helpful because clients may not recognize that IPV is occurring in their relationship. So, when asking if abuse or violence is happening, they may say no. However, if a partner is listening to the conversation, screening in this manner may not be a safe option. Thus, one way to help ensure safety is to ask questions that can be answered with a yes or no response (Simon, 2021). For example, therapists can assess IPV by asking about specific acts of violence: “Has there ever been a time when you or your partner tried preventing one another from leaving a room?” Therapists would proceed by asking a variety of questions that entail different types of abuse. By doing so, if the other partner(s) was listening, they could not hear what questions their partner was saying yes or no to, given the partner being interviewed at the time is wearing headphones.

If the partner does say yes to even one violent incident, Stith and colleagues (2011) recommend assessing perceived safety. These safety questions can include an overall question of whether they feel safe right now and whether they feel safe with the therapist asking their partner(s) the same questions. Another potential adaptation is to ask the client to respond to the yes or no questions using the chat function of the teletherapy platform. If the therapist has been asking questions in a yes-no format, another consideration is then to ask if the partner feels comfortable expanding on the answers out loud. If the partner feels safe, then the therapist can continue gathering a history of the violence and then proceed to meeting with the other partner(s); should they report no, the chat function may be a way to proceed.

If the partner feels safe expanding on the history of violence in the relationship, then therapists should proceed by asking about frequency, context in which the violence occurred, and potential injury/lethality. Gathering information regarding the history of violent incidents assists the therapist with determining the type of violence occurring. Clients’ descriptions will reveal whether the violence is being used to control the partner or whether the violence is enacted during specific conflicts, which is more often indicative of a difficulty with solving problems in a constructive manner (i.e., SCV). When the motivation is to control, violence is not bound to specific conflicts but is a globally used tactic (i.e., IPT). Also, if one partner does not feel safe in the relationship or does not feel safe with the other partner(s) being asked questions about violence, there is likely a high level of fear that is more often found in controlling relationships, not SCV. Finally, the severity and frequency of violence is another strong indicator of the type of violence occurring, as using violence to control often leads to more frequent and severe acts.

Overall, when assessing IPV via TMH, therapists must consider how to establish a safe sharing environment and how to go about asking the screening questions. The above adaptations are suggested to ensure as much safety as possible. The authors recommend that therapists keep in mind the screening standards established in DVFCT (Stith et al., 2011) and consider the context in which violence is occurring (i.e., control versus conflict-specific) to establish a systematic process for determining the appropriateness of conjoint therapy.

Assessing Technology-Perpetrated Abuse over TMH

Therapists must also screen for technology-perpetrated abuse (Bowels, 2018) using the same recommendations described above to ensure privacy for each partner. Assessing technology-perpetrated abuse may be especially essential for young couples as it is more common in younger generations (Eckstein, 2016). This might be an outcome of growing up in the generation of technology. To assess the potential installation of spyware, therapists can ask clients if they have a home security system (e.g., Ring) or other smart technology, such as Alexa, automatic locks, or other technology similar in nature. With these forms of technology, therapists can ask if clients have experienced glitches or resets, such as cameras, lights, and music turning on and off, thermometers changing temperature, and random locking and unlocking of automatic locks. Additionally, therapists can assess the installation of spyware on digital devices, such as phones, laptops, and tablets by asking if any have ever randomly reset or restarted, if cameras have randomly turned on, if there are applications on the device they do not recognize, if the battery dies more quickly, and if the device suddenly opened an application while using it. Finally, therapists can ask if they have received any unknown or suspicious emails that contained links the client may have clicked on. These technological abnormalities represent potential indicators that technology-perpetrated abuse is occurring (Bowels, 2018).

To assess tracking of clients, therapists can ask if their partner(s) seem to know where the client is always located, such as physically showing up at the location or sending messages or calling asking why the client is at a certain location. If the answer to either question is yes, therapists can ask if the client shares their location with their partner(s) via their phone or social media accounts or if their location is not private on their accounts. Also, therapists can assess tracking by asking clients if they have checked their car or residence recently for the presence of unknown devices. Additionally, to assess potential monitoring, therapists can ask clients if they share bank or social media accounts with their partner(s), if their partner(s) has the password to their digital device(s) or accounts, or if they suspect their partner(s) knows of these passwords.

Finally, to assess potential online harassment, therapists can ask clients if their partner(s) incessantly calls or messages them, either via a phone or social media account, if their partner(s) has threatened revenge porn, if their partner(s) has “used mobile phones or social networking sites to try and control who you can be friends with or where you go,” and if their partner(s) has “constantly checked up on what you have been doing/who you have been seeing, for example, by sending your messages or checking your social networking page all the time” (Barter et al., 2017, p. 378).

When asking these questions, it is critical therapists state that the purpose is to ensure confidentiality, not for suspicion of abuse. This is necessary as the perpetrator may realize that the therapist is assessing violence, and then may lie or exert undue influence on the victim to lie as well. While this section focuses on ways in which technology-perpetrated abuse can be identified, refer to the treatment section for suggestions on how to address this form of abuse.

Assessing High-Conflict Couples over TMH

Assessing conflict in relationships is also essential as high-conflict couples can be prone to violence. When assessing high-conflict couples over TMH, therapists should consider the above suggestions to ensure privacy for each partner. Additionally, Wrape and McGinn (2019) recommend that therapists and clients discuss elements particular to ensuring safety early in the therapeutic process, such as boundaries during TMH sessions or negotiated time outs when clients are escalating. When utilizing TMH, therapists should be overt with clients that being in different locations can alter the ways in which a therapist might interrupt escalation during session, and that this will require everyone to work together during these sessions. Specific strategies for de-escalating conflict over TMH are provided in the section on treatment.

Considerations specific to the assessment of high-conflict couples include exploring the couples’ relationship history, their interactional patterns, and family of origin experiences. This allows the therapist to better understand any triggers of relational conflict, adverse childhood experiences, or attachment injuries that should be focused on during treatment (Anderson et al., 2010). Therapists should also pay attention to indicators of violence and aggression when assessing high-conflict couples (Anderson et al., 2010). While these aspects may be assessed at the same time as IPV, therapists working with high-conflict couples may ask questions such as, “What does conflict look like in your relationship or how is conflict handled?”

When Conjoint Therapy Is Not Appropriate

Although couples presenting to therapy with a history of violent incidents are most likely going to fall under the category of SCV, there may be times when this is not the case. If at least one partner fears for their safety, this requires the therapist to respond differently than if fear was not a concern. Similar to in-person sessions, the therapist must be prepared to provide resources for the victim, such as contact numbers for local domestic-violence organizations and safe shelters. Therapists must also consider aspects of their client’s identity that may limit the types of resources that are available to them, such as lesbian women having the potential of all partners having access to the same women’s shelter or transwomen not being allowed to stay at a women’s shelter. In these circumstances, or if the client happens to be in an area in which a safe shelter is not accessible, then the therapist must discuss alternatives, such as seeking shelter at a friend or family member’s house. The therapist will also need to address necessary items the victim will need to take with them, if they decide to leave the home. Therapists must approach cases in which one partner fears for their safety carefully, as victims are at the most risk of harm when they attempt to leave an abusive relationship (Landenburger, 1998). Thus, it is crucial that therapists communicate this fact to the victim, so they can make an informed decision regarding whether to leave at that moment and how to go about leaving. The following suggestions will assist therapists in treating these situations with the utmost caution.

A way to assist the victim leave the home during a TMH session is to encourage them to do so when the therapist is meeting with the other partner. The therapist can request to meet with the perpetrator in another room and have them wear headphones, reducing what they may be able to hear outside of the room. The therapist can inform the perpetrator that they have requested their partner to turn on the television or to step outside the home to increase privacy. These steps are ways to justify minimizing the likelihood of the perpetrator knowing what is occurring outside of the room, giving the victim a chance to leave.

There are, of course, risks involved. The perpetrator may pretend to wear headphones or decide to get up and check on their partner during the time in which the therapist is supposed to be meeting with them individually. Due to this, it can be recommended that the therapist instructs the victim to be as quiet as possible and only gather what is absolutely necessary to speed up the leaving process. If the perpetrator does catch their partner in the midst of leaving and the situation becomes violent, the therapist should contact law enforcement. A reminder that if the clients are not located in the same area, the therapist will need to contact the police department in the clients’ area (calling 911 will connect to the therapist’s local emergency department, not the clients’).

If the couple has only one electronic device to conduct therapy, and it is in a common space, this likely means that the victim would not be able to leave during the TMH session. If this is the case, then while meeting individually with the victim, the therapist should still provide the same resources discussed above as well as discuss necessary items to take with them when they decide to leave. The therapist can help the victim identify times when it would be safest for them to leave the house, which would be a time when the perpetrator is not physically present. This can only occur safely, though, if the victim is wearing headphones.

It may also be the case that the victim is not ready to leave their abusive partner. Just like in-person sessions, the therapist should provide resources and discuss items to take with them and safe places to go. Another important consideration is to help the victim clearly define times when it is necessary for them to leave because their safety is compromised. Escape routes in the home should be identified as well as acknowledging when law enforcement intervention is needed. To learn about additional considerations, therapists can visit The Office of Women’s Health, which provide safety planning recommendations established by the U.S. Department of Health and Human Services. Additionally, it is critical that the therapist does not simply cancel therapy because the couple is not appropriate for conjoint sessions. The therapist must provide a reasonable explanation to the perpetrator as to why couple’s therapy cannot occur at the time in a way that does not endanger the victim. Please see suggested explanations at the end of this section. The hope is that by finding ways to delay couples therapy it would allow the therapist to still check in with the victim and give more time for the victim to leave.

Additionally, there may be instances where the victim does not want to end the relationship. This is a challenging situation in which the therapist has a duty to promote safety as well as a duty to respect client autonomy. If after the assessment the client states a desire to remain in the relationship, then the therapist must make it clear that couple’s therapy cannot occur. The therapist must explain that if fear is present, then discussing difficult relational topics with the perpetrator would likely lead to future abuse. It is also crucial for the therapist to explain that while individual therapy with the client (i.e., the victim) may be possible it still creates a risky situation in which the perpetrator may monitor the individual sessions or limit what the victim can report through threat of violence. Although difficult, at the end of the session, it is ultimately the victim’s decision to stay or leave, and the therapist must respect either choice. Thus, it is imperative that the therapist avoid using victim-blaming language, such as implying that if the victim stays that they are responsible for potential future violence. Overall, the authors recommend the therapist still provide resources and discuss tips on how to leave safely in case the victim does decide to leave in the future.

The final important topic of discussion is how to explain to the perpetrator why the therapist will not conduct conjoint therapy. Some explanations that can promote safety for the victim include, “It would benefit both of you to process your concerns individually with a therapist before starting couple’s therapy;” an individual therapist for each of you could teach you important communication skills that all couples need before discussing concerns together.” The underlying message is that the explanation given should not implicate the victim or make it sound like it was something the victim said that led to the therapist’s decision.

The above recommendations are an adaptation of in-person considerations when helping victims safely leave a therapy session. The authors do not purport that these recommendations should be applied in every scenario in which safety is of concern. Rather, they are meant to provide therapists with a starting point to consider how to intervene quickly when safety is compromised during teletherapy. In the scenario described above, law enforcement may be the best source of intervention, with the therapist calling them during the teletherapy session. Overall, it is critical for therapists to carefully assess these situations as all IPV interventions present some risk.

Treatment

Technology-Perpetrated Abuse

It is important to note that current research lacks recommendations regarding how to interrupt or stop technological abuse. However, the Safety Net Project (2018) provides suggestions that therapists and clients can discuss as potential options. First, they recommend that victims change their usernames, passwords, and potentially create new email addresses that do not include the victim’s name. Second, they suggest victims check their device settings to ensure no other devices are linked to it, turn off Bluetooth when not using it, delete applications they do not recognize, and monitor for spikes in data usage, as it may indicate the use of spyware. Third, victims should check their devices and applications to see if their location is being shared. If so, victims can change their location-sharing preferences in the settings feature. Fourth, if tracking is suspected on a vehicle, law enforcement and a mechanic can often locate such a device. Finally, as a potential last resort, victims may need to purchase new devices.

However, before implementing any of the above suggestions, the Safety Net Project (2018) recommends that victims document instances of technological abuse to provide as evidence, if law enforcement becomes involved. Also, victims must consider that enacting any of these steps may anger the perpetrator, potentially leading toward retaliatory violence. Thus, therapists and clients must discuss the risks associated with any decision. Ultimately, though, law enforcement may need to become involved if safety is a concern, and safe shelter may need to be sought via a local domestic violence organization.

Intimate Partner Violence

Although Hertlein and colleagues (2021) stated that dealing with IPV over TMH may increase risk to the victim(s), it is important to consider that safe treatment procedures for violent couples already exist (Stith et al., 2011). It is also noteworthy that practicing skills at home might make it easier to repeat in the future than if the couple practiced in an artificial environment, such as an office (Smith et al., 2021). Although Smith and colleagues (2021) made this assertion in the context of family play therapy, the authors argue that it can apply to any experiential intervention, such as practicing new skills in-vivo. The following TMH adaptations for treatment with couples experiencing IPV are based on Stith and colleagues’ (2011) DVFCT program.

Stith and colleagues (2011) recommend that therapists provide psychoeducation to all partners. This psychoeducation includes defining different forms of abuse and introducing the cycle of violence. Defining all forms of abuse is critical as couples may not be aware that certain behaviors are abusive. Over TMH, therapists can screenshare the handouts of the types of abuse during session and then send them via a HIPAA compliant system. Concerning the cycle of abuse, the therapist and couple map out their own cycle outlining how each partner thinks, feels, and behaves when escalating toward conflict, what happens when the violent incident occurs, how all partners respond to each other after the violent incident, and how each partner deescalates the situation after the violent incident. Over TMH, the therapist can screenshare a document and type in the couple’s cycle. The therapist can also send this cycle to the couple as a helpful reminder in future conflicts.

In DVFCT, therapists should create safety plans with each partner during individual meetings (Stith et al., 2011). These safety plans are not to be shared with the other partner(s). Please refer to safety plan considerations in the above section. Over TMH, the same ways to increase privacy that have already been discussed should be implemented here as well. DVFCT does not provide recommendations for how to adjust safety plans when addressing IPV over TMH or when technology-perpetrated abuse is occurring. The authors believe the same elements that would go into a safety plan for in-person services should be included in safety plans over teletherapy as well. However, it may be advisable to include the safety measures for technology-perpetrated abuse (see Safety Net Project, 2018) discussed above in the safety plan. This should also include specific considerations for partners who report concerns over cyberstalking, as enacting a safety plan could still result in a partner knowing their new location. Further research is needed to identify ways in which safety plans might require adaptation in these areas.

Next, the therapist should discuss with each partner individually their own signs of escalation (Stith et al., 2011). The therapist could utilize the cycle of violence already completed during a previous session and add the identified signs of escalation using the same screensharing function and HIPAA compliant messaging system apply here as well. Afterwards, the partners come together to create their individualized negotiated time out (NTO; Stith et al., 2021). Negotiated time out is a skill taught to couples that aims to accomplish several tasks. These include increasing the couple’s awareness of their escalation cycle and helping them implement de-escalation skills to prevent them from reaching a point where violence is likely to occur. Please refer to Stith and colleagues (2011) for a detailed description of the NTO as research has shown that when therapists do not follow the recommendations for NTO, perpetrating partners can use NTO as an additional way to manipulate or control their partner. Using the screenshare function, the therapist can type each step of the NTO on a document. After constructing the NTO, therapists facilitate a discussion on how to start difficult conversations (Stith et al., 2011).

Similar to in-person sessions, the therapist can guide the couple through a difficult conversation and have them practice their de-escalation skills and the NTO. Because the therapist is not in-person, they will have to develop different ways to intervene during times of high conflict. Researchers suggest that TMH can help high-conflict couples reduce the intensity of their conflict by having clients take turns speaking due to restrictions in hearing one another over technology, as well as the ability to place partners in breakout rooms to allow for privacy and time to take a break from therapy (Burgoyne & Cohn, 2020). These strategies should be explained to clients at the start of therapy and explained as a way the clients can use NTO during session. If the clients cannot identify they need the NTO, the therapist can call it and place one partner into the breakout room. Therapists should discuss with clients when this would be used, and what each partner should be doing during this time, using similar strategies to the NTO. Another strategy therapists can use is calling a client’s phone during session to get their attention. Therapists may also use nonverbal de-escalation techniques, such as turning off their camera to give clients a visual indication to slow down or muting the clients if they are using separate devices for TMH sessions.

The above strategies can also be used with high-conflict couples. O’Reilly Treter and colleagues (2021) also recommend that therapists working with high-conflict couples continuously monitor conflict levels, assess the safety of each partner during conflict, and encourage clients to institute de-escalation strategies outside of therapy. Anderson and colleagues (2010) recommend that therapists working with high-conflict couples focus on personal responsibility of each partner within conflict, as well as use of Cognitive Behavioral or Narrative Therapy interventions to challenge current ways of thinking (e.g., cognitive distortions [CBT], problem-saturated narratives and the influence of dominant discourses that may privilege power/control/violence [Narrative Therapy]) that perpetuate conflict.

Although treatment adaptations for TMH exist, practicing skills in a location where abuse has already occurred might be triggering, and a different location may need to be identified (Smith, 2021). The authors feel the same applies to IPV. If discussing violence or difficult relational topics becomes too triggering because of the location in which the discussion is occurring, the couple might need to find another location in which they can meet online. If this is not possible, then the couple may not be suitable for TMH. This decision should be collaborative; however, the therapist may need to make the ultimate decision as the couple may not have the insight to know that the location is overly triggering. To determine whether the location of therapy may need to be changed, the therapist should ask about factors that may be contributing to the intense, internal escalation. For example, the therapist can ask both partners about what memories and feelings are elicited when in said space and whether it is difficult to implement de-escalation strategies due to these memories and feelings. Overall, the therapist must both initiate this conversation and potentially make the final decision.

Discussion

This manuscript demonstrates that therapists must put a lot of forethought into how they go about assessing violence via TMH. This includes establishing a safety plan before beginning the intake appointment, implementing measures to ensure privacy for each partner, and preparing how to phrase/ask violence-related assessment questions. This manuscript also emphasizes the importance of not neglecting the assessment of technology-perpetrated abuse. Forgetting this type of violence is understandable as most therapists are taught about forms of violence that occurred prior to the widespread adoption of technology and digital media. However, failing to address it could lead to therapists missing a crucial form of IPV. Although there is overlap between assessing violence in-person and online, it is evident that assessing violence over TMH requires specific considerations to ensure privacy and safety. It is essential that therapists are aware of these considerations to prevent situations that could elicit violence and to respond effectively when assessment indicates violence is present.

Although treating violence within the context of couple’s therapy via TMH has not been studied, it is possible for existing in-person treatments to be adapted to TMH. The authors demonstrated how DVFCT can be tailored to implementation via TMH. As shown, the application of DVFCT over TMH is very similar to its application in-person. The authors also described how skills used with high-conflict couples can be applied to violent couples as well. This integration indicates that therapists must also draw on skills they have developed when working with challenging couples to working with violent couples. It is important to remember, though, that regardless of the precautions and skills executed during treatment, violence could still erupt between a couple during a TMH session. Thus, therapists should make clear to clients that if violence were to occur during session, then law enforcement will be contacted. This should be stated at the start of treatment to couples that are appropriate for conjoint therapy.

Throughout assessment and treatment, it is crucial that therapists avoid using victim-blaming language. This means therapists must not use language that implies the victim is responsible for the abuse, such as “Why are you staying with someone who abuses you?”. As in all cases of IPV, the perpetrator is solely responsible for their choice to use violence. When all partners are perpetrators, therapists must emphasize that each partner is responsible for their decision to engage in violence but is not responsible for their partners’ decision to engage in violence. Avoiding victim-blaming language may be challenging when faced with a victim who does not want to leave a dangerous relationship. However, therapists must ultimately respect the victim’s autonomy to make their own decisions while also adhering to laws regulating mandatory reporting.

Future Directions

The suggestions provided in this manuscript are based on previous research and professional experience the authors have providing therapeutic services to clients via TMH. However, empirical studies are necessary to provide evidence for the aforementioned recommendations. Future empirical studies on TMH should include couples experiencing IPV who are appropriate for conjoint therapy. Doing so will assist with determining the efficacy of the suggestions made here and in previous works as well as determining whether TMH is an appropriate modality for treating IPV. Researchers should determine whether clients feel safe addressing IPV in non-supervised clinical sites (e.g., home based TMH), due to being in a different location from their therapist, and how being in the same location that violence has occurred influences aspects of therapy. Future research should also continue examining the ways in which individuals can utilize technology to perpetrate abuse and how therapists can assess for it, with special attention to issues of safety if a device is being monitored. Additionally, future research should examine the potential similarities between high-conflict couples and couples experiencing IPV as there may be therapeutic skills that overlap between these two populations. Also, future research should examine further adaptations that may be necessary if children are in the home. For example, if abuse between the partners is actively occurring, then a report to child protective services may be required, and safety plans will have to consider children’s safety.

Conclusion

Due to the prevalence of technology-perpetrated abuse and IPV, therapists will inevitably be confronted with these issues via TMH. Thus, it is imperative that therapists are equipped with violence specific clinical guidelines that are adapted to TMH. In this manuscript, the authors assert that IPV, including technology-perpetrated abuse, can potentially be addressed in the context of couple’s therapy over TMH. To support this assertion, the authors outline how to determine whether couples experiencing IPV are appropriate for conjoint therapy. Assessment and treatment recommendations are also provided with a specific focus on adaptation to TMH. These adaptations focus on establishing and maintaining safety, which include ensuring privacy, developing unique ways to interrupt and soothe moments of high conflict, and creating a TMH emergency plan that notes who to call during emergency situations. This manuscript extends previous research by providing new and innovative recommendations for both assessment and treatment over TMH. These include adapting assessment and treatment considerations from DVFCT to TMH, suggestions on how therapists can assist victims with leaving the home during a TMH session, how to integrate addressing technology-perpetrated abuse and high-conflict couples in tandem with IPV over TMH, ways to deescalate conflict over TMH, and specific safety recommendations during assessment adapted to TMH. Overall, the authors believe that the recommendations provided here will assist therapists with making sound decisions when confronted with technology-perpetrated abuse and IPV over teletherapy.

Declarations

Conflict of interest

The authors have no funding nor conflicts of interest to disclose.