Conjoint Couple Therapy with a Woman Survivor of Intimate Partner Violence: Strengths and Challenges

Abstract

Intimate Partner Violence (IPV) or Domestic Violence (DV) affects the mental health of women. Systemic family therapy has been found to help bring change in a couple's relationship and the cessation of violence in the relationship, provided both couples are motivated by the therapy to preserve the marital relationship. This article presents a case of offering brief tailor-made individual intervention as well as couple therapy for a woman with depression experiencing violence.

Intimate Partner Violence (IPV) or Domestic Violence (DV) is globally a public health problem. IPV/DV can be defined as any “violent, abusive, or threatening behavior among adults who are relatives or partners/ex-partners.” ¹ IPV/DV can be physical, sexual, or emotional violence among intimate partners, such as same- or other-sex partners or married or unmarried partners or directed towards children. ² According to the recent report by the National Family Health Survey 2021, ³ the number of married women aged 18–49 to ever experience spousal violence has sharply increased, doubling from 20.6% in 2014–2015 to 44.5% in 2019–2021. Sexual violence among young women aged 18–29 has risen from 10.3% in 2014–2015 to 11% in 2019–2021. IPV is frequently connected to health issues ranging from small injuries to serious health repercussions and even death. ⁴ The survivors experience significant anxiety, depression, post-traumatic stress disorders, suicidality, and substance abuse.^5,6 Survivors of IPV/DV frequently visit health facilities with IPV-related health issues but rarely disclose their IPV experiences to clinicians, due to lack of privacy; fear of threat, violence, and re-traumatization; shame, and guilt. ⁷ Often, clinicians fail to identify IPV due to the time constraint, fear of offending women, and lack of training and skills in identifying IPV.^8,9 Meta-analysis by Karakurt et al. ¹⁰ suggests that couple therapy helps violent couples improve communication difficulties, ¹¹ issues in conflict management, ¹² and relationship difficulties. ¹³ This report illustrates the process of offering a brief tailor-made individual intervention as well as couple therapy for a woman with depression undergoing IPV, in the clinical setting. A written informed consent was taken from the patient for the purpose of publication.

Case Scenario

A 28-year-old married woman, homemaker, with primary education, from rural lower socioeconomic background and having two children, presented with complaints of low mood, reduced interest in activities, reduced energy, decreased sleep and appetite, and a history of multiple suicidal attempts in the last one year, with worsening of symptoms and active suicidal ideation for the past six months following separation from her husband and children. The onset of the symptoms was gradual, and the course, continuous. She was diagnosed with severe depression without psychotic symptoms. She was treated with Electroconvulsive Therapy (ECT), and medications were initiated. She gradually improved with treatment and, upon consent, was referred to AWAKE a special clinic for women experiencing IPV, where she was offered individual therapy and couple therapy to address marital violence.

Psychosocial Assessment

The patient had a non-consanguineous arranged marriage with mutual consent when she was 18. She lived in a nuclear family with her husband and two children. She reported that the early years of the marriage was alright. Gradually, she started noticing the controlling and dominating behavior of the husband, who would verbally abuse her for minor issues. Five years into the marriage, he started consuming alcohol and there was increased verbal and physical abuse whenever he was intoxicated. About a year ago, his niece joined their family after her husband’s demise. Since then, the violence towards the patient had aggravated drastically. Eventually, it was understood that the husband’s family wanted him to divorce the patient and marry the niece. According to the patient, the couple’s interpersonal issues intensified when the husband started avoiding her but continued to abuse her physically. He would tell her to leave, so that he can marry the niece. The patient made multiple deliberate self-harm (DSH) attempts, and parallelly, the violence from the partner continued. During one such episode, around six months ago, she was sent to her parents’ house, without her children. She wasn’t allowed back into her family of procreation, nor was she allowed to meet her children. She had filed a complaint at the local police station against the husband and the in-laws for DV and for prohibiting her from meeting the children. According to the patient, the police had advised the husband and in-laws to allow the patient to meet the children, but they did not oblige. Furthermore, the husband kept forcing her to go for a divorce, and the abuse continued over the phone. The patient reported that she could not deal with the mental trauma and pressure from the husband, which resulted in an emotional breakdown, ultimately resulting in worsening of depression and multiple serious DSH attempts.

Interventions

Therapy Goals

The short-term objective of individual sessions was to evaluate the patient’s current requirements and concerns as well as to enhance social support and safety through risk assessment and safety planning. The long-term objective was to teach coping and problem-solving skills, conjoint couple therapy sessions to address ongoing relationship issues, and to educate regarding legal options available to preclude further IPV and also have the custody of the children.

Individual Sessions

The initial stage of sessions focused on building rapport with the patient, validating her emotional experiences, and offering supportive therapy to acknowledge her psychological distress. The mother, who was the primary caregiver, was educated about the suicide risk prevention strategies, and we ensured close monitoring of the patient in the ward. The therapist offered a safe space for the patient to express her feelings and concerns. The therapist empathized with her feelings and emotions by providing supportive statements. As she started feeling better clinically, further sessions focused on resolving the ongoing marital problems. Using a problem-solving approach, ¹⁴ she made an elaborate list of her problems, chose a few concerns that bothered her the most, and tried to list out their possible solutions. She wanted to continue the marital relationship and also get her husband treated for his drinking problem. She was referred to the free legal aid clinic, where she was made aware of the legal means of having the custodial rights of the children. The transtheoretical model of behavior change ¹⁵ was applied to understand that the patient was in the contemplation stage of behavior change, unsure about seeking assistance and keeping in mind family and societal pressure. She was also worried about raising the children without a father and how the society might treat the children and herself. She wanted to exercise legal action as a last option and resolve the marital issues with the formal network of family members. The therapist observed that the patient minimized the abuse by blaming herself. Her self-esteem was low, as she constantly spoke in a degrading manner about her values and self-worth. In order to interrupt the cycle of violence and gain control of her position, the therapist assisted her in becoming aware of the dynamics and power control that existed within the marital relationship. She was educated on her legal choices and rights. In further sessions, the patient’s decision-making and problem-solving abilities were strengthened, which improved her self-efficacy to handle the situations. Safety skills were taught to safeguard herself and her children, in view of the ongoing IPV. Information about the local women’s helpline was provided to call for help in a crisis.

Couple Therapy

The traditional approach to the treatment of couples experiencing IPV is to have separate sessions with each of them. Couple therapy may be helpful for couples who have experienced mild to moderate psychological and/or physical abuse, though separation of the abusive partner and the survivor may be required to maintain safety in cases of extreme physical abuse. Conjoint treatment, when deemed safe, helps intervene in couple interactions contributing to the abusive cycle and yields the optimal outcome. ¹⁶ Couple treatment for IPV is also indicated when the violence is reciprocal, its intensity is mild to moderate, and both partners voluntarily agree to the therapy to end the violence and wish to remain together. ¹⁷

Since the patient wished to continue the marital relationship and have couple therapy, the therapist contacted the husband to visit the patient in the hospital. The husband was initially reluctant to visit her but later agreed to undergo marital or couple therapy. He had entered the contemplation stage regarding drinking of the transtheoretical model of behavior change. ¹⁵ In the beginning, he tried to justify the violence, blaming alcohol for his abusive behavior. He also justified that when things get out of control, his family suggested going for divorce and marrying his widowed niece. In the initial psychoeducation sessions, emotional regulation was taught to the couple through anger management and stress reduction techniques. The training in communication and conflict resolution targeted constructive conflict management by the couple. The sessions focused on reducing the risk of aggression and, parallelly, revoking the relationship lost due to IPV (Table 1). Verbal descriptions were given of constructive and destructive communication. Effective expression of feelings and listening skills were explained, along with corrective feedback. The cultural influences, including the in-laws’ involvement in the relationship and gender roles in the relationship, were explored, because those were the presenting concerns of the couple. Mutually acceptable ways to improve the quality of the marital relationship were discussed. The couple was also explained deescalation skills, including about being empathetic and non-judgmental and respecting each other’s personal space and boundaries. The patient was also allowed to describe the marital difficulties. Both appeared to have dysfunctional communication and relationship patterns and poor conflict resolution skills.

Table 1.

Details of the Sessions and Techniques.

Session Phases	Objectives	Techniques Used
Initial phase (Sessions 1–4) Duration: 30–45 min	• Address the suicidal risk of the patient • Establish rapport • Psychoeducation of mother • Assess the immediate needs of the client and offer support • Conduct risk assessment and safety planning	• Psychoeducation of mother on managing the suicidal risk of the patient • Psychological first aid to handle the crisis • Reassurance and ventilation • Education about identifying the signs of abuse and awareness of the dynamics of a violent relationship
Intermediate phase (Sessions 5–11) Duration: 45 min to 1 h	• Reduce passive and active violence in the home environment. Increase positive coping and healthy communication in the couple’s relationship • Motivational interviewing with husband to address drinking behavior • Impart positive parenting skills and directions for legal proceedings to the patient • Explore social support and make an appropriate referral based on the needs of the patient	• Problem-solving approach • Supportive techniques • Conflict resolution skills - Positive coping strategy to deal with trigger situations • Couple communication skills • Behavioral and cognitive tasks • Emotional regulation skills and stress management • Discussion on parenting strategies • Guided discussion • Referral
Termination phase (Sessions 12–16) Duration approximately 20 min	• Discuss safety and assertiveness skills with the patient • Follow up on family functioning, treatment compliance, and economic self-sufficiency of the patient • Enhance the self-confidence and self-esteem of the patient	• Discussion on approaching legal and societal options for ensuring safety. Education on the healthy expression of emotions and utilization of the support system • Ensuing treatment adherence using psychoeducation • Acknowledging the client’s strength

The husband’s patterns of minimization and blaming the patient for violence were confronted and he was made to own his behavior. Treatment goals with the husband included psychoeducation about the forms of violence in intimate relationships and options with which IPV can be substituted, improving individual accountability for the use of violence, reducing and finally eliminating IPV through anger management and conflict resolution techniques, and improving communication and problem-solving abilities to enhance relationship satisfaction and constructive couple interactions. The sessions focused on teaching the healthy ways of having reciprocal communication with the patient without indulging in violence/abuse. The couple was taught about open communications and sharing of household and child- rearing responsibilities. Victim blaming was addressed with an emphasis on changing the attributional style and owning responsibility for the abuse. Separate sessions were also held with the husband to address the drinking behaviors and to teach healthy coping and problem-solving skills. The legal consequences of a second marriage and persistent DV were also explained to him in the individual sessions.

The patient was discharged with consent for a tele-follow-up with the therapist.

Follow-up Sessions

The follow-up tele-sessions were held by phone, separately with the client and the couple. During the sessions, the therapist ensured utmost safety of the client. Before the session, she was instructed that if the husband suddenly entered the home while the session is in progress, she should convey the matter to the therapist using code words. She was also instructed to respond only with “yes” or “no”, use code words, or switch to a neutral topic if he was around while she is disclosing a recent episode of violence. Currently the patient report that the violence from the husband has stopped and that his drinking is occasional only. Her self-esteem and depressive cognitions have improved significantly. The follow-up sessions guided the couple to prevent tendencies for relapse and to engage in mutually pleasurable positive behaviors.

Strength and Challenges in Couple Therapy

Offering couple therapy had specific challenges in the current case scenario. The strength was that the therapist relied on the family system theory, which acted as a secure base for the therapist to go back to when overwhelmed by the complexity of the clinical work before her. Treatment of couples with IPV necessitate understanding the dynamics present in the system that created the partner violence. In this case, the therapist could identify the base of triggering factors for the cycle of violence and cease it, as both had poor conflict resolution skills. The therapist could identify the cycle of violence and how it is maintained, and giving feedback was helpful in the therapy. Cycle work refers to identifying the defeating pattern of interaction within a couple that is repetitive and negatively reinforcing. Based on systemic patterns, the therapist could identify triggers, primary and secondary emotions, and inter- and intra-personal elements at play in the context of cycle work. The structured, supervised sessions helped reduce anxiety and increased the therapist’s confidence in carrying out the sessions. Having been already trained in structural and systemic family therapy in the institute was helpful for the therapist.

The challenge in using couple therapy was the uncertainty about using systemic foundations and maintaining safety of the couple at the same.

At times, the fear of compromising client safety overwhelmed the therapist. The therapist had to manage her own anxiety in the session, anticipating violence at the home despite assessment and planning for safety overwhelmed and burdened the therapist. There were feelings of great worry about applying systemic work with the couple to bring change in the relationship and uncertainty about sustaining the change in behavior patterns in complete cessation of violence.

Discussion

This article focused on the process of conjoint couple therapy for IPV using family system theory, ¹⁸ with special attention to the issues of accountability, healthy communication, and conflict resolution strategies. Using these techniques, meaningful results were obtained in the form of cessation of violence and enhancement of healthy communication patterns in the husband. Family systemic approach helps the couple recognize the inequalities in power between the partners and helps develop a more equitable model of interaction. It also helps both partners to understand their present behaviors in light of the attitudes, expectations, and gender role stereotypes they acquired in their families of origin. Rather than justifying the perpetrator’s actions, systemic approach can be employed to encourage the man to accept full responsibility for his behavior and empower the woman to take control over her safety and emotional well-being.^19,20

According to Sprenkle et al., ²¹ in couple therapy, the clients commonly attempt to justify their behavior by blaming the partner. With regard to the problematic attributional style, avoiding the blame game resulted in taking accountability and owning responsibility for the violent behaviors. Conjoint treatment encourages the offender to commit to change and assume responsibility for his behavior. ²² Treatment can be tailored for each couple based on meticulous screening and the application of safety precautions. In the present case, the husband was taught de-escalation skills, resulting in non-abusive behaviors with the patient. Though they are currently in the action phase of the transtheoretical model of behavior change, ¹⁵ there may be relapses as it happens in some cases. Hence it is crucial to continue to follow up with such couples.

Conclusion

Even though couple therapy is not encouraged, conjoint couple therapy is an appropriate intervention for IPV if certain conditions are present as determined by the clinician. ²³ Couple therapists should undergo structured training in systemic therapy and have practice skills and cultural competency while dealing with cases of IPV. Conjoint couple therapy should be taken into consideration only after careful assessment of the appropriateness of couple therapy for that particular couple and after taking necessary precautions to ensure the safety of both partners. ¹⁰