The Assessment Process (Part 1)

Because of the inherent risk of harm to others present in domestic violence counseling, it is critically important that counselors approach the assessment process with a clear set of goals and expressed expectations. These goals help to set the context of counseling from the onset and serve as a continual frame of reference that both counselor and client will refer to throughout the treatment process. Goals of the assessment process may include the following.

Set ground rules for counseling
Develop rapport with the client
Assess the client’s motivation for treatment
Assess the client’s suitability for treatment
Provide immediate behavioral interventions for violence control
Assess the client’s history of violence and social history
Assess the client’s risk for further violence
Make collateral contacts with other professionals involved with client
Provide client with informed consent for counseling
Develop treatment plan in cooperation with client

Making it Safe for You

No matter what population of perpetrators a counselor may work with (high or low risk), she or he is likely to encounter homicidal or suicidal situations, and therefore it is crucial that counselors/programs institute the safeguards that are necessary to respond to crises. These safeguards include a security plan for home and offices (both the mental health provider as well as the client’s significant other), a good working relationship with local law enforcement agencies (police and prosecutors), coordination with local victims services (shelters, counseling programs, advocacy programs), on-call consulting mental health professionals, and advanced training in crisis management. Additionally, because of the possibility that providers will be called into court to testify about a client’s violence, it is important that clinicians have legal council available who will advise them in how to adhere to professional legal and ethical standards. Lastly, because of the high risk that domestic violence clients present to clinicians, liability insurance is highly recommended. Familiarity with the laws relating to confidentiality, child and elder/adult dependent abuse, and dangerous situations is a must for counselors working with domestic violence cases.

Setting the Frame: Informed Consent

Setting the frame of treatment is an important first step in helping clients stop their violent behavior. This done through the informed consent process, which is telling the client the realistic limits of treatment, and setting and communicating the expected rules of conduct. It is crucial that each client understands the informed consent and agrees to the program rules and follows them exactly as they are set forth, to assure that they derive the most benefit from the experience.

The informed consent statements to clients and their partners should at a minimum include the limits of treatment. Although some studies have indicated a high remission rate of violent behavior while the perpetrator is in treatment and for some time afterwards, many clients do continue to re-offend even while participating in highly effective treatment programs. Therefore, a specific statement to both parties will communicate the seriousness of the domestic violence while at the same time present a sobering statement about the real chance that violence will continue and may become more serious over time.

The therapeutic techniques used in the Domestic Violence Court-Mandated Perpetrator Treatment Program help clients learn how to identify and communicate emotions in an adaptive manner, and how to change attitudes, both of which ultimately help to prevent violent behavior. However, program staff cannot guarantee that every person will stop his/her violent behavior. Many clients have continued their violence while participating in the treatment program. Both victims and perpetrators must not be lulled into a false sense of security simply because they are in counseling. Individuals who have a problem with violence need long-term counseling in order to break those patterns. Some clients do not change because they are not emotionally motivated to change. Others may genuinely want to stop their violence but are prone to setbacks. Certain clients are in need of a more intensive treatment plan over and above once-a-week sessions. A few, but a significant number, of clients may ultimately need an inpatient, hospital-based program or jail if they are unable to effectively utilize once-a-week counseling in a constructive manner.

Given these realities, clinicians are NOT in a position to certify that a client is guaranteed to never commit violence in the future as the result of group participation. Thus, written communications to the court and verbal communications to partners are limited to factual information about the client’s attendance and motivation as demonstrated by such a thing as completion of homework assignments and participation in sessions.

Informed Consent

The problem of domestic violence has received considerable attention in the past few years. Counseling programs for batterers, have become increasingly available to both men and women. However, because of the high lethality associated with domestic violence, even when people go into counseling, there continues to exist a real and present risk for continued violence.

The techniques you will learn in counseling are meant to help you learn how to identify and communicate your emotions in an appropriate manner, and how to change attitudes, both of which ultimately help to prevent violent behavior. However, we cannot guarantee that every man will stop his violent behavior. Many clients have continued their violence while participating in the treatment programs. Therefore both victims and perpetrators must not be lulled into a false sense of security simply because they are in counseling. Individuals who have a problem with violence need long-term counseling in order to break those patterns. Some clients do not change because they’re simply not emotionally motivated to change. Others may genuinely want to stop their violence but are prone to setbacks. Certain clients are in need of a more intensive treatment plan over and above once-a-week sessions. A few, but a significant number, of clients may ultimately need an inpatient, hospital-based program or jail if they are unable to effectively utilize once-a-week counseling in a constructive manner.

If there is another incident of physical (all forms), sexual (all forms) or psychological (threats to harm and threats to kill) violence victims are encouraged to call the police and/or your partner’s probation officer (if perpetrator is on probation) and/or civil remedies (such as, temporary restraining orders, separation/divorce) for relief from victimization.

Additionally, you, the client, may decide that this program is not for you. If that is the case, we encourage you to seek out another program immediately. The longer you go without counseling, the greater the risk for continued violence. The greater the risk for violence, the greater the possibility that counseling will no longer be an option — instead, incarceration may be the only choice. Therefore, if you decide to leave our program, we recommend that you continue to attend sessions until you are ready to enter into another counseling situation so there is a minimal amount of time that passes between programs. If you leave the program, your partner will be notified of this fact, and we will communicate any concerns we may have as to your potential for future violence.

Confidentiality

Along with informed consent about the effectiveness of treatment, counselors must address the issue of confidentiality. If a counselor begins an interview process and has not procured a release to discuss their findings with the referring agency (usually the probation department), and say the client walks out of the interview prematurely or refuses to cooperate in other ways, technically, the therapist would be in violation of the law and ethical standards protecting client’s right to confidentiality by calling the probation officer who made the referral. To avoid being in the compromised position, therapists are encouraged to procure a signed authorization prior to commencing the assessment process. An example of an Authorization to Release Information is included in the appendix of this workshop.

Along with this discussion, therapists are encouraged to discuss all the limitations with regard to confidentiality, including mandated disclosures and permitted disclosures. Typically, this discussion should include the mandated disclosures associated with child abuse, adult dependent and elder abuse, and threats to others. Permitted disclosures include psychological abuse of children (California law) and certain forms of adult dependent and elder abuse. Therapists are also permitted to make disclosures (California law) when the client presents a danger to self, others or the property of others. Other permitted disclosures are when the therapist has procured a signed authorization to release information to others, such as a probation officer or another therapist.

Therapists must be familiar with the specific wording of laws in their states in order to determine which types of situations where they must report and those situations where a therapist may report, according to state law.

When discussing the case with non-mental health professionals, therapists should use discretion in what information they reveal. Certain diagnostic observations, testing data and social history material may not be necessary to tell a probation officer of whether or not a client is appropriate for treatment in a particular program. Therefore, it may be useful to explicate to the client what will and what will not be discussed with the probation department. Although many providers are certified to offer treatment by the local criminal justice agencies, professionals need to understand that their primary duty is to the welfare of their client or patient. Arguably, reporting reoffenses to the court or probation, of additional acts of violence by a patient can result in dire consequences, only one of which may include incarceration. Therefore, these reporting requirements should not be taken lightly and therefore it may be prudent for the therapist to discuss with the client the possibility of these actions prior to their occurring.

Confidentiality Guidelines

By law and professional ethics, your sessions are strictly confidential. Generally, no information will be shared with anyone without your written permission. If you are seeing another therapist or health professional, it may be necessary for us to contact that person so that we can coordinate our efforts. If this is necessary we will ask for your permission. There are, however, a number of exceptions to this confidentiality policy.

If we are ordered by the court to testify or release records.
If you are a victim or perpetrator of child abuse, we are required by law to report this to the authorities responsible for investigating child abuse.
If you are a victim or perpetrator of elder or adult dependent abuse, we are required by law to report this to Adult Protective Services or other appropriate authorities.
If you threaten harm to yourself or someone else, we may be required to call the police and warn the potential victim, or take other reasonable steps to prevent the harm.

If you are mandated by the court to attend these sessions, we will need to have your permission to speak with the probation department or other criminal justice agency that is monitoring your compliance with the court orders. In these conversations we will be reporting the following information:

Reoffenses of violence towards anyone
Violations of court orders
Missed appointments
Participation in session (verbal participation and completion of homework)
Compliance with session rules

It is also important that clients respect the confidentiality of your fellow session members. Therefore, it is very important that participants not disclose any information discussed by other group members to anyone outside of the session, including counselors, probation officers, partners, friends, and family members.

Partner contact. It is a requirement of your participation in Domestic Violence Treatment Program that counselors meet with your partner before you are accepted into the program. Once you are accepted into the program, we will have weekly phone contact with your partner to assess whether or not you have perpetrated violence and to receive feedback on how you are incorporating the educational material from your counseling sessions into your relationship. In addition, every six weeks we will meet with you and your partner to evaluate your progress in counseling and determine if additional treatment options are necessary. If you are separated or divorced from your partner, we must have contact with any subsequent individuals with whom you become emotionally involved. This can be very difficult for some clients because it involves their telling their new partner about their history of violence. If you are truly committed to changing your pattern of coping with conflict and emotional stress, we strongly encourage you to inform any new romantic attachments of your history of violence and participation in this program. These partner follow-up policies are a requirement for all participants in our program.

Setting the Frame: Privilege

Confidentiality is both a legal and ethical issue and essentially involves the restriction on the volunteering of information (with certain limited exceptions) outside the courtroom - whereas privilege is a legal issue involving rules of evidence involving the right to withhold testimony in a legal proceeding. In most cases, clients will be referred post sentencing and therefore already on probation. Occasionally some clients will seek treatment while awaiting trial for a domestic violence related offense. In the later instances, it is critical that therapists clearly define their role with their client.

Is the evaluator going be the client’s therapist or expert witness/advocate in court? Although these roles may not always be mutually exclusive, it is generally not a good idea to mix them. Take for example the therapist who evaluates and testifies for a client during the trial phase. If this therapist becomes the treatment provider during the probationary phase of the process, they may end up having to report additional acts of violence that possibly may result in the client being incarcerated. Of course, this is assuming the client stays with the evaluating therapist who was not able to convince the jury of a more favorable disposition in the criminal case, in the first place. Additionally, expert witnesses are suppose to be objective, with no investment in the outcome of the case other than to present their clinical findings or professional opinion to assist the trier of fact. The therapist is seen as more of a support and advocate for their client. Acting in both roles can result in a compromise in both roles. The appearance of objectivity is necessary for effective expert testimony. A treating therapist acting an expert witness can appear as having a bias or financial or personal interest in the outcome of the case. At the same time, a treating therapist who is working to develop a therapeutic alliance may appear unnecessarily distant or not invested to a client who is wanting someone to fight on his/her behalf, not to mention the disappointment that may develop within the client as a result unfavorable disposition. Therefore, it is recommended that therapists choose one role or the other and not try to help their clients in too many ways.

Therapists also need to be familiar with, and explain to their clients, the exceptions to the psychotherapist patient privilege laws in their state. Certain exceptions in evidentiary procedure may require the therapist to testify against their client in a court of law. Most therapists will choose to testify when ordered by the judge rather than be found in contempt of court and face a jail sentence, a fine or both. Therefore it is critical that therapists inform their clients of this limitation to confidentiality.

Some clients may want their therapist to contact their attorney to help provide information for their case, but not testify in court. Once again, therapists must use extreme caution when discussing clinical material with non-mental health professionals.

Developing Rapport: An Overview

Developing rapport is critical to working with perpetrators of violence, as it is with any type of client. Many domestic violence clients, in particular, are skeptical of the counseling process in general and therefore counselors may be viewed with low credibility. Therapists should not take for granted the fact that the court-mandated client is an involuntary consumer of services and therefore the process of developing rapport will be complicated, extremely difficult or altogether impossible. Let’s examine why developing rapport may be extremely problematic with this population and how therapists can work to develop a therapeutic alliance that will pave the way for successful treatment outcome.

A significant percentage of abusers may not feel a great deal of anxiety about their problem and therefore may not feel motivated to change something that they haven't even identified as a problem in the first place. Aside from the obvious mandatory referral from the court system, there are many perpetrators who enter into treatment because their partner is making that demand upon them. Although external forces may be sufficient to motivate many men and women into the therapist’s office, the counselor must not depend on those influences to help them maintain their participation, let alone incorporate the therapeutic interventions around them to a significant degree.

Many male clients hold the view that asking for help in the form of counseling is tantamount to admitting weakness or worse, acknowledging that they are crazy. Because of the history that many perpetrators of violence have had with abusive and domineering parents, these clients are likely to enter into counseling with a great deal of distrust of the process. They are not likely to want to make themselves vulnerable to someone whom they perceive as having power over them (especially if they have been referred by the criminal justice system). Because of these issues alone, it is crucial that counselors approach their work with batterers with genuine sensitivity and empathy so that positive rapport is possible.

Many therapists may ask, “How does one establish rapport with a client who has extreme distrust of mental health professionals specifically or difficulty making meaningful attachments with others in general?” The answer to this question falls more into the domain of the art of psychotherapy than to the science of psychology. It is critical that persons wrking with perpetrators approach their clients with compassion and understanding, and with a belief in the process and a conviction in the importance of the goals. Therapists need to examine their negative attitudes toward people who use violence, or else these feelings and beliefs will get communicated to their clients either overtly or unconsciously. Just as therapists pick up subtle messages and cues from their clients, the clients will sense whether or not the therapist truly cares, understands and judges. This is not to say that therapists should collude with clients' view that they are victims of circumstance -- but they should realize that many of these individuals have had horrific family of origin experiences and their violence to a great degree may have been influenced by those experiences. Likewise, many of the people perpetrating violence are also suffering from depression, psychoactive substance disorders and other psycho-physiological illnesses and therefore need help from a professional who is skilled in treating multiple conditions. However, because of their resistance to addressing psychological issues in general, along with their sensitivity to feeling blamed, weak or devalued, batterers present strong obstacles to receiving the help that therapists enthusiastically want to provide. So walking that fine line between support, understanding and empathy on one side and limit-setting on the other, maintaining the treatment goals while remaining willing to confront minimization, denial and externalization -- this is the greatest challenge for therapists working with perpetrators of violence.

Much of what is defined as necessary for effective treatment by probation departments, state legislatures and battered women’s advocates is defined by confrontation, limit-setting, consequences and self responsibility. A steady diet of these interventions may be sufficient for some clients with a more healthy psychological personality; however many of the clients referred by the courts do not fall into this category. According to the research of Dr. Donald Dutton and others in the field, there is mounting evidence that many batterers are suffering from attachment or character disorders. If this is the case, then the clinician needs to consider the differential application of confrontational interventions, and the use of interpretation. Confrontation is the intervention of choice when encountering clients who are acting out in self-destructive or other-destructive ways. However, many batterers do not have a fully developed sense of self, which is why they often look outside themselves for definition and control. Therefore a certain amount of interpretation of defensive acting out is necessary, both to help clients better understand themselves and the function their violent behavior serves, and to help clinicians develop a working alliance so that clients feel understood by their therapists. Although it is helpful to develop cookbook approaches to working with this clinical population, one can readily see that the practical application of the theory can be specific to each client.

Therapists may consider helping clients understand the psychological meaning or purpose of the violence. For many clients, defenses of avoidance, hostility, blaming, denial, substance abuse, or attempts to control others, themselves or their feelings cover up a tremendous sense of emotional vulnerability and psychic pain. Teaching clients to understand the difference between defensive anger or hostility and legitimate emotional expression may also help them to begin the initial process of understanding their violence in a broader psychological perspective.

It is necessary for therapists to show genuine empathy toward clients, in order for them to learn how to be empathic toward others. It is very easy to feel disgusted and exasperated by the clients' acting-out behaviors both outside and inside of the consulting room, but therapists must remind themselves, and their clients, of the difference between the feelings they are trying to avoid, protect and soothe, etc. and the defensive behaviors themselves. Maintaining an empathic and supportive stance in the face of tremendous denial, and sometimes hostile and aggressive behavior, can be challenging to even the most seasoned of therapists.

Lastly, many men and women are drawn to the domestic violence and child abuse fields because of their own experiences as either a victim, a perpetrator or both. Therapists with unresolved feelings about their own family abuse are likely to either displace anger and hostility upon their clients or to collude with their clients' minimization and denial. Having a personal history of childhood abuse or family violence can certainly be an asset when working with batterers, but when the therapist’s psychological issues are left unchecked those experiences can become a detriment to effective treatment. Obviously, it can be particularly problematic when a therapist has had a recent history of perpetrating violence towards others. Like any experience, this can be an asset or a liability to the treating therapist. Clients who have been victims of abuse in their childhood are likely to project tremendous negative feelings onto the therapist, act out, and look or even pull for negative reactions in the therapist. The possibility for projective identification and countertransference is very real for the treating therapist. Therefore, because of the inherent complexity of treating violent individuals and the potential for therapists to act out or react to the client’s material inappropriately, it is recommended that persons who have had experiences of either victimization or perpetration of violence should participate in their own psychotherapy and on-going consultation with peers or a supervisor while working with this clinical population.

The Therapeutic Alliance

Theoreticians and clinicians have for many years used the term “therapeutic alliance” differently. Terms like therapeutic alliance, working alliance, positive therapeutic relationship, positive transference and helping alliance have all been used to describe an important element necessary for success in therapy. Here in this workshop, I use the term therapeutic alliance to mean that point in the therapeutic relationship when the client or client on one hand elevates the therapist to a position of authority, but on the other hand believes that this power and authority is shared between them, that there is a deep sense of collaboration and participation in the process. In this way a positive attachment develops between the client and the therapist. This process contributes most importantly to a sense of safety that is essential for the development of trust between therapist and client, and as a result the client develops a deep commitment to the therapeutic journey.

The Penn Psychotherapy Project has articulated two types of therapeutic alliance: Type 1 and Type 2. Type 1 therapeutic alliance is more evident at the beginning of therapy, where the alliance is based on the client’s experiencing the therapist as supportive and helpful. These perceptions are typically influenced by the client’s perception that the therapist is warm and caring. In other words, therapist empathy is an important element in the development of a therapeutic alliance. In addition to empathy, other factors such as the gender of the therapist, the therapist’s perceived expertness and the client’s past experiences in similar relationships may also contribute to this early type therapeutic alliance.

Type 2 therapeutic alliance is more typical of the later phase of treatment, where there is a joint struggle against what is impeding the client, a shared responsibility for working out treatment goals, and a sense of we-ness. It is the Type 1 therapeutic alliance that clinicians need to attend to immediately with the court-mandated domestic violence perpetrator; otherwise the second type will probably never develop.

What can clinicians do to develop a positive therapeutic alliance with the court-mandated client? Freud’s suggestions, made almost seventy-five years ago, still hold true today. A friendly, sympathetic attitude toward the client is beneficial for the initial development of the alliance. There is some evidence that the client's endorsing of the tasks involved in therapy will also contribute to the development of a therapeutic alliance. As mentioned earlier, the client wants to feel both that that the therapist is an authority, and at the same time that there is a sense of collaboration in the treatment process. When clients agree with the technical aspects of the treatment process and feel that the therapist is willing to negotiate the treatment goals, they are more likely to view the therapist as both accepting and supportive.

Using the therapeutic relationship is another means toward developing a therapeutic alliance. Clients will bring to the therapeutic encounter dysfunctional interpersonal patterns that are often reactivated during therapy. If the therapist responds in a manner that confirms or plays into these patterns, then these dysfunctional beliefs or expectations are likely to be maintained or exacerbated. However, if the therapist uses the appearance of these maladaptive patterns as an opportunity to help the client recognize and examine them, it is possible that these patterns will be disrupted and the client will get a better grasp on his or her interpersonal dynamics. The exploration and discussion of in-therapy interpersonal dynamics may have a greater impact on the therapeutic alliance than the sole discussion of out-of-therapy events. Therapists who are more engaging of clients in this way are also likely to improve the therapeutic alliance.

Lastly, clinicians who use both interpretation and confrontation with clients (as opposed to primarily confrontation) are more likely to develop a positive therapeutic alliance. If clients perceive therapists as being either critical or controlling, they are not likely to feel that therapists are either accepting or supportive.

Client Motivation: An Overview

Clients must have some discomfort in their lives in order to produce the required motivation to change. Unfortunately, most court-mandated clients do not feel discomfort about their problematic behaviors. If they feel any discomfort, it’s mainly about the fact that they are being forced to go to counseling. The relationship between discomfort and motivation is not linear but curvilinear. When a client has too little discomfort, this generally results in only a modest amount of curiosity about themselves. Most persons who lack this curiosity are also not very interested in paying for a service that they believe will provide no benefit to them. On the other hand, clients with too much discomfort, and particularly those with too little ego strength, can find group or any type of therapy so emotionally overwhelming that it may not be able to meet their highly pressing psychological needs. A moderate amount of discomfort may motivate a person to pay the price (both literally and figuratively) necessary for successful therapeutic outcome. However, clients who enter into therapy, as mentioned above, must also have faith in the therapy process.

Where does this faith come from? The popular media (books, movies, television, newspapers and magazines) have provided the general public with stories involving therapy. These stories include personal accounts about how therapy has helped people, interviews with therapists and psychologically oriented stories. Many people either know someone who has been in therapy, or they have learned through the media about what therapy generally consists of. Asking clients about these experiences can help the therapist understand and address any misconceptions the client may hold about the therapeutic process.

Clients also develop faith from the therapist him/herself. Therapists who strongly believe in the value of the therapeutic process, as well as in the methods being employed, can convey their belief to the client. Additionally, therapists who have evaluated their work and who can show the client outcome studies can help the client develop faith in the treatment process.

When clients believe in the omniscience of authority figures, they are more likely to at least try therapy on the word of another. However, many perpetrators of domestic violence, because of early childhood abuse experiences, may react negatively to an authority figure and thereby avoiding a potentially helpful experience just because someone is telling them it may be good for them.

Hearing about other group members' improvement from the members themselves can be the most powerful way for clients to develop faith in the therapy process. Clients who have been in the therapy group for some time can provide the necessary support for new clients who may be skeptical of the therapy process in general.

Lastly, clients who stay in treatment long enough to observe changes in themselves, which have directly resulted from their participation in treatment, are more likely to increase their faith in the therapeutic process. When all else fails, the therapist must ask the client to take a leap of faith. Of course, with the court-mandated client, this leap of faith is not necessary. It is more the leap from jail that is the primary motivating factor.

Male Perpetrators and Therapy

The issue of motivation is particularly problematic with male clients. The principles upon which therapy was developed (cooperation, reflection, connection, etc.) are usually not encouraged in male children to the degree that other qualities are emphasized (competition, independence, etc.). As a result the notion of therapy is often a foreign concept to many men. Therefore, it is necessary for many male clients to make a conceptual leap or a psychological adjustment in order best utilize the therapeutic processes. The early stages of therapy with men involve their learning the rules, or tricks of the trade as it were. Helping men see the value of therapy can be quite a formidable task for clinicians. At the same time, in order for clinicians to assist men in making use of the therapeutic process, professionals must understand male psychology and adapt therapeutic interventions accordingly to best fit with the male client.

Male clients often wonder how talking about their problems can bring about a change in their life situation. Many male clients are often looking for pragmatic answers to their problems. In order for them to see therapy as valuable, these clients must perceive that they have received something from the therapeutic encounter -- something practical or concrete. Typically, therapists initially attempt to raise the clients’ expectation that they will receive something for their efforts. For many female and some male clients, this expectation is sufficient for them to set aside their immediate needs in favor of something they may receive in the future. But for many male clients, particularly those referred by the criminal justice system, it is critically important that therapists not simply raise their client’s expectations but help them to feel that they are gaining a direct benefit from the session. This is particularly important in view of these clients' high drop-out rate. Typically, the first few sessions of counseling are focused on the therapist-collected information. For the client who may have a great deal of skepticism about unfamiliar methods of treatment, it is important to help him/her attain some type of meaningful gain right from the onset of counseling. Such gains may include behavioral interventions, providing structure or clarity during a crisis, and normalizing certain thoughts and feelings within a cultural context. In some cases, it may be appropriate to actually give a client something concrete, such as a book.

There is a large body of literature that has examined differences in male and female development. Men’s development can be described as one of separation rather than attachment. For many men, their childhoods were characterized in terms of detachment, self-sufficiency and independence. Problems were to be solved on their own, and asking for help was a sign of weakness. In addition, many perpetrators of violence experienced only abusive, exploitative, indifferent or unavailable caregivers in childhood. As a result, these clients view authority figures as questionable, at a minimum, or as downright dangerous in the extreme.

When we understand the incongruency between male psychological development and the principles of psychotherapy, it becomes very clear why so many court-mandated men may have difficulty with treatment programs developed by domestic violence advocates and clinicians. First, the majority of these programs require clients to admit that they are having a problem that they cannot solve alone. Also, many programs focus on dealing with anger and other feelings, and these emotional waters are often difficult for men to navigate. Many programs are also very intellectual (rather than practical) in their analysis of the causes of domestic violence. Lastly, programs using methods such as extreme confrontation may be causing the client to re-experience the power dynamics with abusive parents. These common characteristics in domestic violence programs for male batterers may be ultimately contributing to men’s reluctance to participate in therapy in the first place.

How can a therapist work with the realities of the male psyche so as to reduce resistance and to facilitate the therapeutic process? The male client’s resistance can be somewhat mitigated if the counselor utilizes empathy as the primary means of engaging the client, rather than focusing exclusively on responsibility and confrontation. Viewing the abuser as a wounded individual is a step in the right direction. In addition, the therapist needs to focus on the collaborative aspect of the therapeutic encounter, rather than promoting the mythology that the therapist holds the answers to the client’s problems --that the therapist is the authority. It is also important to explore with the client the meaning behind his behaviors and problems, rather than further promoting shame by focusing solely on the problematic aspects themselves. Therapists can take some of the charge out of these issues by exploring with the client his thoughts and feelings about admitting to having a problem in the first place, or about needing or even being forced to seek assistance from others. It is also imperative that the specific long-term treatment goals (above and beyond the three violence-related goals described in the treatment section of this workshop) are generated by the client and therapist together, and not by the therapist alone. Therapists can mitigate the amount of resistance to change, acting out, or uncooperative behavior in general by demonstrating greater sensitivity to their client's gender and cultural issues.

Motivation in Clients of Color

In addition to the gender issue, cross-cultural awareness is critical when working with male and female clients of color. Research in psychotherapy with ethnic minorities indicates that they show a significantly higher dropout rate than do Anglo or majority culture clients. Certainly, the lack of bilingual therapists and therapists of color contributes to the high dropout rate among clients of color. However, even if the client and therapist are matched with regard to ethnicity, it doesn’t guarantee that the therapist will work in a manner that is congruent with the client’s worldview. As with the issue of men and psychotherapy, therapists must think about how their particular therapeutic orientation must be adapted to meet the needs of the client. Many therapists get caught up in utilizing techniques that are consistent with EuroAmerican values or worldviews but that clash with other cultures or ethnic groups. For example: with Native American clients, counselors may need to allow for longer silences, or pose questions that guide and advance rather than strongly direct; with African-Americans, counselors might need to recognize the value of extended family kinship and the importance of nonverbal communication skills; with Asian-Americans, counselors may need to appreciate their strong family values of privacy and nondisclosure, their hierarchical family roles and the connection between emotional and physical problems; with Hispanic-Americans, the counselor may need to recognize the strong patriarchal family patterns, incorporation of spiritual practices, and the value of personalismo (personal greeting, handshaking, the use of first names and small talk) in developing rapport. Counselors should not be afraid to ask clients directly about their cultural values, but they should not use this questioning technique as a replacement for learning more about the specific ethnic groups through independent research.

In additional to the unique characteristics of specific ethnic groups, therapists conceptualize of their clients' problem can potentially influence how clients may view the therapy process. Those models that view domestic violence as simply a tactic for gaining power and control carry an undercurrent of client devaluation that may cause some clients to distrust the therapist and the therapy process in general. Some examples of cross-cultural conceptualizations are: an Asian-American male’s violence may be attributed to an imbalance in energy forces within the body, and therefore he may also require herbal or acupuncture treatments; domestic violence among Native American men may be conceived as a spiritual illness, and therefore the client may also need to visit a medicine person or another spiritual leader in the tribe.

The means for problem resolution can also be problematic if it is inconsistent with the client’s cultural, psychological or temperamental makeup. For the Native American man, one part of the treatment plan may include a “vision quest” or a series of “sweats” or “chants.” A Hispanic or African-American man may benefit from family therapy and advocacy services that address important social needs, which may be strongly contributing to stress and conflict at home. Or, an elder relative of an Asian-American male may be brought into treatment to help motivate him to deal with his problem with violence.

And lastly, if the stated goals of treatment are inconsistent with the client’s goals or worldview, then the client will find many reasons to avoid the therapeutic situation. This conflict is frequently experienced when the therapist pushes a client to separate or divorce his spouse. For many clients of color, a person’s identity is defined through the family and is not viewed as a separate entity, as it is common in EuroAmerican culture. Therefore, leaving a partner because of violence may not be as straightforward or obvious an alternative for the client as it may be for the treating therapist.

It is difficult to talk about different genders or cultures or ethnic groups without making some generalizations. However, it is important that therapists understand that not all client characteristics are necessarily attributed to gender, culture or ethnicity. Therefore, culturally competent therapists should know when to generalize and be inclusive, and when to individualize and be exclusive; they should know when not to stereotype while at the same time not ignoring important cultural qualities. How does one know when to generalize and when to individualize? This is a challenge that all therapists must face, and the answer may fall within the art rather than the science of psychotherapy. However, a step in the right direction would involve the therapist forming a “hypothesis” about the client, rather than arriving at a premature conclusion about the status of a client based on his/her particular culture or gender. Errors are more likely to occur when the therapist makes erroneous gender or culture-based assumptions about a client and then attempts to apply a theoretical model or intervention based on those assumptions. Instead, when working with clients of a different culture or gender, the therapist should develop working hypotheses, find creative ways to test them and then act based on that acquired information. In this way the therapist can begin to identify those issues more closely related to gender or culture and those issues more related to individual personality or psychopathology.

In general, therapists must have a good knowledge and understanding of their own worldviews as well as of those of their clients. Understanding the sociopolitical realities and influences in the daily lives of their clients must be balanced with an understanding of the psychology of trauma and personality development. Developing the ability to translate generic theories and interventions into gender and culturally relevant strategies is one of the greatest challenges to therapists working with this clinical population. These are but a few issues therapists must consider when working with male clients, clients of color or both. Counselors should become familiar with the growing body of literature on cross-cultural counseling and gender issues in psychotherapy.

Evaluating the Motivation of the Court-Mandated Client

In evaluating the court-mandated client, many therapists expect that the client will agree to participation in the program simply because it is better than going to jail, and not because he/she has a genuine desire to change. It is frequently written that most court-mandated clients are motivated by external pressures rather than by personal discomfort about their behavior. There is more than a kernel of truth in these expectations. However, motivation is not a black-or-white phenomenon. There are varying degrees to which clients are motivated to change their behaviors. Although many domestic violence clients may initially appear to be lacking a rudimentary desire to engage in psychotherapy, and may even come into an evaluation session with a hostile and oppositional attitude, such evidence should not by itself be sufficient to reject a candidate. Once clients settle into a session, perhaps after venting feeling about their situation, most will in some subtle or not-so-subtle ways, albeit reluctantly, acknowledge that their violence is a problem in need of changing -- if only for the purposes of pleasing the therapist or cooperating with the court. The challenge here is for therapists to help the client change the focus of motivation from external factors to internal ones. Don’t forget, this externalization -- seeking cause or attributing blame outside one self -- is a defense mechanism that many clients utilize to avoid discomfort or emotional vulnerability in their lives, and it is not just limited to problems with violence. This type of defense manifests in other areas of the client’s life as well. Therefore, for many clients, the idea of focusing directly on themselves and their psychological issues may be an extremely foreign concept and as a result may evoke uncomfortable feelings that may manifest in defensiveness or overt hostility. Even with openly hostile or otherwise uncooperative clients, their bravado may only be a defense against a sense of inferiority or defectiveness. Therapists must not be misled by these undesirable behaviors, but must look to the underlying psychological causes and respond with appropriate interventions.

Of course, even after successive therapeutic interventions, some perpetrators will continue to state adamantly that they have a right to be violent or that they have no desire to change. These individuals may not be good candidates for an outpatient treatment program. For these clients, inpatient treatment or incarceration may be necessary in order to make a dent in their defensiveness.

Theory aside, what types of concrete or observable behaviors may clinicians initially look at to form a hypothesis about the client’s degree of motivation? Below are a series of questions that may be used as an initial screening checklist:

1. Does this client attend the scheduled appointments?

2. Does this client complete the necessary paperwork?

3. Does this client cooperate (answer questions) during the clinical interview?

4. Does this client provide the counselor with necessary names for collateral contacts?

5. Does this client complete any assigned homework between assessment interviews?

6. Does this client verbally acknowledge responsibility for violence or express remorse?

7. Does this client verbally express a desire for counseling?

8. Does this client agree to cooperate with the final treatment plan?

9. Does this client continue perpetrating violence between assessment interviews?

10. Does this client provide relatively correct information as corroborated by other sources?

As mentioned earlier, motivation is a complex concept that is related to multiple variables. Not all indicators of a client's degree motivation are as easily measurable as those described above. Some indicators are interpersonally based in that they are more directly related to the dynamic that exists between the therapist and the client. Some clinicians may view motivation as related to clients' ability focus on themselves or their tolerance of self-reflection, versus primarily focusing on their partner, the courts, the police or the therapist. Therapists may also view motivation as indicated by clients' curiosity about their own behaviors or their ability to think psychologically; for example, how well are clients able to identify or allow themselves to feel their emotions, or step back and reflect on themselves? These more abstract questions, as well as the concrete ones described above, will help the clinician develop some working hypotheses about the client’s desire for change.

One advantage to smaller group counseling programs (as opposed to large education classes) is that over time clients who are experiencing ambivalence about working on their issues will begin to manifest defense patterns (withdrawal, externalizing, displacing, etc.) within the group or individual sessions. Therapists who observe these defense patterns occurring in session can address them clinically through the use of interpretation or confrontation. In large educational type programs clients can comply with the expectations of the program without addressing their psychological resistances to change.

Ultimately, time will tell whether or not the client has genuinely made the commitment to engage in the therapeutic process and work on his/her psychological issues. Clients who genuinely use the treatment process to improve their lives will report not only changes in themselves but also that others have noticed a change in their demeanor as well. These others will include their partner, family members and fellow group members.

Relapses

Although re-offenses will be discussed in greater detail later, it is important to mention how relapses in violence or aggressive acting-out relate to the issue of motivation. As mentioned above, continued acts of violence may be an indicator of low motivation. Likewise, the lack of violence may be an indicator of higher motivation. However, lack of violence may also be a sign of compliance, which is not the same as motivation because it is unlikely to sustain a person subsequent to treatment. One presupposition of the approach outlined in this workshop is that extremely motivated, well intentioned and hardworking (in the psychological sense) clients can have relapses. A psychological analysis of domestic violence must include the idea that the client will experience both progress and setbacks in the process of therapy. The idea that the client is in complete control of his/her behavior stems from the sociopolitical perspective that emphasizes power and control, self-will and accountability. If clients' behavior was completely under their own control, they really wouldn’t need therapy in the first place. Intervention would then be sufficient after clients decide they are no longer going to be violent. Therefore, relapses must be viewed as opportunities for the client and the therapist to deepen the work, achieve higher level coping skills, and/or refine the treatment goals or interventions. In this way treatment can be viewed as a process of both moving forward and moving backward, but with the net result of the client developing more sophisticated coping mechanisms to the vicissitudes life.

Motivation and Reports to Third Parties

It is obvious from this discussion that there is no single guaranteed method of assessing or even understanding client motivation for treatment. However, many probation departments or courts may require the therapist to assess or comment on the client’s degree of motivation. Therapists should exercise extreme caution when making written assessments about motivation because such reports can have dire consequences on their clients' lives. It is recommended that therapists be extremely clear about how they assess motivation for treatment, particularly when a client is refused admission due to lack of motivation. Perhaps a checklist such as the one above can be utilized to justify a rejection of admission into a particular treatment program.

Furthermore, it is suggested that even with clients who are admitted to the program, it should be stated that the client displays sufficient motivation to pass an admission threshold, but it remains to be seen if the client can sustain the necessary level of motivation to actually make use of the therapeutic interventions. It is recommended that evaluations be conducted periodically on a number of behavioral variables (see Client Evaluation Form in appendix) some of which may suggest degrees of motivation for change. In other words, the level of motivation it may take to bring a particular client into a program may not be a sufficient level to sustain his/her continued participation in that program three or six months down the line.

Many programs evaluate the client’s progress within the first eight to twelve weeks of treatment so that changes in the treatment plan can be implemented before the client is firmly entrenched in a negative pattern of engagement. For example, if by the end of the first evaluation period the client is still saying he/she does not have any problems with anger or violence, the therapist may want to address this issue clinically with the client. But if, after a specified period of time and a revision of the treatment plan or interventions, there is no change in this area and behavior change is not forthcoming, the therapist may want to reconsider whether or not the client is motivated for this particular treatment program or any program for that matter. It is suggested that therapists receive either professional or peer consultation when assessing these situations.

Determining Suitability

Determining suitability for the program relates to assessing who is likely to benefit from your program (given the realities of your program’s constraints) as well as determining special client needs that your program cannot provide for (therefore making collateral referrals necessary). Suitability issues include such factors as dangerousness, medication needs, psychoactive substances, developmental disabilities, language and culture issues, gender, types of violence perpetrated, transportation, and client work schedules. Suitability relates directly to the clinician's assessment of the client’s biological, psychological, family and social needs, and the development of a treatment plan that addresses each level of need. Many domestic violence clients have a variety of psychosocial needs that few providers can address completely. Therefore, collateral referrals will be necessary for many cases. Therapists should be well aware of the resources in their community in order to facilitate the referral process.

High Risk Cases

Once-a-week outpatient treatment is typically not sufficient for high-risk domestic violence cases. Other support measures need to be employed to reduce the risk for violent acting-out, and thereby promote the safety of family members as well as others. What is considered high risk? This issue is discussed in greater detail in this workshop in the section on dangerousness; however, high risk cases usually involve histories of lethal violence, histories of serious physical injuries, threats to kill, active and untreated psychoactive substance abuse/dependency, other active and untreated psychiatric disorders, and/or high psychosocial stress. It is unrealistic to minimally treat a client who has greater needs and expect that he/she will not re-offend during the course of treatment. In fact, that type of treatment planning is a setup for failure. With the court- mandated client the potential consequences are devastating, not to mention the psychological and economic effects on the victim and other family members.

Batterers with severe psychiatric disorders may require an evaluation for medication. Depression, anxiety, other affective disorders, post-traumatic stress disorder and psychoactive substance disorders are not uncommon in violent individuals. Some clients may even require a period of hospitalization in order effect stabilization. Many perpetrators with moderate to severe alcohol or drug problems will need inpatient or outpatient chemical dependency treatment either before or while receiving domestic violence treatment. Likewise, clients in need of medication for depression, anxiety or post-traumatic stress disorder may not be appropriate for a once-a-week domestic violence outpatient program until those conditions are well stabilized. Clinicians are encouraged to develop relationships with psychiatrists, chemical dependency treatment programs and psychiatric facilities prior to the need arising, so that referrals for medication evaluations, management, substance abuse treatment or hospitalizations may be easily facilitated.

In these types of domestic violence cases the dangerousness is not a static issue, but will depend on the client’s status with regard to his/her psychiatric impairment or psychoactive substance disorder. Life stresses may occur that interfere with the client’s ability to control impulses or make use of the therapeutic interventions. Hopefully, the high-risk cases will be identified at an early step in the assessment process. Nevertheless, there will be some perpetrators who appear to be good candidates upon assessment, but later on begin to deteriorate. Therefore, programs should have guidelines in place for handling cases where a client’s level of dangerousness changes. Counselors should seek peer or professional consultation in order to develop the most effective response to a client’s level of dangerous. In this way treatment decisions with high-risk cases are determined in concert with colleagues rather than by one person.

Other Special Treatment Issues

Not all suitability issues relate to psychiatric diagnosis or level of motivation. Some clients may have difficulty engaging in a particular treatment program for real, pragmatic reasons. Developing specific groups or services for monolingual non-English speaking clients, as well as services for individuals with moderate to severe learning, physical or developmental disabilities may be necessary in some communities. Likewise, some clients of a specific gender, ethnicity or sexual orientation may prefer to participate in a group or with a provider of a similar background. Although sometimes clients may utilize this preference in order to avoid treatment, participating in specialized groups will often be an extremely valuable experience for them. Therefore, if the demands are present, programs may consider the development of specialized groups or services for any of the above situations. Additionally, there are logistical issues such as work schedule, transportation issues and educational level that may affect the match between the client and a particular treatment program. Therefore therapists may need to develop a more comprehensive treatment plan for their clients with special needs. In addition, clinicians may find themselves in the position of advocating for their recommended plan to the probation department or the referring agency. The issue here is that mental health professionals must abide by their responsibility to treat the client in a manner that is consistent with the standard of care, and should not allow the State or referring agency to define how their treatment will be conducted.

Most outpatient batterer programs are designed for those clients who fall within the average range of abilities. These programs may not be sufficient, or may not be suitable at all, for the client whose functioning is either far below the average or far above. In general, the best client for once-a-week therapy tends to be the individual whose behaviors need immediate changing (but are not so dangerous as to put others at risk of being hurt), who is not suffering from a severe psychiatric disorder (including psychoactive substance disorders), who is of average intelligence, who is able to comfortably converse in the language of a group, and who is at least somewhat motivated to change. Clients who do not fit this mold will probably need some adjunctive services to address their unique biological, psychological, family or social concerns.

Assessment of Suitability Summary

Does this client have a history of lethal violence or of causing severe injuries to self or others?
Does this client evidence enough control over behavior to benefit from once-a- week counseling?
Does this person have a psychoactive substance abuse problem?
Does this person have a psychiatric problem placing him/her in need of medication or other treatment interventions?
Does this client have any learning, physical or developmental disabilities that may interfere with the educational component of the program?
Is this client in a state of severe psychosocial crisis?
Does this client have a history of treatment failures?
Does this client have a sexual orientation, ethnicity or gender that is different from the other clients in your group/program?
Does this client have transportation problems?
Does this person have the kind of work schedule that makes attending weekly sessions difficult?

If a client presenting for treatment can answer "yes" to any of the above questions, clinicians should consider: 1) whether or not this client is suitable for your program; 2) whether or not collateral referrals must be made for this client in addition to once-a-week domestic violence group treatment services; and 3) whether or not this client is ready for psychological treatment.

Required Reading

Psychology and Domestic: Violence Around the World