Conducting effective family therapy is never a one-size-fits-all proposition. In our work with families, we must keep in mind that, just as the dynamics in each family are different, so, too, must be our approaches. This is particularly the case for people who are experiencing intimate partner violence, or IPV.
The cases of three patients described below illustrate that point well; I've changed the patients' names to protect their anonymity.
She is a hardworking immigrant making minimum wage as a housekeeper. She presents to her psychiatric outpatient appointment with complaints of being sad and anxious. When asked about her husband and their relationship, she says tentatively that they disagree about things. She doesn't acknowledge any abuse until she is asked directly, then she hangs her head down and looks ashamed. "He tells me I am not a good wife." With encouragement, she admits that she would like to leave him but has nowhere to go and is afraid that he will really hurt her if she tries to leave. "I tried before, and he threatened to kill me if I tried again."
She is a well-educated woman working as a writer and has a good income. She presents to her psychiatric outpatient appointment with complaints of being sad and anxious. When asked about her husband and their relationship, she says that he is abusive to her. She states that she would like to come into therapy to figure out why she has not been able to leave him. "What ties me to him?" She says her friends tell her she should leave. "There must be a reason I stay; can you help me figure it out?"
She is a successful saleswoman and comes into the office with the complaint that she and her husband are having problems. On direct questioning, she affirms that the two do engage in direct fighting that gets physical at times. She says she often initiates the violence. She wants to stay with her husband and says they both want to make a go of things. They want to come into couples therapy and work on improving their relationship. But they fear that if they do go to a therapist together, as soon as she says there is violence in their relationship, she will be refused treatment.
Different cases, approaches
Belkis benefits from treatment that focuses on support, education about domestic violence, and help with developing a safety plan (see sidebar). She wants to leave but needs the help and structure to do so.
Melanie enters individual therapy, and comes to understand that in her relationship with her husband, she is reenacting the relationship she had with her parents. As a child, she felt like she was there only to help her mother dean and care for her siblings and that her needs and desires did not matter.
She felt that her elder brother was the favorite and that she had to support him as he pursued his studies. In her current relationship, she strives to matter as a person and not be seen as someone to do the cooking and the chores. When she understands that the dynamic that binds her to her husband is the same dynamic that she experienced growing up, she feels relieved.
Zelda and her husband want couples therapy. Both are committed to stopping the violence as well as learning how to solve problems, communicate better, and meet each other's needs by asking and negotiating. Before entering couples therapy, they agree to stop any violence while in treatment. The therapist teaches them skills to "take a time out" when conflict arises. As I've written previously, if patients are unable to discuss the issue calmly, they bring it to therapy (Adv. …