Merging Psychiatry and Psychotherapy to Better Serve Patients Facing Domestic Violence

In his Evolution of Psychotherapy 2022 session “Domestic Violence: Ways to Reduce Interpersonal Violence,” Donald Meichenbaum, PhD, research director at the Melissa Institute for Violence Prevention, examines how relationship violence can escalate over time, how to implement safety plans with clients, and why a “team approach” is best. For clinicians and psychotherapists alike, Dr Meichenbaum says it's important to understand the sequence of relationship violence, prioritize safety of patients while being mindful of the presence of any kind of co-occurring disorders or comorbidities, and always practice empathy and advocacy. 

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Donald Meichenbaum, PhD, is currently research director of the Melissa Institute for Violence Prevention in Miami, Florida. (melissainstitute.org). He is one of the founders of cognitive behavior therapy. He was voted one of the most influential psychotherapists of the 20th century. His latest books include Roadmap to Resilience (roadmaptoresilience.com) and Evolution of Cognitive Behavior Therapy: A Personal and Professional Journey.

Read the Transcript: 

Thank you for the invitation to present. My name is Don Meichenbaum. I'm a clinical psychologist and I'm actually presenting from Buffalo, New York, where I reside. For 45 years, I was a researcher at the University of Waterloo in Ontario, Canada, and took early retirement, and became research director of the Melissa Institute for Violence Prevention in Miami, Florida. So, the topic of intimate partner violence, how to assess it and how to treat victims of violence, is a topic that I've been heavily involved in, so I welcome this opportunity to share our experiences.

What inspired your interest in domestic violence research and prevention? 

Well, for someone who has been developing cognitive behavior therapies to help victims as well as perpetrators, this has been a longstanding issue for me. And, if you consider the epidemiology of approximately 2 million women in the United States as well as around the world being victims of domestic violence and the accompanying family violence, this has been a topic that I've been heavily involved in. My major focus is also not only on victimization, but I've also written a book on resilience and how people, in spite of these kinds of traumatic events, are able to bounce back and deal with ongoing adversities.

During your session, you discussed the process in which individuals progress from being angry to becoming violent. Why is this process important to be aware of? How can clinicians better monitor this process in patients?

One of the things we know about aggressive behavior is that it's relatively stable over one's lifetime. In fact, the stability of aggressive behavior is comparable to the stability of a person's IQ, and therefore this becomes a practical issue in terms of ways in which we could identify high-risk individuals to begin with, and in fact, I'm in the midst of writing a book about how women can make smart choices that are safe when picking a partner. So, how can they assess the violence potential of prospective partners? Therefore, that's an important kind of concern, and then we need to understand, how do people get from being angry to aggressive? It turns out that people who are perpetrated as anger usually have some kind of provocation, some kind of trigger, and that they view as a threat. In order to get from anger to aggressive behaviors, individuals need the accompanying attribution of intentionality. They really need to think about that this person did whatever happened on purpose.

Moreover, there are a variety of other cognitive emotional components that contribute to this kind of process. A person's emotionality sort of derived from [inaudible 00:04:13] and hippocampus, actually they hijack their frontal lobe, the kind of executive processes. They tend to demean the individual. There are different kinds of aggressive behavior and different types of perpetrators that I can comment on. The real question is, how can this audience of psychiatrists and therapists be of most help? I think it's really important for we as therapists to systematically assess for the potential violence. For example, I see couples who are in marital distress in therapy, and it's a mandate for me to examine both individually with each of the partners as well as them together about whether in fact there has been any violence. I need to ask questions about the nature of their relationship, whether in fact any kinds of arguments have escalated.

It turns out that the individuals who are perpetrators often begin that relationship with what is called love bombing, and then they sort are able to establish some kind of relationship with their partner, but that soon extends into issues of power and control, isolation, jealousy and the like. So, it behooves us as therapists to understand the sequence and nature of the relationship. For instance, in 40% of the cases of high school dating, there is some form of violence. So, the key question is, are the clients that I see, both men and women, safe? In fact, one of the things that's important to know is that the incidence of intimate partner violence is comparable in gay and lesbian couples as it is in heterosexual, so it doesn't only have to do with gender, it has to do with the issues of power and control. I hope that gives you a feel for the sequence by which individuals move from anger to aggressive behavior.

Well, actually you could predict violence all the way from childhood to high school ages, and then it becomes a predictor of the kind of aggressive behavior. So, in our present efforts to assess the violence potential of a prospective partner, it would be valuable for a therapist to get the sequence of the relationship with it, to see the degree to which the partners felt safe with each other. Did they ever feel threatened or were they ever forced to do something against their will? And then the other kind of issue is if in fact they're at risk, perceive themselves at risk, what can we as therapists do to help them increase the likelihood of safety? I need to underscore that we need to be remarkably sensitive to cultural and racial differences, that the issue of how we intervene has to be culturally sensitive in the kinds of questions we ask.

This may have some important implications for any kind of safety planning that I as a therapist need to do with my clients. The clients are not helpless, these women and men who are victims. They are actually resourceful in protecting themselves and their children. Of the 2 million women who are victimized in the United States, for instance, something of the order of half of them have children who have witnessed that violence. And as I noted, 40% of the instances of when you have intimate partner violence, there's also family violence. There are certain kinds of predictors, or one for instance is the use of alcohol. Alcohol and substance abuse often go along with this kind of intimate partner violence. So, we as therapists need to be sensitive not only to the safety of our clients, but also the presence of any kind of co-occurring disorders or comorbidity.

How can psychiatrists collaborate more closely with psychotherapists when treating patients dealing with domestic violence at home?

Well, I think that a team approach is really important. In fact, we as therapists need to see the degree to which we can act as citizens of the world, not only as therapists, if we're going to address the issue, the remarkable issue of violence, especially violence towards women, and now the increasing violence towards particular minority populations, then some of these levels of interventions have to be at the societal level. In fact, there are more animal shelters in the United States than there are domestic shelters. How we can systematically assess for violence on a regular basis for the clients that we see, the degree to which we could be culturally sensitive in that assessment, the way in which we could help our clients have a safety plan, one of the things we need to know is that when women are in the midst of separating, that's when they are most high-risk for violence.

So, some women may decide to stay in the relationship because of safety. They're concerned that various kinds of court proceedings and like aren't going to be sufficiently protective, that they're going to a shelter with their children and family will not stigmatize them, that there will be supports. So, I guess the major kind of message is not only do we have to be therapists, we have to be advocates for the clients that we see in order to ensure and increase the likelihood of their safety. We have to be advocates with society to provide the kinds of resources and the kind of protective features. Some of us may be involved with police training in terms of how they respond to domestic violence episodes. So, our mission must be broader than just helping the client who's sitting before us.

What final takeaways do you want to leave our audience with?

Well, the degree to which we as therapists need to be nonjudgmental, that we need to have accurate empathy, we got to keep in mind that the quality and nature of the therapeutic alliance that we have with clients, whether they're victims or not, is three to four times more important than any specific intervention we use. We need to monitor on a regular basis, session by session, using some kind of feedback-informed assessment about whether that therapeutic alliance is really working, if in fact the patients we see feel that they're heard and respected, that we've developed a trusting relationship and that they feel comfortable in doing these kinds of issues. We can do therapy on an individual basis, group basis, and under certain circumstances, even when there is violence, and there's research to indicate that under the right circumstances, you could even do it with couples. Conveying your compassion, your accurate empathy, if you do that and get feedback on a session by session basis, you're doing your job well.