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InPsych 2015 | Vol 37

October | Issue 5

Cover feature : Domestic and family violence

Working with domestic violence: A clinician’s guide to ethical and competent practice

‘No-one can see you
No-one can hear you
If you escape, no-one will believe you.’

(referred to as the Torturer’s Boast by Kate Millet in Sexual Politics [1970])

Given the high prevalence of domestic violence in Australia, psychologists are likely to be working with clients who are living with violence at home, or have done so in the past. Most victims of domestic violence who present to a psychologist for help are women and children. They may present with symptoms such as depression, anxiety, insomnia, flashbacks, anger, guilt or exhaustion.

Sally is a young mother of two toddlers. She presents with anxiety and insomnia. She says she doesn't know why she feels tired all the time, says her husband is too busy at work to help with the kids but that he sets ‘high’ standards at home.

George and Sarah want couple counselling. George says that Sarah’s PMS is really bad, that she can’t manage the kids and has lost interest in sex. Sarah seems reluctant to say anything.

Ingrid comes to her session with bruising to her face. She says she bumped herself on the wardrobe. She wants help managing her two teenage boys who have been getting into trouble at school for bullying.

Any of these presentations may be indicative of domestic violence, and it is important that psychologists have the necessary competencies to assess and work safely and effectively with clients where domestic violence is an issue. This article provides a guide to assist psychologists to work ethically and competently in this area.

Core competencies for psychologists working in domestic violence

The core competencies required to work effectively with this client population include:

  • Ability to respectfully explore the client’s personal experience,
  • Assessment of risk, including understanding the evidence-based factors that indicate dangerousness,
  • Knowledge about the impact on victims and of trauma-informed work practices to achieve recovery, and
  • Understanding of the system in which victims find themselves, such as police and court processes.

Ability to respectfully explore the client’s personal experience

Unless a client is directly referred by a domestic violence service, it is likely that you will suspect domestic violence to be a factor rather than it being initially openly disclosed. In fact, many victims of domestic violence fail to disclose their situation to family, friends, work colleagues, and health professionals, including psychologists (Mitchell, 2011; NSW Health).

The context of a client’s life is always important, but especially in relation to domestic violence. Many clients do not regard non-physical violence as domestic violence even when it is making their life unbearable. Ask open questions that give clients a way to safely disclose, ensuring non-judgemental language and not rushing to problem-solve. For example:

  • ‘How are things at home?’
  • ‘How are you getting along with your partner?’

You might be able to link proffered symptoms to a question, as in the following examples:

  • ‘You seem quite anxious. How are things at home?’
  • ‘How does your partner react? Is your partner helpful when you are feeling like this?’

If there are indications of abuse, use an approach of naive curiosity to ask more direct questions, such as:

  • ‘Does your partner ever make you feel afraid?’
  • ‘Are you worried about your safety or your children’s safety?’
  • ‘What happens when …?’

Listening to and believing the client can be a moving and liberating experience for someone who is living with fear or with little personal autonomy. Two reactions are common when clients disclose and are heard – surprise that other women are experiencing what they are experiencing, and relief at being believed. Communicating belief is important in engendering hope and as a reality check. ‘That sounds very frightening for you’, for example. It is also helpful to endorse the decision to disclose, ‘I know this is very difficult to talk about, I am glad you did.’

It is also important to be clear that abuse, violence, humiliation, or threats are unacceptable. It is important to be explicit that violence and sexual abuse within a relationship are crimes, and that the responsibility for such crimes remains with the perpetrator, not the client. In naming abusive behaviours as such, use language that the client can relate to such as:

  • ‘No-one deserves to be treated this way’,
  • ‘Do you know that what you are describing is regarded as domestic violence?’

Above all, be aware of your own values and biases. Questions such as ‘Why have you stayed so long?’ or ‘What could you be doing differently?’ are unhelpful and imply shared responsibility for the abuse. A client’s sense of self and safety may be precarious or confused, so it is important they stay in control. Refer to a client’s sense of control by asking, for example, ‘ What would you like to deal with first?’ Clients who get respectful, skilled and informed support will make good decisions for themselves.

Assessment of risk, including understanding the evidence based factors that indicate dangerousness

The Victorian Common Risk Assessment Framework (CRAF) is a good evidence-based assessment tool for domestic violence (Department of Human Services, 2012). It is a straightforward model and has an inventory of evidence-based factors that indicate dangerousness.

The CRAF bases assessment of risk on three factors:

  • The victim’s assessment of risk/safety
    Using the client’s own assessment of risk has two key advantages. Victims of domestic violence know the perpetrator best and have a highly nuanced understanding of what is and is not safe. It also establishes the assessment as a collaborative process, supports disclosure and reinforces the client’s own wisdom and autonomy. Including the client’s assessment demonstrates a willingness to believe their experience and helps elicit the story. A psychologist’s ability to ask practical and useful questions will lead to a better understanding of any threats to the safety of the client and of any children involved.
  • Evidence-based indicators
    CRAF provides an Aide Memoire that lists evidence-based risk factors for domestic violence. These include:
    - Victim considerations, such as pregnancy, mental health issues and level of social isolation,
    - Perpetrator factors such as use of weapons and types of violence, and
    - Relationship factors including recent separation and financial problems. There are definite behaviours associated with the likelihood of future harm, such as choking, and practitioners should be aware of and alert to such indicators.
  • Professional judgement
    The professional judgement of the psychologist will rely on observation, weighing the significance of risk factors, the likelihood of risk re-occurring or escalating, and assessing the risk to children.

These tenets of assessment are equal in weight, and it is important to refer often to the client’s expertise in their own situation. Safety is always a priority. Be sure to speak to the client independent of their partner or children. Do not be afraid to ask if the client feels safe to return home or to attend the next appointment. Ask about the children and know how to alert authorities in a way that protects anyone at risk. You might need to plan with the client around future safety and ensure she has relevant emergency numbers.

Know and refer to specialist services for wider case support. Domestic Violence Resource Websites and smartphone Apps like Aurora, LiveFree and Daisy are very useful.

Knowledge about the impact on victims and trauma informed work to aid recovery

Use all the usual means to relieve symptoms and encourage hopefulness and positive behaviour change. There are many losses to grieve, including the loss of the future that should have been. Post-trauma symptoms are common, so use techniques that relieve symptoms and aid personal autonomy. Normalise, rather than pathologise symptoms and reactions. The guiding principal is to ask ‘What happened to (the client)?’, not ‘What is wrong with (the client)?’. Symptom relief is less likely while the client is still living with harassment or abuse.

Many women are diagnosed with psychological disorders after seeking help, which can be used as a weapon by their partners in court situations. Both individual and couple counselling practices can contribute to the pathologising of individuals by focussing on presenting psychological symptoms. Failure to contextualise violence can lead to misdiagnosis, victim-blaming and failure to recognise abuse.

The many manifestations of domestic violence are all likely to be psychologically harmful. Respectful interventions do not imply, explicitly or implicitly, that victims contribute to the violence or insist they leave a perpetrator. Respect victims’ autonomy – trust them to make decisions in their own time. Victims leave when and if they feel safe to do so, as leaving such a relationship can be lethally dangerous. Work from an understanding that using violence is a choice and that the victim is in no way responsible for that violence. Complaints and reports of abuse should on no account be minimised or the violence excused.

Understanding of the system in which victims find themselves, such as police and court processes

Domestic violence is a social malady, some say an epidemic. It is important for professionals to appreciate the impact of societal expectations and responses to this issue. A starting point would be a commitment to working within the APS Guidelines for working with women and girls (2012), such as recognising power imbalances in relationships and understanding gender role stereotyping.

The service system and legal system can disempower people. Perpetrators often use the legal system to further harass and abuse victims. Dangerous insistence on power and control is not always recognised in courts, for instance, most children killed by their fathers in recent years have been killed while on access visits. Past violence is not always seen for what we know it is – the best predictor of future violence.

Working with domestic violence is confronting and practitioners need sustaining self-care strategies in place as well as good supervision. Psychologists are in a unique position to support clients to find safety and recover from trauma and to help them to achieve better outcomes. It is challenging, complex, sensitive and sophisticated work – work that is not yet done.

The author can be contacted at psychrespect@optusnet.com.au

References

Disclaimer: Published in InPsych on October 2015. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.