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Counseling clients involved with violent intimate partners: the mental health counselor's role in promoting client safety.

Mental health counselors regularly counsel clients who are in intimate relationships with partners who are violent. There is a dearth of literature addressing safety-related considerations when counseling clients in relationships that involve intimate partner violence (IPV). The authors draw on the literature to address safety-related counseling considerations that can be applied when counseling these clients. This article provides information about how to accurately assess IPV, explores safety-related ethical issues that arise when counseling clients in IPV relationships, and explains the use of safety plans as a tool for promoting the safety of clients in IPV relationships.

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Intimate partner violence (IPV) is the term commonly used to encompass violence perpetrated by any relationship partner, not just a spouse (Campbell, 2004). At some point in their lifetimes, 34% of women are victims of IPV (Browne, 1993; Tjaden & Thoennes, 2000). People from all socioeconomic, age, and racial backgrounds can become victims (Browne, 1993).

Intimate partner violence has significant short- and long-term consequences. For instance, 30-55% of female homicides are perpetrated by intimate partners (Campbell, 2004; Nicolaidis et al., 2003), and IPV is the direct cause of 21% of female emergency room visits each year (Browne, 1993). IPV also affects children; it is estimated that 3.3 million children each year witness IPV, and many of these children experience enduring long-term impacts (American Psychological Association [APA], 1996).

The psychological consequences of IPV for victims include depression, anxiety, and suicide (Coker et al., 2002). Victims of IPV often develop such psychological problems as increased rates of post-traumatic stress disorder, depression symptoms, self-injury, anxiety, psychosomatic complaints, substance abuse, and lowered self-esteem (Bacchus, Mezey, & Bewley, 2003).

The increased risk of psychological problems associated with experiencing IPV increases the likelihood that victims will seek out counseling services. Because mental health counselors often encounter clients who are involved in violent relationships with intimate partners, their ability to facilitate the client's safety, and accurately assess the potential for further violence is "a required professional ability" (Elbogen, 2002, p. 591).

A review of the counseling literature reveals no discussion of the counselor's role in assessing and facilitating the safety of clients who are experiencing IPV. This article provides information related to safety-related ethical issues, accurate assessment of violence, and the use of safety plans to promote the safety of clients who are in IPV relationships. Because women are most at risk for IPV (U.S. Department of Justice, 2002), the main focus of the article will be on women as victims.

A lack of training on IPV might help explain counselors' inability to accurately identify and intervene when counseling clients who are in dangerous relationships (Walker, 2004). In a recent survey of 500 American Mental Health Counselors Association members, Bozorg-Omid (2007) found that 50% of those surveyed reported that they received no training in graduate school on the topic of IPV. Of the 50% of participants who did receive training, 78% reported that the training was inadequate. Therefore, it is important that increased discussion of this topic occurs within the professional literature and within counselor training programs. This article is an attempt to bridge this gap and contribute to the development of the literature base that might help educate counselors on issues associated with IPV and client safety.

RISK FACTORS FOR IPV

General Predictors of IPV

Certain perpetrator characteristics correlate with engaging in IPV. Controlling behaviors and jealousy in the context of intimate relationships are predictors of later IPV (Campbell et al., 2003; Glass, Koziol-McLain, Campbell, & Block, 2004). Related to these characteristics, individuals who have ideologies that focus on having power and control over women are at increased risk of perpetrating IPV (Glass, Koziol-McLain, Campbell, & Block, 2004). Mossman (1995) provided a profile of individuals who may be at risk of doing so. The characteristics included being male, being youthful, having low socioeconomic status, minimal educational attainment, the presence of violent role models, having an abuse history, loss of a parent, experiencing violence during adolescence, a culture that regards violence as an acceptable way to resolve conflicts, the availability of weapons, lower intelligence levels, neuropsychological impairments, substance abuse/dependence, and the presence of a psychotic disorder.

Predictors of Escalated Violence or Homicide

The most serious IPV-related risk is partner homicide. The risk of female homicide is heightened when, for whatever reason, there is an increase in the severity or frequency of abuse (Campbell, 2003; Glass, et al., 2004). Various risk factors that predict escalated IPV and homicide have been identified. According to Campbell et al. (2003), stalking, strangulation, forced sex, abuse during pregnancy, a pattern of escalating severity or frequency of physical violence, perpetrator suicidality, a perception of impending danger on the part of the victim, and concomitant child abuse are predictors of escalated IPV and homicide. If the violent partner has recently experienced life stressors, crises, or transitions, there is also increased risk of serious harm to the partner. In one study male partner unemployment was the most important demographic risk factor for female homicide (Campbell et al.).

Drug and alcohol use on the part of the violent partner has also been shown to heighten the woman's risk and is more likely to predict completed homicides (Campbell et al., 2003; Glass et al., 2004); violent partners who binge drink are especially at risk for murdering their partners (Campbell et al.). Similarly, Glass et al. found illicit drug use highly predictive of fatal IPV, and Block and colleagues (2000) found that women partners were especially vulnerable to life-threatening or fatal violence when the women were intoxicated at the time of the partner's assault.

Abuse during pregnancy has also been found to be a risk factor in female homicide; in one study of completed homicides, 23% of the murdered women had been abused during pregnancy (McFarlane, Campbell, Sharps, & Watson, 2002). McFarlane et al. found that abuse during pregnancy occurred in 4-8% of sampled women's pregnancies, and violence during pregnancy was more common than some other conditions for which health care professionals routinely screen. Due in part to a loss of mobility, abuse during pregnancy heightens the woman's risk of being murdered by a partner (Browne, 1993). The increased stress on couples during the life transitions that accompany pregnancy can also cause an escalation of IPV (Browne).

A victim's attempt to leave an abusive relationship can place her at especially high risk because attempts to leave abusive relationships can increase the risk of homicide (Campbell et al., 2003; Glass et al., 2004). Also, according to Campbell et al., women who separated from their abusive partners after a period of cohabitation experienced increased risk of homicide. Also, violent partners are significantly more likely to perpetrate homicide if their partner is leaving them for a different partner.

Gun ownership by the violent partner is also associated with female homicide (Glass et al., 2004). While federal law prohibits persons convicted of domestic violence assault from owning firearms, many violent partners may still have guns or gun access (Glass et al.).

A thorough assessment of the risk of violence includes an ability to accurately assess IPV. A thorough assessment also includes assessing for risk factors that may place the client at risk for homicide. Haggard-Grann (2007) reported that risk assessment should go beyond the basic prediction of whether partner violence will occur, suggesting instead that counselors attempt to elicit more specific information related to the prediction of IPV such as "what, when, where, and to whom" the violence might occur (p. 299).

To predict the possibility of escalated violence or homicide, mental health counselors need first to be able to accurately assess client IPV experiences, including the nature and extent of the IPV and the presence of risk factors.

ASSESSING VIOLENCE IN RELATIONSHIPS

The assessment of relationship violence begins with accurate detection of abuse (Kropp, 2004). It is important to ask all clients about past or current abuse-related experiences. However, many women are not routinely asked about relationship abuse experiences as part of the assessment process (Bacchus et al., 2003). Generally, clients should not be asked about potential abuse experiences in the presence of a partner because they may not feel free to disclose information for fear of later retaliation (Bacchus et al.).

The first step in completing a thorough assessment of relationship violence is to clearly communicate to clients how abuse and violence are defined (Lawson, 2003). Many clients do not recognize or identify their experiences as IPV and thus may have difficulty recognizing the signs that violence has occurred, or escalated violence may soon occur (Lawson). Once a client becomes aware of what behaviors constitute violence and abuse, she is in a better position to help the counselor accurately assess the violence, thus facilitating identification of appropriate interventions.

A thorough assessment of IPV should include assessment of the nature, duration, extent, and intensity of violent and abusive acts (Lawson, 2003). Inquiries related to the following areas can help the counselor better identify the nature of the abuse and the potential for increased violence: detailed description of a typical abuse experience, the most severe abuse experience, the most recent abuse experience, and the frequency of abuse (Lawson).

Although there are a variety of formal assessment measures that counselors can use to assess for IPV, screening checklists or assessments should never be part of a homework assignment because of the risk that may arise should the abusive partner have access to them. That is, if the abusive partner gained access to the assessment material, an acute escalation of violence could ensue.

The Index of Spouse Abuse (ISA; Hudson & McIntosh, 1981) is a 30-item self-report scale that measures both the degree of abuse and the potential for subsequent violence. The ISA also gives the client a description of types of violence--physical, emotional, and verbal. Scores on the instrument range from 0 to 100 for both physical and nonphysical violence. The instrument is brief; it can be completed in about five minutes. The ISA is one of the instruments most widely used to reliably screen for physical and psychological abuse (Samuelson & Campbell, 2005). In both the original sample and a follow-up study with African-American women, the coefficients of internal consistency reliability were over .90 (Campbell, Campbell, King, Parker, & Ryan, 1994). However, the instrument was found to have three subscales instead of the original two when factor analysis was used with the sample of African-American women. While there are questions about the scale's psychometric properties, it can be useful to help clients identify abusive behaviors and engage them in the counseling process.

Counselors may also benefit from the use of the Spousal Assault Risk Assessment Guide (SARA; Kropp, Hart, Webster, & Eaves, 1994). This instrument is used to identify individuals at risk of future IPV. The SARA is a 20-item checklist designed to measure risk factors for spousal assault; counselors make a rating of low, medium, or high risk. According to the authors, individuals who were rated as at high risk for spousal assault were found to be more likely to engage in IPV. The four main sections on the SARA rate criminal history, psychosocial adjustment, spousal assault history, and current offense. In a study of 2,681 offenders, Kropp and Hart (2000) found that the instrument significantly discriminated between offenders with and without a history of spousal violence, and between individuals who engaged or did not engage in later spousal violence. Similarly, Grann and Wedin (2002) found the instrument to have significant predictive validity, which increased with individuals who had committed more severe crimes. This instrument may have use as an educational tool by allowing the counselor to discuss with the client items on the scale that would increase the probability of future IPV.

There are a variety of additional assessment measures that counselors may use to assess for IPV and its impacts on victims, among them the Abuse Assessment Screen (AAS; Helton, McFarlane & Anderson, 1987), the Conflict Tactics Scale (CTS; Straus, 1979), the Danger Assessment (DA; Campbell, 1986), the Domestic Violence Survivor Assessment (DVSA; Dienemann, Campbell, Landenburger, & Curry, 2002), the Prenatal Psychosocial Profile (PPP; Curry, Burton, & Fields, 1998), Psychological Maltreatment of Women (PMW; Tolman, 1989), and the Trauma Symptoms Inventory (TSI; Briere, 1996). Like the ISA and the SARA, these scales can be used from a psychoeducational perspective to help the client identify abuse, understand the risk factors, and work with the counselor to develop safety strategies and plans.

Arrigo (2000) has provided suggestions for communicating assessment/risk assessment information to clients and recommends that counselors refrain from using absolute language--they should avoid telling clients that they are in a situation that will absolutely result in further IPV or death. Instead, they should clearly present information about factors that enhance the risk for IPV, help clients process the information, and ultimately empower them to make their own decisions about their future. Counselors should discuss why each risk factor is relevant and explain how the risk factors were combined to develop an assessment of risk (Grisso, 1998). A thorough assessment of risk that is appropriately conveyed to the client is an important element in promoting her safety.

ETHICAL ISSUES ASSOCIATED WITH COUNSELING CLIENTS IN VIOLENT RELATIONSHIPS

The American Counseling Association (ACA) and the American Mental Health Counselors Association (AMHCA) state that counselors have an obligation to promote the welfare of clients (ACA, 2005, Standard A. 1; AMHCA, 2000, Principle 1.A.1 ; Welfel, 2002). It is important that counselors thoroughly understand both their role and responsibility in promoting safety and how to assess and facilitate client safety. Counselors are encouraged to promote the autonomy and ability of clients to make their own choices. The concept of client autonomy--the idea that clients have inherent freedom and dignity--implies that clients are ultimately free to make their own personal welfare-related decisions (Welfel, 2002). A key component in the process, however, is that clients be aware of the abuse, the risk factors associated with its continuation and escalation, their options, and the ramifications of staying in the situation or leaving.

As this would imply, counselors are ethically obligated to manage and monitor their reactions to clients and to avoid actions that seek to meet their own personal needs at the expense of the client (ACA, 2005, Standard A.4; AMHCA, 2000, Principle 7.H.). Nonmaleficence--the do no harm principle--is a fundamental ethical principle that is highly relevant to counseling clients who are in abusive relationships (AMHCA, 2000, Principle 2.B.). Because women are at increased risk of abuse and homicide at the time they leave a relationship (Campbell et al., 2003; Glass et al., 2004), a counselor may inadvertently raise the risk by encouraging a client to leave a relationship before she has a clear safety plan and supports in place. Respecting client autonomy and interests (AMHCA, 2000, Principle 1.A.1) is binding in all situations except when it is in conflict with equal or greater duties, such as ensuring client safety (Welfel, 2002). Then the question becomes: how do counselors respect client autonomy and do no harm, while also facilitating client safety and welfare?

While it may be a difficult ethical choice, counselors working with clients in violent relationships should not suggest that clients leave the relationship. The counselor's main concern when working with clients in IPV relationships should be on promoting their safety. It is important for counselors to recognize that at the time a client leaves an IPV relationship, her risk of being stalked or murdered escalates (Jewkes, 2002). In fact, 33% of women who are murdered are killed by a former partner after a relationship has ended (Rennison, 2003). Thus some clients are safer in an IPV relationship until they are fully prepared to leave and have a thoughtful plan as to how they will move forward (Walker, 1994).

On average, women leave and return to an abusive relationship five to seven times before leaving permanently (Ferraro, 1997). Thus, even if counselor recommendations to leave an IPV relationship are met with initial compliance, there is a strong likelihood that the client will return to the relationship. The return may then isolate the client from the counselor; the client may blame the counselor for her having left the relationship, thus creating unproductive therapeutic tension.

Finally, professional counseling and its ethics codes are founded on a strength-based developmental model that emphasizes human resilience and empowerment (Kress, 2006). Thus it is important to appreciate that clients in IPV relationships are moving through a developmental process and are constantly assessing how they wish to proceed in managing these relationships. Also, consistent with a counselor's professional identity, clients should be empowered to make their own decisions related to proceeding in such relationships; to tell a client how to manage such relationships may disempower her.

Informed consent, confidentiality, and issues related to a client's children are additional ethical issues that should be considered in the context of client safety and IPV. Counselors need to obtain informed consent from their clients about the limitations to confidentiality (ACA, 2005, Standard B.1; AMHCA, Principle 3.A.). One limitation is the counselor's responsibility to prevent clear and imminent danger to the client or others (ACA, 2005, Standards A.9.c; AMHCA, Principle 3.C.). Certainly, it is important that counselors also be aware of the legal aspects of the duty to protect because there are differences by state (Welfel, 2002).

Partners who are violent toward significant others are at increased risk of being violent toward children (Tjaden & Thoennes, 2000). Therefore, women should be made aware of their own responsibility to protect their children and the counselor's responsibility to protect them if the children appear to be at risk of harm (Remley & Hurlihy, 2001; Waugh & Bonner, 2002). Counselors should be clear about the limitations of confidentiality if a client reports that children are involved when violent behavior occurs. There is a greater possibility that in these situations they may need to break confidentiality to protect the children.

Another legal and ethical counseling consideration when counseling victims in IPV relationships relates to notes and records. Walker (2004) stated that clients have a right to understand that the assessment process may yield information that can or will be made available to other people. The violent partner may obtain knowledge of the victim's participation in mental health counseling if the information is provided to an identifiable third party, such as private insurance companies or permanent health care records, and this could escalate violence (Walker). Clients and counselors should also understand the extent to which records or clinicians may be subpoenaed by the courts should the legal system become involved. Thus, counselors should be thoughtful in how they present information in client records.

Careful consideration of the ethical and legal issues is important in facilitating client safety. Because the ethical issues related to counseling women in IPV relationships can be complex, we suggest that counselors consult with others (e.g., supervisors, colleagues who regularly work with IPV situations, etc.) to ensure that their practice is ethical.

FACILITATING CLIENT SAFETY: SAFETY PLANS

Once IPV has been established, and ethics-related issues have been considered, one of the most important actions a counselor can take to minimize risk and facilitate client safety is to help the client draft a safety plan (Lawson, 2003; Walker, 1994). This section discusses use of safety plans and general counseling considerations related to facilitating client safety.

A client in a violent relationship should not leave the counselor's office without having a comprehensive safety plan (Lawson, 2003). The initial counseling session may be the only one in which the counselor can help protect the client from future harm; the client may not be able or may choose not to return to counseling. Thus, it is critically important to emphasize safety and develop a safety plan in the first session.

A safety plan is a detailed plan that highlights the woman's role in making the safest decisions possible while in a violent relationship. The safety plan allows the woman to prepare in advance for managing such situations. It should be emphasized to the client that although she does not have control over her partner's violent behavior, she does have a choice in how to respond and how best to get herself and her children to safety. The safety plan should be tailored to the individual's unique needs (e.g., a client who does not live with the violent partner will have different safety considerations than one who lives with the perpetrator). The following are important aspects of safety plans (Lawson, 2003):

* keeping a purse and car keys in a place that is easy to access for quick escape

* deciding where she will go the next time she needs to leave the house or go somewhere safe (there should be a back-up safe place as well)

* telling friends or neighbors about the violence and requesting that they call the police if they hear suspicious noises or witness suspicious events

* identifying the safest rooms in the house, school, etc., where she can go if she fears an argument will develop (i.e., the lowest-risk places)

* storing an escape kit (e.g., a copy of a protection order, extra keys, money, checks, important phone numbers, medications, social security cards, bank documents, birth certificates, change of clothes, bank and house information, address book, school and vaccination records, and valuables) somewhere safe (preferably not in the house)

* processing the safety plan with children when appropriate

* identifying individuals to call in a crisis and safe places to go when leaving (e.g., domestic violence crisis shelters)

* identifying and practicing escape routes and rooms that are safe and not close to weapons (e.g., what doors, windows, elevators, stairwells, or fire escapes would you use?)

* identifying safe places to go when leaving.

In relation to the safety plan, areas of discussion might be exploration of issues related to police protection, legal action, domestic violence shelters, community resources, and social supports (Browne, 1993). Counselors should become familiar with both the state laws that relate to IPV and local resources that may be helpful to clients.

It is also important to discuss the client trusting her intuition and judgment. Many women who are murdered by their partners had previously reported to others that they believed the partner would eventually seriously harm or kill them (Campbell et al., 2003). Moreover, many victims who are experiencing IPV have an excellent understanding of their partner's abuse patterns and sense when more serious harm is a possibility. Encouraging clients to trust their instincts and to do what they can to de-escalate the situation may be helpful in promoting client safety and should be discussed in relation to the safety plan.

CONCLUSIONS

This article has presented information about promoting the safety of clients in IPV relationships. It highlighted the counselor's responsibility to assess for and address IPV and emphasized the counselor's role in educating clients about IPV and the potential for continued risk of violence and escalated violence.

Counselors should be aware of the ethical issues associated with promoting safety and times when reporting may be mandated, as when children are endangered. Counselors should also monitor their countertransferance reactions and not pressure clients to leave IPV relationships; while it can be personally frustrating when a client chooses to stay in an abusive relationship, the counselor must support her decision to stay or leave the relationship. The main concern of counselors working with clients in IPV relationships should be promoting their safety.

Counselors can be helpful in empowering clients to deliberately plan how they want to proceed in managing IPV relationships; clients can determine how they will choose to address the threat of violence. One of the most useful tools counselors can apply in promoting client safety is a detailed safety plan--a concrete plan that can help prepare clients to manage relationship violence.

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Victoria Kress, Jake Protivnak, and Lauren Sadlak are affiliated with the Department of Counseling and Special Education at Youngstown State University. Correspondence concerning this article should be addressed to Victoria E. Kress, Beeghley Hall. Department of Counseling and Special Education, Youngstown State University, Youngstown. OH 44555. E-mail: vewhite@ysu.edu.
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Author:Kress, Victoria E.; Protivnak, Jake J.; Sadlak, Lauren
Publication:Journal of Mental Health Counseling
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Date:Jul 1, 2008
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