Unit 5

Ethical Considerations for Clinicians Treating Victims and Perpetrators of Intimate Partner Violence

Kristin D. McLaughlin

Department of Psychological Sciences University of Missouri, Columbia

Intimate partner violence (IPV), a subcategory of domestic abuse, is a prevalent national health concern that many clinicians will face during their careers. It is important that clinicians become aware of the numerous ethical considerations that are relevant to this population. The existing literature has not yet examined the ethical issues faced by clinicians working with IPV clients through the lens of the most recent American Psychological Association ethics code. This article provides a brief overview of the historical context and the current state of the literature pertaining to IPV. Then it examines the unique ethical challenges associated with the treatment of IPV clients through the American Psychological Association ethics code. Recommendations are provided throughout this article to help clinicians make ethical decisions, maximize the benefits their clients receive from therapy, and minimize violence risk.

Keywords: intimate partner violence, IPV, ethics, treatment

Although intimate partner violence (IPV) has recently figured prominently in the media spotlight because of scandals within the National Football League, IPV has been a prevalent health concern for decades. Specifically, IPV refers to the abuse of one partner by another in a relationship, regardless of marital status. IPV represents a subcategory of domestic violence, in which the term domestic violence also encompasses violence toward other members of the household, including children or elders, whereas IPV focuses specifically on the members of an intimate relationship dyad (World Health Organization, 2012). Historically, it was considered acceptable in the United States for a husband to physically abuse his wife, as evidenced by court rulings such as in the Mississippi case of Bradley v. The State (1818), which concluded that men could beat their wives in the name of “moderate chastisement” so long as they use a rod no bigger than their thumb (Buzawa & Buzawa, 2003). IPV became a criminal offense in the United States in the 1970s (Erez, 2002). Batterer intervention programs were developed and implemented in the late 1970s to meet the demand for treatment for IPV perpetrators (Rothman, Butchart, & Cerdá, 2003). As IPV awareness increased through efforts of the feminist movement

Correspondence should be addressed to Kristin D. McLaughlin, Department of Psychological Sciences, 219 Psychology Building, University of Missouri, Columbia, Columbia, MO 65201. E-mail: [email protected]

ETHICS & BEHAVIOR, 27(1), 43–52

Copyright © 2017 Taylor & Francis Group, LLC

ISSN: 1050-8422 print / 1532-7019 online

DOI: 10.1080/10508422.2016.1185012

and the criminal justice system’s interventions, mental health professionals began to see more and more men, women, and couples in therapy for help with violence in their relationships.

Clinicians may encounter numerous ethical challenges while working with IPV clients. The challenges presented by IPV clients vary greatly depending on multiple factors, such as whether the client is a victim or a perpetrator, whether the treatment is individual or for couples, and whether the client is court-mandated into treatment. It would behoove clinicians to prepare themselves for these challenges by having a comprehensive understanding of the many possible ethical issues that could come up with this type of client. Therefore, follow- ing a brief introduction to the current state of the IPV literature, the ethical challenges associated with treating IPV clients are then addressed through the lens of the American Psychological Association (APA; 2010) Ethical Principles of Psychologists and Code of Conduct, herein referred to as the ethics code.

UNDERSTANDING IPV

Although IPV is typically thought of as physical abuse, it also encompasses emotional, sexual, psychological, and economic abuse, as well as stalking (APA, 2002). Approximately 35.6% of women and 28.5% of men in the United States have experienced rape, physical violence, and/or stalking by intimate partners in their lifetimes (Black et al., 2011). Emotional abuse by intimate partners occurs more commonly, such that nearly half of the men and women in the United States report having experienced it (Black et al., 2011). These prevalence rates vary across ethnic groups, with high rates of IPV occurring among African American and Native American populations (Black et al., 2011). IPV often occurs bidir- ectionally, though physical violence perpetrated by women is typically less severe. IPV occurs across all age groups, with the highest period of risk occurring in adolescence and young adulthood.

Many victims experience negative health consequences, such as unwanted pregnancy, chronic stress, depression, and posttraumatic stress disorder (Campbell, 2002). Homicide, the most extreme outcome of IPV, is unfortunately not uncommon: Nearly 57% of female homicides and 74% of all murder-suicides are committed by intimate partners (Stenzel, 2001; Violence Policy Center, 2008). Risk factors for IPV include low socioeconomic status, general relationship conflict, violence in the family of origin, and heavy alcohol consump- tion (Jewkes, 2002; Kwong, Bartholomew, Henderson, & Trinke, 2003).

Various factors maintain IPV and make it extremely difficult for victims to leave their abusive partners. Fear of retribution, insufficient economic resources, and love for their partners are often cited as reasons why victims stay in abusive relationships (World Health Organization, 2012). For women who have children with their partners, the fear of losing custody of their children or of their children being harmed constitutes a serious concern (World Health Organization, 2012). Perpetrators of IPV often exhibit a “cycle of violence” that progresses through tension building until the battering episode, followed by a temporary reprieve from violence during the “honeymoon phase” before the cycle begins again (Walker, 2009). During the honeymoon phase, victims of IPV may become convinced that their partner did not mean to harm them or that their partner will change, thus allowing the cycle to perpetuate itself.

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THE APA ETHICS CODE AND IPV

Various articles have taken an ethical perspective on the treatment of IPV clients, though none have examined this issue via the ethics code (Bourne, 1995; Ryan, 1995). Given the prevalence of IPV and its impact on mental health, it is not unreasonable to assume that most clinicians will work with clients affected by IPV at some point in their careers. To make ethically informed decisions when treating IPV clients, a thorough understanding of the ethics code as it pertains to issues relevant to IPV clients is necessary. Therefore, this article endeavors to contribute to the existing literature by providing an examination of common ethical issues that clinicians with IPV clients, whether the victims or the perpetrators, may expect to face during treatment.

The General Principles

The ethics code puts forth five principles that are intended to serve as aspirational goals for clinicians, three of which are directly relevant when working with IPV clients. Principle A: Beneficence and Nonmaleficence encourages psychologists to “strive to benefit those with whom they work and take care to do no harm.” Clinicians regularly have to determine how to maximize benefit and minimize harm when working with IPV clients. With this population, maximizing benefit and minimizing harm may often put the clinician in a Catch-22 situation. For example, helping the victim escape his or her abusive relationship may seem like the best way to minimize harm. However, leaving the relationship may significantly increase the victim’s immediate risk as his or her abuser might retaliate violently. On the other hand, the victim may want the clinician’s help figuring out a way to stay in the abusive relationship. If the clinician helps the victim stay in a violent relationship, the clinician could actually encourage risking further harm to the victim. The clinician, in collaboration with the client, will need to weigh these risks throughout therapy.

When treating IPV clients, it may prove difficult for clinicians to reconcile the demands of Principle A with those of Principle E: Respect for People’s Rights and Dignity. Principle E recognizes that clients have the right to self-determination, and by extension that victims of IPV have the right to choose to stay with their abuser. In some situations this might prove difficult for a well-meaning clinician to accept. Clinicians may believe that in order to do no harm (Principle A) they must report the victim’s partner to the police. Legally, in states where such a report would not be mandated by law, the clinician will be violating the victim’s rights to self-determination (Principle E) and confidentiality, possibly even leading to serious harm to the victim if his or her partner retaliates violently (and ultimately violating Principle A).

For some clinicians, treating IPV clients may prove particularly difficult due in part to their personal biases against these individuals or these actions. If a clinician were to allow their biases to prevent them from providing fair treatment to IPV clients, they would not be aspiring to Principle D: Justice. Principle D states that psychologists “recognize that fairness and justice entitle all persons to access and benefit from the contributions of psychology” and that psychologists must “take precautions to ensure that their potential biases … do not lead to or condone unjust practices.” Clinicians should evaluate their personal feelings toward victims and perpetrators of IPV before working with them. If the clinician feels significantly biased toward this population, he or she may consider reviewing the literature relevant to how and why IPV occurs in order to get a more nuanced understand of the people who experience IPV. Consulting

ETHICAL CONSIDERATIONS INTIMATE PARTNER VIOLENCE 45

with a knowledgeable colleague or seeking supervision are other ways clinicians can reevaluate their personal biases and perhaps come to a more helpful understanding of IPV clients. The clinician may also choose not to treat clients who are dealing with IPV, preferring instead to refer them to treatment elsewhere.

Confidentiality and Its Limits

Confidentiality is key for ensuring the trust and safety of IPV clients. The importance of confidentiality is evidenced by Standard 4.01: Maintaining Confidentiality, which states that “psychologists have a primary obligation … to protect confidential information.” Indeed, reporting IPV could prove harmful to clients who are victims, such that it may raise the risk of retaliation, discourage treatment seeking, or even put the victim’s life in danger (Hyman, Schillinger, & Lo, 1995). For perpetrators on probation or in mandated treatment, reporting IPV could mean that the client will be removed from treatment and sent to prison for violating his or her probation.

Despite the importance of confidentiality and the risks of reporting, there are various instances in which the clinician must break confidentiality in order to protect the client or others from significant harm. Standard 4.05: Disclosures states that “psychologists disclose confidential information without the consent of the individual only as mandated by law or where permitted by law for a valid purpose such as to … protect the client/patient, psychologist, and others from harm.” Three instances are covered here and are particularly relevant to IPV clients, requiring the clinician to disclose confidential information: Tarasoff situations, risk of suicide, and child abuse.

Tarasoff and Violent Clients

In 1976, the Tarasoff v. Regents of the University of California ruling established the “Duty to Protect,” which charged psychologists with the responsibility of protecting potential victims from violent clients. Since that landmark case, many states have established their own versions of duty to protect laws, which vary from mandatory to permissive laws. Duty to protect laws also vary in terms of their requirements, such as whether the potential victim can be identified, how imminent the threat of harm is, and how life-threatening the potential harm might be. Remaining familiar with relevant state laws is necessary for determining how to manage a client who has the potential to become violent.

The first step for determining if a client seems at risk for a Tarasoff situation is to do a thorough evaluation of violence history and current violence risk. It is often the case that IPV perpetrators will be court ordered into a batterer intervention program, where violence risk assessments and limited confidentiality are normal aspects of the program and the clinicians who run them specialize in the assessment and treatment of IPV (Rosenbaum & Dowd, 2009). However, some perpetrators do voluntarily enter treatment with nonspecialists for related concerns, such as substance abuse or marital discord, and may not disclose IPV until a strong alliance has been established (Rosenbaum & Dowd, 2009). It may also be the case that nonspecialists do not regularly assess IPV during their normal intake procedures, which may cause violent clients to go undetected. Specialist or not, clinicians must remain vigilant in their identification and assessment of IPV. Therefore, clinicians should routinely inquire about IPV

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during their initial intakes and regularly afterward. Numerous self-report measures have been developed for use in individual and couple’s therapies that can help clinicians identify IPV (for a comprehensive review of these measures, please refer to Aldarondo & Straus, 1994, and Rosenbaum & Dowd, 2009).

Identifying past IPV is often not significant to trigger a mandated report, though the clinician will need to be familiar with relevant state laws in order to be certain. Following the identifica- tion of a violent client, the clinician will need to remain alert to potential future violence. The clinician may be faced with a Tarasoff-type situation when working with IPV clients if his or her client threatens to seriously harm their partner during a session. Once a threat has been made, the clinician has a responsibility to determine if there is reasonable concern that the client may go through with the threat. This will involve a thorough in situ assessment of violence risk, including clients’ level of intent, their ability to carry out the threat, and their attitudes toward causing harm to their intended victim (Borum & Reddy, 2001). If the clinician finds that there is reasonable cause to be concerned about violence, the clinician will have to consider possible courses of action that will prevent harm from coming to the intended victim, such as contacting the partner or the police, hospitalizing the client, or using a clinical intervention (Borum & Reddy, 2001).

Suicide Risk

Similar to violence against others, suicide risk is another reason why clinicians may have to break confidentiality. Victims of IPV are at an elevated risk for suicide, and for many of them suicide may seem like their only option for escaping their abuser (Clay, 2014; Jewkes, 2002). If necessary, the clinician will have to disclose confidential information in order to protect the client from harming him- or herself, such as involuntarily hospitalizing the client. Screening for suicidality during an initial intake will help with the early identification of suicide risk, thereby enabling the clinician to target and hopefully reduce that risk early on in treatment. Clinicians should remain aware of the numerous additional factors that increase suicide risk, such as current psychopathology and suicidal ideation; past suicide attempts; and demographic factors like age, sex, and employment status (Pope & Vasquez, 2010). Knowing the additional risk factors will help clinicians conceptualize their clients’ unique risk in terms of what is already known about who is at most risk for committing suicide.

Clinicians should also familiarize themselves with how to sensitively assess suicidality. For example, the clinician will need to ask direct questions about ideation, intent, plan, and means to commit suicide during a crisis interview (Toth, Schwartz, & Kurka, 2007). Numerous resources exist to help clinicians assess suicidality and manage risk when working with suicidal clients (e.g., Bongar & Stolberg, 2009; Toth et al., 2007). Doing a comprehensive assessment is paramount when try to determine if the client poses a suicide risk significant enough to warrant the disclosure of confidential information without the client’s consent.

Child Abuse

Although the focus of therapy might be the violence between two adult partners, IPV also often co-occurs with child abuse. Studies have found that nearly 40% of families with IPV will have co-occurring child abuse and that the child abuse may be perpetrated by the IPV

ETHICAL CONSIDERATIONS INTIMATE PARTNER VIOLENCE 47

perpetrator, the IPV victim, or both (Appel & Holden, 1998; Smith Slep & O’Leary, 2005). Clinicians need to remain aware of this risk and prepared to make a report if necessary when working with IPV clients who have children. Another important consideration is that some states consider exposing a child to IPV to be the equivalent of emotional abuse and neglect, requiring a report to be filed by the clinician (Rosenbaum & Dowd, 2009). Reporting child exposure to IPV may result in significant harm, such as the child being removed from his or her parents, further victimization of the IPV victim, and possible loss of probation privileges (Rosenbaum & Dowd, 2009). Therefore, it is important that clinicians consider all possible courses of action and the relevant legal constraints with the overarching goal of minimizing harm.

Discussing the limits to confidentiality (Standard 4.02) is an integral and critical aspect of providing informed consent (Standard 3.10 and Standard 10.01). By explaining the limits to the client’s confidentiality at the outset of therapy, and as needed during the course of treatment, the client will be able to proceed through therapy in an informed way and will be able to make informed decisions about when to disclose certain information to the clinician. Where possible, the clinician should attempt to get the client’s consent to make a disclosure, as this will also allow the client his or her right to self-determination and demonstrate the clinician’s respect for that right (Behnke, 2007).

Avoiding Harm

Standard 3.04: Avoiding Harm is closely tied to Principle A and charges clinicians to “take reasonable steps to avoid harming their clients/patients … and minimize harm where it is foreseeable and unavoidable.” Clinicians can avoid harm to their clients by doing thorough assessments of IPV, being aware of when to report violence, and by providing evidence-based treatment. In persistently violent relationships, minimizing foreseeable and unavoidable harm may entail empowering or assisting the victim to leave the relationship. Forming a safety plan is yet another way clinicians can help victims stay safe.

Early intervention and prevention of future IPV is another way in which clinicians can avoid harm. Various groups, including the World Health Organization and the Centers for Disease Control and Prevention, have recognized the need for IPV prevention and early intervention (Black et al., 2011; World Health Organization, 2012). Early intervention is perhaps the most possible with child and adolescent clients, as IPV is particularly prevalent among adolescents and young adults (Halpern, Oslak, Young, Martin, & Kupper, 2001; Kaura & Allen, 2004). Violence has also been shown to be transmitted intergenerationally, causing children exposed to parental IPV to be at greater risk for future IPV themselves (Ehrensaft et al., 2003). Therefore, early intervention efforts might be particularly effective with children who have been exposed to parental IPV. Given the prevalence of IPV, clinicians should regularly assess child and adolescent clients for violence in their intimate relationships as well as in the home, even if exposure to IPV is not the presenting problem. Furthermore, by providing psychoeducation to children and adolescents about IPV and the many forms that it can take, clinicians may help their clients identify and avoid future violent relationships before they go too far, preventing the clients from ever becoming victims.

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Competence

Standard 2.01: Boundaries of Competence states that psychologists must function within the limits of their competence and, when working with a new population outside of the scope of their expertise, they must seek additional education and training. Clinicians are also charged to maintain their competence over time by keeping up with the current state of the literature, seeking out additional education, and treating diverse clients (Standard 2.03). Various factors may make it difficult for nonspecialists to get experience working with IPV clients, particularly with perpetrators. Perpetrators often do not willingly seek out treatment for their violent behavior (Rosenbaum & Dowd, 2009). If IPV perpetrators do end up in treatment, it is often the case that they were court-mandated into treatment and therefore will typically be sent to specialists in batterer intervention groups (Rosenbaum & Dowd, 2009). These factors may cause a dearth of opportunities throughout the nonspecialized clinician’s training to receive experience treating perpetrators. If a nonspecialized clinician is working with a client who later discloses IPV, he or she should seek a consultant who has experience with IPV clients. If no such consultant is available, the clinician should strongly consider referral to a specialist (Rosenbaum & Dowd, 2009).

Working with clients who have IPV issues can have a significant emotional impact on clinicians. In one study, clinicians with high caseloads of clients with IPV issues reported an initial loss of self-confidence, feelings of powerlessness, and burnout (Iliffe & Steed, 2000). These side effects may limit the clinician’s ability to effectively treat his or her clients and may diminish competency. Therefore, clinicians should make sure to monitor their emotional state and find time for self-care when working with difficult cases such as these. In their study, Iliffe and Steed (2000) found that physical activity and limiting the number of IPV clients on their current caseload, among other self-care activities, were all effective coping strategies for clinicians dealing with burnout.

OTHER ETHICAL CONSIDERATIONS

Record Keeping

Treating violent clients may raise the amount of risk the clinician faces from the legal system. The legal system, the victim, or the victim’s family may try to hold the clinician accountable if a client harms themselves or somebody else. With that in mind, when treating a client who frequently engages in violence, or is suicidal, it becomes important to take detailed notes for risk management purposes. Highly detailed documentation will enable the clinician to defend why he or she thought the client was not at risk for violence or the measures that the clinician took to protect the client and others from harm. When recording information that is relevant to the client’s violence, a clinician should also record the source of the information, such as whether the partner or the client themselves reported it and the date the information was received (Monahan, Appelbaum, Mulvey, Robbins, & Lidz, 1993).

When treating couples or doing group therapy, it is important to consider if the client’s charts should be kept separately or together. The APA Guidelines for Record Management suggests that clinicians keep separate records when treating couples and groups (APA, 2007). This may

ETHICAL CONSIDERATIONS INTIMATE PARTNER VIOLENCE 49

be a particularly prudent way to keep charts when the clinician works with IPV clients. Given the nature of their presenting problems, violent clients may find themselves in situations where their records have a greater likelihood of subpoena than those of nonviolent clients. Keeping separate records for each client will help the clinician limit unnecessary breaches in confidenti- ality if one client’s records are requested.

Conflict Between State Law and the Ethics Code

Many of the issues just described, particularly those that involve disclosing confidential infor- mation, are predicated in part on the laws in the clinician’s jurisdiction. Definitions of violence risk and child maltreatment vary across state lines, and clinicians will not be able to make informed decisions about reporting without knowing the definition that applies in their own state. Clinicians may experience conflicting demands when both attempting to abide by the law and adhering to the Ethics Code. Standard 1.02: Conflicts between Ethics and Law, Regulations, or Other Governing Legal Authority advises psychologists to “make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the [Ethics Code].” The initial step for a clinician’s facing conflicts between state law and the ethics code may involve seeking consultation from knowledgeable sources, such as from other clinicians who have dealt with similar issues or psychologists on the state ethics board. These sources may be able to help the clinician determine how to reconcile the source of the conflicting demands.

RECOMMENDATIONS

The following are recommendations

1. Assess violence risk and suicidality regularly and thoroughly. This may involve altering current intake procedures to include questions about IPV or the administration of self- report questionnaires dedicated to identifying IPV. Also, it is important to periodically review the literature on what factors elevate violence and suicide risk.

2. Familiarize yourself with the relevant state laws. Mandatory reporting laws, such as duty to warn or duty to protect, vary across state lines in terms of what will trigger a mandated report. States also differ on if they consider exposure to IPV to constitute child maltreat- ment. Clinicians should feel comfortable enough with their state laws to know when a client triggers a mandated reporting law.

3. Seek consultation from clinicians who have experience working with IPV clients. Receiving consultation from a colleague who has worked with victims and perpetrators of IPV can be a valuable resource for clinicians who are stuck in ethical gray areas. When dealing with situations that could result in professional liability (such as Tarasoff- type situations), consulting with an attorney or a psychologist on the state ethics board may help the therapist manage their risk and minimize harm.

4. Research local and national resources for victims and perpetrators. Being familiar with local victims shelters before a crisis arises will help the clinician create a safety plan with the client. Having a list of hotline numbers available for clients to take home with them could make an important difference in their safety if another violent episode occurs. If it

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turns out that the clinician has an IPV perpetrator as a client, knowing about local batterer intervention groups will help the clinician make a referral if necessary.

5. Remain aware of the legal options that are available to victims that may help them stay safe, such as orders of protection. For clinicians who are unfamiliar with the resources that are available to IPV victims through the criminal justice system, “Domestic Violence and the Law: A Practical Guide for Survivors” may be a helpful first resource (Young Lawyers’ Section of the Missouri Bar, 2011). Otherwise, consultation with an attorney is an option.

SUMMARY

Due to the nature of the population, clinicians who provide treatment to IPV clients are likely to encounter ethical and legal dilemmas throughout treatment. The ethics code is a valuable resource for clinicians who are attempting to navigate such ethical dilemmas with the client’s best interests in mind. The ethics code charges clinicians with the task of maximizing benefit and minimizing harm to their clients, a balancing act that may be particularly difficult while working with IPV clients. Clinicians can accomplish this aim in various ways. First, remaining familiar with IPV in general, assessing IPV regularly, and staying aware of one’s own biases and competence is important. Then clinicians must determine if they will refer IPV clients to a specialist or provide treatment themselves. Providing informed consent to treatment, and in particular detailing the limits of confidentiality, is absolutely necessary before proceeding to treat an IPV client. During treatment, clinicians must regularly assess violence risk in order to guide treatment toward preventing further harm. Consultation is a useful and highly recommended resource throughout the process of treating an IPV client. Ultimately, through familiarity with the ethics code, clinicians stand to positively benefit many IPV clients who seek treatment.

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