This study analyzed the responses of masters and doctoral counseling students to two domestic violence scenarios Couples Counseling in Domestic Violence 1 Endorsement of Couples Counseling in a Domestic Violence Case as a Function of Training Mona Bapat and Terence Tracey College of Education Arizona State University Biographical Information: Mona Bapat is a doctoral candidate in the Counseling Psychology program at Arizona State University. Her primary research focus is on issues of intimate partner violence. Terence Tracey is a Professor in the Counseling and Counseling Psychology programs at Arizona State University. His research efforts have focused on the topics of client-therapist interaction in psychotherapy. Correspondence should be addressed to: Mona Bapat, Division of Psychology in Education, 302 Payne Hall, MC-0611 Arizona State University, Tempe, AZ 85287-0611. Email: mbapat@asu.edu. mailto:mbapat@asu.edu.� Couples Counseling in Domestic Violence 2 Abstract Reactions of students in helping professions to domestic violence were examined with respect to whether or not the students had any training in domestic violence. One hundred, four students read one of two vignettes describing a domestic violence case and responded to statements related to treatment options. The vignettes differed only in education level and occupation of the target of the violence. Students with training in domestic violence evidenced less willingness to endorse couples counseling as a treatment option than those without the knowledge or training. This main effect held across both SES conditions. Couples Counseling in Domestic Violence 3 Endorsement of Couples Counseling in a Domestic Violence Case as a Function of Training Domestic violence is an extremely prevalent problem and one that is important for mental health professionals to understand. Kragh and Huber (2002) summarize that “over two million United States women are abused each year by their husbands or partners and as many as four thousand women are killed during these batterings” (p. 290). Thus, it is probable that every mental health worker will at some point in his or her career work with a client who has been involved in a violent relationship (Hansen & Harway, 1993). Therefore, knowledge and training in the area of domestic violence appear to be needed in order for mental health professionals to help targets of violence most effectively. However, there has been little research evaluating the relation of training in domestic violence and interventions used in domestic violence cases. The focus of this study is on the relation between reactions to a domestic violence situation and the level of training in domestic violence of the mental health professional. We were most interested in endorsement of different treatment options, specifically couples counseling. In addition to our assessment of the relation of training to intervention endorsement, we also focused on the potentially confounding variable of socio-economic status (SES) of the target. Although males can certainly be targets of domestic violence from female perpetrators, we will focus on trainees’ reactions to a domestic violence scenario with a female target in a heterosexual relationship, given that females are more likely to seek help for the abuse (Graham-Kevan & Archer, 2005; Koopmans & Lamers, 2006). In working with domestic violence, the potential of increased harm can quickly arise and requires attention. Domestic violence involves the perpetrator’s effort to control his partner (AZCADV, 2000; McMurran & Gilchrist, 2008); therefore, there is the potential for violence to increase, especially if she attempts to leave. In other words, the possibility of her leaving his Couples Counseling in Domestic Violence 4 control could lead him to use greater violence in an attempt to get her to stay. Further, challenging times for families, such as the current financial crisis, could contribute to an increase of harm to targets of domestic violence. The National Domestic Violence Hotline reported a 21% increase in calls in September of 2008 (beginning of the financial crisis) compared to the same month in 2007 and callers reported the financial stress as a factor associated with the violence in September of 2008 (Sotelo, 2009). However, the literature documents that the focus of practitioners on decreasing harm to the women is not always a primary focus. In a survey of 362 therapists conducted by Hansen and Harway (1993), 40% of the practitioners failed to address the issue of violence in a hypothetical case and 91% of those who addressed the conflict inappropriately considered it to be mild or moderate. In a second study conducted by Hansen and Harway (1993), the single most common response by psychologists when presented with a rather extreme case of violence was focusing on the couple’s marital problems. Furthermore, with knowledge of the lethal outcome of the case, only 50% of the participants indicated that their intervention of choice was to seek protection for the wife. So it is important to recognize these dangerous situations and choose an appropriate intervention that decreases harm to the target. Use of Couples Counseling in Domestic Violence Cases Anecdotal data have shown that mental health professionals believe couples counseling can be the solution in domestic violence (Montreal Men Against Sexism, 1995); in addition, the US Air Force Family Advocacy Program provides various services in response to spousal abuse, of which marital therapy is most frequent (O’Leary, 2001). However, marital therapy it is not a recommended intervention in the literature, particularly when the partners are engaged in physical violence. Both McMahon and Pence (1996) and Hansen and Goldberg (1993) suggest Couples Counseling in Domestic Violence 5 that couples counseling can be effective; however, only when the couple is no longer engaging in violent transactions. Montreal Men Against Sexism (1995) conducted a study in which at six- week follow-up, half of the couples with domestic violence that received conjoint therapy reported violent incidents, and at six months, all couples that were in conjoint therapy reported further violence. While there was no control group in this study, it does provide some support for the treatment recommendations noted above. Regardless, couples counseling as an automatic treatment recommendation needs to be carefully considered. Couples counseling involves helping the couple to identify and reach goals, just as in individual counseling. In order for couples counseling to be effective, one partner cannot feel threatened by the other, and in general there would need to be an agreement on the problem for which the couple is seeking help. In cases of domestic violence, there will likely be a disagreement between the partners on the nature of the problem. Domestic violence is one partner trying to control the other so abuse perpetrators often blame their partners for issues, or do not acknowledge that a problem exists (AZCADV, 2000), and out of fear women may not openly express themselves in the presence of their partner. Montreal Men Against Sexism (1995) state that one result of conjoint therapy with domestic violence is that “therapy can end up mimicking the batterer’s rationale for his violence.” Williamson (2000) also recommends that couples counseling be avoided and to instead work with the woman to improve her situation. There are a number of possible outcomes if couples counseling is recommended or used when a woman seeks help for domestic violence, and we will list some of the main ones. One, the couple may not return for another session due to the perpetrator’s lack of acknowledgement of any problem. Hansen and Goldberg (1993) state that some research shows that helping the perpetrator develop insight into his responsibility for the violence fails to reduce the violence or Couples Counseling in Domestic Violence 6 change his behavior. Two, the perpetrator could become more abusive because his partner has exposed their situation to an outside party or three, the couple may continue to attend therapy and the perpetrator, given his desire for control, will attempt to control the sessions and misuse guidance provided by the counselor to further abuse at home. O’Leary and Murphy (1999) state that in cases where the violence has become more severe and more male perpetrated, couple therapy may perpetuate a severe imbalance of power. Finally, there exists the possibility that the perpetrator will not agree to go to counseling at all. Consequently, attempting only to work with the woman in individual counseling is the preferred intervention because it gives her time for herself in a safe environment to deal with the situation. As a side note, in working with male perpetrators of partner violence or when identifying a strategy for reducing partner violence on a macro scale in our society, batterers intervention programs (BIPs) have shown to have a significant impact in alleviating abusive behavior in intimate relationships (Bennett et al., 2007). However, “50% of the participants never complete the program, regardless of whether or not they are court-ordered” (Bennett et al., 2007, p. 42), which further supports the importance for mental health professionals to focus on targets of violence who ask for help and what they can do to deal with the situation. Training of Mental Health Practitioners We expected that the presence of training in the area of domestic violence would be related to mental health workers reactions to domestic violence situations. We define training in this study as technical training, as received in a formal course. The literature has demonstrated that there is an absence of training in working with domestic violence cases among mental health workers. Campbell, Raja and Grining (1999) found that of 14,119 licensed counselors, social workers, clinical social workers or clinical/counseling psychologists they surveyed, only 59% of Couples Counseling in Domestic Violence 7 them had training in domestic violence. Such lack of training could lead to responses to domestic violence situations that are not in the best interest of the client, or could even cause her harm. We hypothesized that these results of Hansen and Harway (1993) could come in part from a lack of specific training. We thus sought to examine if the presence of formal training resulted in treatment endorsements that may be more protective of the woman, specifically a decreased tendency to endorse couples counseling. Socio-economic Status and Domestic Violence In addition to the presence of training, we examined the factor of socio-economic status (SES) of the women in the vignettes. Although the literature does not provide any information on mental health professionals’ perceptions of domestic violence in relation to SES of targets, one misconception is that domestic violence only occurs in lower SES populations. Shapiro (1984) states in his chapter about working with people experiencing domestic violence that, “Frequently there was a need to hide the abuse from public view. Secretiveness was strengthened by concern with public opinion and fears of damage to social standing and occupational status” (p. 116). Shapiro (1984) goes on further to say that some therapists can “reflect a customary middle-class abhorrence of violence” (p.118), implying that there can be a denial of the existence of family violence by and within the middle-class population. Nevertheless, for Shapiro (1984) the family violence that was seamless to outsiders was the most frequent type in his clinic, and Adragna (1991) has found that 22% of the divorces in middle-class marriages are attributable to domestic violence. Therefore, even though domestic violence exists in all SES classes, it is possible that the perception of a relation between domestic violence and social class could affect decisions of practitioners. Mental health professionals may use different interventions with targets of a higher Couples Counseling in Domestic Violence 8 SES than with those of a lower SES. Because a woman is of a higher SES and possibly in a stronger financial position to be on her own, a mental health worker may view her situation as less grave than that of a woman of lower SES. The professional may expect this woman to be more intelligent and to be able to leave the relationship more easily. Therefore, if the client remains in the relationship, the helping professional may believe that the couple is simply having marital conflict that can be alleviated with couples counseling. However, her situation can be just as severe as that of a woman of a lower social status, with various factors hindering her ability to escape. Furthermore, contrary to a misconception that domestic violence only entails physical abuse, it also entails verbal, emotional and financial abuse (Tolman, Rosen & Wood, 1999). Examples of financial abuse include the target’s partner taking her money, or putting more financial responsibility on her, so she may still not have complete control of her financial resources (AZCADV, 2000). However, given the potentially greater financial wherewithal of women in higher SES groups, we expected that study participants would recommend couples counseling more highly for the woman of higher SES. In summary, given the lack of education in domestic violence received by mental health professionals, and the amount of controversy in utilizing couples counseling as an intervention in domestic violence cases, it is important to empirically measure the perceptions held by students in helping professions and to determine the extent to which they would endorse couples counseling. We expected those with no training in domestic violence to more highly endorse couples counseling for the couple in the vignettes than those with training in the area, and that this endorsement would be greater for the woman of high SES. We have examined the relationship between these two factors and the students’ level of endorsement of the following Couples Counseling in Domestic Violence 9 treatment options: going to a shelter, group counseling, individual counseling and couples counseling. Method Participants The study participants were 104 male and female undergraduate and graduate students taking classes in the education college of a large southwestern university. These classes included counseling, counseling psychology and various education classes. Eight-three percent were female and 17% were male. Our sample included individuals ranging from 20 to 60 years of age with a mean age of 30 years. Sixty percent were graduate students and five percent were undergraduates; 35% did not report their year in school. Further demographic details of the participants are presented in Tables 1 and 2. Table 1 has participants’ religious affiliation in addition to gender and major. Table 2 has ethnicity and marital status. Table 1 Study Participant Gender, Major and Religious Affiliation _____________________________________________________________________________________ Gender School Major Religious Affiliation _____________ ________________________________ _________________________________ Male Female Psychology Unidentified Christian None Other Unidentified Grad Undergrad _____________________________________________________________________________________ 17 83 59 1 40 38.2 13.2 15.2 33.4 ____________________________________________________________________________ Note. Vales are percentages based on 104 total participants. Couples Counseling in Domestic Violence 10 Table 2 Study Participant Ethnicity and Marital Status _____________________________________________________________________________________ Ethnicity Marital Status _________________________________________________ _______________________________ White Hispanic Asian Black Other Unidentified Single Married Unidentified _____________________________________________________________________________________ 66 9 6 4 10 5 50 18.4 31.6 ____________________________________________________________________________ Note. Percentages based on 104 total participants. Instrument Each student completed a survey that we created. The survey included a two-paragraph description of an abusive scenario adapted from Wise and Bowman (1997), five statements that were rated on a Likert-type scale, and a demographic section. The two scenarios were identical except for the manipulation of the educational level and occupation of the target. The text of the first vignette was: Josephine Smith has contacted your agency. She requests help after an incident with her husband that left her with a cut on her right hand. Ms. Smith, a 35-year-old college instructor with a master’s degree in chemistry, tells you her story. She had arrived home in the evening after teaching a late-afternoon class, spent some time with her 10 year-old and 15 year-old daughters, and started preparing dinner. Approximately ten minutes later, her husband, Mark Smith (an engineer), arrived home from work and became angry because dinner was not yet ready. He walked into the Couples Counseling in Domestic Violence 11 kitchen yelling that he has things to do and that dinner should be ready on time, then picked up a knife and threw it at her. As Josephine started crying and treating her wound, Mark left the house. The following morning, she called the “Life Help Agency.” For the second scenario, “college instructor” was replaced with “cashier in department store”, “master’s degree in chemistry” was replaced with “who has never attended college” and “after teaching a late-afternoon class” was replaced with “after working late.” After reading the vignettes, the participants rated five statements on a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). These statements were related to the treatment recommendations that the participant would give to the woman in the vignette as though they were an employee of Life Help Agency, specifically: individual counseling, group counseling, couples counseling, and going to a shelter. For example, one statement read “I recommend couples counseling for Josephine and her husband.” In addition, to test the validity of the SES manipulation, study participants responded to the question “Josephine is intelligent.” If participants are attending to the two conditions, then they should rate the intelligence of Josephine higher in the college instructor condition than in the cashier condition. The treatment recommendations and validity check statement are presented in Table 1. In addition, we asked each participant the question “Have you had any knowledge or training in partner violence?” to which they were to respond yes or no. Procedure Students taking various counseling and education courses were recruited to fill out the survey and the surveys were administered in the classrooms with minimal instruction. The first author attended classes with instructor permission and explained to the classes in a general way that the study would be surveying students’ reactions to a hypothetical domestic violence Couples Counseling in Domestic Violence 12 situation. The first author attended the classes toward the end of class time and explained that participation was voluntary. This way those students who chose to not participate were able to leave while others stayed to complete the survey. Some instructors participated in the college’s research protocol that facilitated undergraduate participation in various research projects for extra credit. The first author also attended these classes to announce the study and, according to protocol, arranged times in a reserved classroom in which students could come to fill out the survey for extra credit. Each student read only one of the two possible vignettes. The first author attended the classes with a stack of the surveys with the vignettes alternating, and randomly passed out surveys to each student from the top of the stack. The students were simply told that they would be reading a short vignette describing a situation of domestic violence and answering questions in response to it. The informed consent letter only told the students that the study will help determine domestic violence-related education needed, and did not indicate the factors to be analyzed. This letter was placed on top of the surveys so that the author could not match faces with handwriting, to ensure anonymity of the participants. To ensure independence of the participants’ responses, the first author was present in the classrooms and observed that students did not discuss the survey with each other and completed it on their own. Study results were not purposely shared with participants but they were encouraged to approach the authors if they were interested in seeing them, or if they had any questions regarding the study. Analysis We first conducted a univariate analysis of variance at an alpha level of .05 to test our SES manipulation. Then, given that we expected students’ responses to the four statements of treatment options to be related to each other, we conducted a multivariate analysis of variance Couples Counseling in Domestic Violence 13 test with the four treatment options as the dependent variables. The two fixed factors of training and SES had two levels; target SES was either “instructor” or “cashier,” and training in domestic violence was “yes” or “no.” Given that we found the MANOVA analysis to be significant (indicating a difference between levels of endorsement of the four treatments), we conducted post-hoc individual univariate analyses so that we could compare the significance of the level of endorsement of the four different treatment recommendations. This allowed us to see how participants’ level of endorsement of couples counseling differed with respect to training and SES versus the other treatments of individual counseling, group counseling and shelter. Results With our first univariate test as a manipulation check at an alpha level of .05, the effect of SES was significant, F(1,103) = 23.04, p < .001. The observed power of this test was .99. Effect size of the difference between the two conditions was measured with eta-squared (η2) and was found to be .18, a large size in the social sciences. Thus, participants very highly perceived the college instructor as more intelligent than the cashier, so they seem to have recognized the intended difference between the two conditions. These results are summarized in Table 3. Twenty-six percent of our sample reported having some training in domestic violence, 43% reported no training, and 32% of the respondents did not report their training level. With our MANOVA analysis, the training effect was significant, F(4,97) = 4.59, p < .005. This test had an observed power of .94 and another high effect size of .16. This indicated that the level of endorsement of each treatment recommendation was significantly different from the others. Thus we conducted post hoc univariate analyses given that the MANOVA showed a difference in level of endorsement between the four treatments. The results of the post hoc univariate analyses are Couples Counseling in Domestic Violence 14 summarized in Table 3. The interaction effect between training and SES was not significant, F(4, 97) = .94, p > .05. Table 3 Univariate ANOVA Results Across Participant Training and Target SES Effects ______________________________________________________________________________ Target SES Training Statement _________________ ________________ df F η2 df F η2 ______________________________________________________________________________ Recommend going to a shelter. 1,103 4.66 .04 1,103 4.10 .04 Recommend group counseling. 1,103 .04 .00 1,103 4.97 .04 Recommend individual counseling. 1,103 .01 .00 1,103 4.60 .04 Recommend couples counseling. 1,103 2.03 .02 1,103 13.92* .11 She is intelligent. 1,103 22.36** .18 ______________________________________________________________________________ *p = .001, **p < .001 The only significant training effect in our post-hoc analyses pertained to the degree to which the participants endorsed couples counseling, F (1,103) = 13.92, p < .001. This test had an observed power of .96 and an effect size of .11. Participants without training were very much more likely to endorse couples counseling than those who had training. The mean and standard deviation for those with no training were M = 3.62, SD = 1.31, and for those with training were, M = 2.62, SD Couples Counseling in Domestic Violence 15 = 1.35. Again, the Likert-type scale on which participants responded was from 1 (strongly disagree) to 5 (strongly agree). Discussion Conclusions As we expected, training in the area of domestic violence was related to how highly students recommended couples counseling for the wife and her husband in our vignette. Those without training in the area more highly recommended couples counseling than those who had training in the area. These results indicate that domestic violence education succeeds in making mental health workers aware of the potential ramifications of couples counseling in domestic violence cases. As we described in the beginning, couples counseling is not an uncommonly recommended intervention in these cases; however, it is counterindicated, particularly in instances where the couple is engaged in violent transactions or the woman feels unsafe in the presence of her partner. There were no significant results related to SES of the target. In other words, participants did not treat the women of high and low SES differently, and the difference due to training held across both SES conditions. This is a positive result showing that these students did not treat the women differently based on SES. These results can probably be explained by a greater awareness of domestic violence in our society today, and people in general understanding that no SES level is immune to domestic violence. Implications and Recommendations Given the significant relationship in this study between training in domestic violence and level of endorsement of couples counseling, it would be appropriate for mental health worker training programs to provide more education in domestic violence to their students. Campbell, Couples Counseling in Domestic Violence 16 Raja and Grinning (1999) found that most mental health professionals receive training in childhood sexual abuse, but they receive less training in domestic violence, and they recommend that training needs to be required in graduate school. They recommend that this training include therapy strategies, referral sources for targets, and legal and medical consequences. In addition, we attest that more comprehensive training would give students the needed formal knowledge of the area in order to more clearly understand the dynamics of domestic violence, the abuse cycle and thus why couples counseling should be considered cautiously. Domestic violence involves the perpetrator’s desire to control his partner and this could be done in various ways, such as through physical abuse, verbal abuse, controlling her interactions with friends and family, or controlling her money (AZCADV, 2000). Thus we recommend that the training include the important factor of control in abusive relationships, a description of the abuse cycle, the above-mentioned ways in which the control is executed and why a target of domestic violence may not be safe in a couples counseling situation. Other factors that are related to domestic violence are alcohol use and issues of anger on part of the perpetrators (McMurran & Gilchrist, 2008). It is also important that training include these factors that can often coincide with domestic violence. Such comprehensive training could allow mental health professionals to help a target avoid increased harm, and help them to understand why couples counseling could be counter- productive. In Table 4 we summarize more specific items that training curricula could include, provided by Payne (2009) through his survey of mental health professionals’ supervisors for their input on training needs. We organized the training topics extracted by Payne (2009) into categories for parsimony in the presentation in the table. Table 4 Couples Counseling in Domestic Violence 17 Possible Topics for Domestic Violence Training Programs Category Topics Basic information The basic dynamics of domestic violence Theoretical perspectives on domestic violence Victim-related issues Indicators that may identify domestic violence victims Documenting domestic violence in the victim’s record Talking with victims of domestic violence The critical complications involved in domestic violence, such as posttraumatic stress disorder and depression Designing a safety plan for victims and children Obtaining a protection order for victims The availability of community (local) resources for victims The special needs of victims of elder abuse Working with community-based services to get needed services to victims (e.g. shelters) Obtaining needed medical care for victims Obtained needed mental health care for victims Family-related issues Assessing a family for the risk of domestic violence Talking with child witnesses of domestic violence The effect of domestic violence on employment The effect of domestic violence on children Table 4 (continued). Couples Counseling in Domestic Violence 18 Possible Topics for Domestic Violence Training Programs Category Topics Developing a rapport with families living in domestic violence situations Perpetrator-related issues Intervening with perpetrators of violence (abusers) Communicating warning signs of abuser lethality Legal issues Legal options and laws available in domestic violence situations Accessing law enforcement or legal options in domestic violence situations Assisting victims in overcoming barriers to legal options Testifying in court hearings Working with the police to assist victims Working with the court system to assist victims Health professional-related issues Coping with frustrations and emotions encountered when working with victims of domestic violence Planning for own safety when working with victims Note. Adopted from Payne (2008). Working with a target of domestic violence is not unlike working with clients on other issues. The role of the counselor is to help the client be safe from danger, help her identify her Couples Counseling in Domestic Violence 19 goals for counseling, and facilitate progress toward those goals. This role does not include being directive and insisting on couples counseling. It is not uncommon for targets of domestic violence in individual counseling to ask the counselor if their partners should attend sessions with them. In such a situation, providing psychoeducation to the client on the possible outcomes of couples counseling would be appropriate. A thorough assessment of the client’s situation can help to determine if she is in an abusive relationship. O’Leary and Murphy (1999) provide instruments including self-report questionnaires and interview techniques that can aid the assessment process. Moreover, these tools can also help to determine the amount of physical danger the client is facing. Safety planning, a harm reduction method, will most likely be a part of the counselor’s work with the client, whether or not she chooses to leave her abuser. The therapist would want to cater to the woman’s requests, and if her goal is to stay with her partner and she asks the therapist to help them improve their communication, couples counseling could be appropriate. The results of this research are limited in several ways. First, only one training program was studied and the results cannot be generalized to students in other programs. Second, the participants were novices to the clinical setting. It is possible that the study would yield different results if the participants were experienced clinicians who had worked with more domestic violence cases. Third, there is the possibility that demographic differences of therapists can be related their reactions to domestic violence, such as gender, level of schooling, ethnicity and religiosity. The literature does not provide information on why such demographic differences of therapists would be significant in their attitudes toward domestic violence, but further research could be done to explore any differences between the reactions of males versus females, undergraduate versus graduate students, Whites versus ethnic minorities, and religious versus Couples Counseling in Domestic Violence 20 nonreligious therapists. Further research could also be done in surveying more experienced clinicians. It is plausible that value differences between groups could lead to different attitudes, in turn leading to different treatment recommendations. Nevertheless, the power of our analyses show that training in the area of domestic violence is a factor in how these students responded to the scenarios presented to them. Couples counseling was recommended significantly less strongly by those students with some training in the area. 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