Potential Problems for Psychologists Working with the Area of Interpersonal Violence
The ad hoc Committee on Legal and Ethical Issues in the Treatment of Interpersonal Violence
The most frequent types of interpersonal violence involve family members, intimate partners, and trusted friends or authority figures. Problems in intimate relationships unleash powerful feelings with great potential for harm to both victims and their families if not handled skillfully and professionally. The following potential problems are identified to remind clinicians of some of the most common land mines encountered:
1. Failing to report child or elder abuse when there is reasonable suspicion (as defined in one's respective state), because it would hinder the therapeutic relationship.
Psychologists sometimes inappropriately assume that the risk to the therapeutic relationship when one considers reporting child or elder abuse should be primary over the obligation to report abuse. Psychologists must comply with the legal mandate to report abuse (Ethical Standard 5.05). Discussion of the limits of confidentiality with the client must happen at the outset of the relationship, or soon after, and thereafter as new circumstances may warrant (Ethical Standard 5.01). Abuse, maltreatment and victimization are severe and complex problems. Psychologists have an ethical obligation to obtain competency in addressing the therapeutic issues as well as in the reporting aspects through training and consultation.
2. Treating a child who will be a witness without considering risk of contamination.
The treating psychologist should be aware of and take into consideration ongoing litigation when treating a child who is the victim of interpersonal violence. If the child is to testify at a later date, there is a risk of contamination in the way therapy is conducted. For example, encouraging a child to repeatedly talk about violent events, and/or encouraging new memories, runs the risk of appearing to over-rehearse or "suggest" information. This does not mean that the treating psychologist cannot discuss acts of violence. It is important, however, that any such discussions be fully documented, including who initiated the discussion. Psychologists must conduct therapy in a way that minimizes risk of contamination during treatment by the psychologist or any family member. Other things to consider include who might be in the room while conducting therapy with the child. In a divorce action where a parent has accused a spouse or former spouse of child sexual abuse, there is a risk of the parent influencing the child's responses if the parent is always in the room with the therapist. The main point is to be conscious of the possibility of contamination, and conduct therapy so that contamination factors are minimized or eliminated.
3. Assuming that the role of a treating clinician is to investigate, corroborate, or substantiate allegations or memories of abuse.
When memories of childhood abuse are recalled during the course of therapy with adults, or when allegations of abuse are disclosed during treatment of a child, the clinician may feel the need to determine whether such abuse actually occurred. However, beyond mandatory reporting of child abuse or neglect, the clinician must be careful to stay within the bounds of the treatment role. Referral for evaluations may be used where appropriate. In psychotherapy, the subjective experience of the client must be the focus of attention to promote healing and recovery from trauma (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section I, Professional Roles).
4. Assuming that it is impossible for forgotten memories of childhood abuse to be remembered years after the abuse.
The APA Working Group on Investigation of Memories of Childhood Abuse Final Report (1996), APA's release of Questions and Answers About Memories of Childhood Abuse (1995), and the APA Presidential Task Force on Violence and the Family Final Report (1996), have reported that experiences of early childhood abuse that have been forgotten can be remembered later. Even though this may not happen often, and most people who were abused during childhood remember part or all of the abusive experiences, adults can forget and then later remember childhood abuse. This has been documented in a variety of research and clinical reports, but additional studies are needed to determine the precise processes and mechanisms that occur during this situation. Assuming that any delayed recall of memories must be false would be inappropriate. There is no scientific evidence to indicate that delayed recall of childhood abuse memories are implanted or induced by psychologists, but it is accepted that pseudo memories of abuse can also occur at times. Post Traumatic Stress Disorder can indeed produce intrusive and delayed recollections of trauma, but it is important for psychologists not to have preconceived ideas about the accuracy of such reports of delayed recall of childhood abuse during the therapeutic process, or in forensic settings. Extreme or rigid statements are not appropriate according to the current state of the knowledge.
5. Conducting familial confrontation sessions with-out taking into consideration the impact on all persons involved, and without making resources available to participants as appropriate.
Therapists have sometimes arranged for familial confrontation sessions in cases of interpersonal violence, and especially in incest cases. If a decision is made to conduct such a session, careful planning is absolutely necessary, including preparing the client for any number of outcomes. The therapist should be certain that the client is prepared for a reaction that does not meet his/her needs or wishes. Typically, the client is an adult who has told the therapist a parent has sexually abused her or him as a child. The therapist requests the parents to come to a session during which they are confronted with this information. By involving other persons, the therapist must keep in mind that these persons may be hearing potentially shocking information for the first time. The therapist has no way of guaranteeing the accuracy of the information the client conveys. In addition, there is the risk that a parent or parents may react in a volatile or unpredictable way. Resources or referrals may be appropriate for participants other than the client. Psychologists should be aware that confrontation sessions are controversial and can have a far reaching impact. If a decision is made to conduct such a session, careful planning is absolutely necessary, including preparing the client for a variety of outcomes. It should also be remembered that bringing outside people into a session requires informed consent from ALL parties, at which point the others may be considered clients themselves in the interpretation of some courts.
6. Providing expert opinions when testifying in child abuse cases without having specific training or expertise in child abuse.
Child abuse has become a specialized area of knowledge encompassing numerous controversial issues. Providing expert opinions in such forensic cases requires specialized training and expertise (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section I, Professional Roles). Psychologists who testify in child abuse cases (whether court appointed, retained by plaintiffs or defendants, petitioners or respondents) must have specific training, continuing education, and experience in working with child abuse cases, issues, research, or assessment. Merely being trained in psychology or being licensed does not automatically qualify a psychologist to testify and provide expert opinions in this area (for further information and discussion concerning these issues, see the Specialty Guidelines for Forensic Psychologists (1991) and APA's Twenty-four Questions (and Answers) about Professional Practice in the Area of Child Abuse (1995). Since research and clinical knowledge concerning child abuse are expanding rapidly, it is imperative that psychologists who provide expert opinions about child abuse maintain current continuing education and can document that they are aware of changes in the state of the art.
7. Treating perpetrators of interpersonal violence without understanding the dynamics of violent behaviors, without proper training and expertise, and without focusing on the elimination of the violent and abusive behaviors.
Given the pervasiveness of violence in American culture, it is unlikely a clinician in practice will be able to avoid encountering victims and perpetrators of violence. Yet a clinician who has not had specific training in the dynamics of violence, and who does not understand the necessity of addressing these issues first, may place others at risk by attempting to apply general principles of psychotherapy without attention to these factors. For example, supportiveness and genuineness on the part of a clinician may inadvertently provide validation for a client who has reason to hide some aspects of his/her behavior, who projects blame onto others, and who sets out to garner support for his/her viewpoint. Gaining validation for his/her perspective may allow the client to continue to justify his/her violence reactions to others. If treatment of perpetrators is necessary, specific training or expertise is required (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section III, Treatment).
8. Treating or evaluating alleged victims of interpersonal violence without being sensitive to or understanding the dynamics of victimization and traumatization, including internalized guilt, powerlessness and lack of control.
The impact of victimization results in a wide range of experiences, from severe psychopathology to mild disruptions in daily living. A common dynamic for survivors of abuse is to blame themselves. Psychologists have an obligation to understand that this self blame is a misperception often stemming from feelings of diminished self-worth. In addition, victims of chronic, sustained, and/or severe interpersonal violence often have a history of being unable to escape the abuse no matter how hard they tried. Thus, the ability to feel empowered and take control and responsibility are rarely part of their repertoire of responses, and the psychologist must take extra care to promote those options and abilities.
9. Trying to determine status of an alleged perpetrator only on the basis of interviews and psychological testing without gathering collateral data.
There is no presently established psychological test or battery of tests which indicates whether a person is or is not a perpetrator. Certainly testing can be one source of data in looking at this issue, but cannot be determinative. In addition, simply interviewing an alleged perpetrator cannot be relied upon without looking at collateral data. There is substantial motivation to distort, minimize, or misrepresent, necessitating an examination of data from other sources. This does not mean that interviewing the alleged perpetrator is not important, nor does it mean that psychological testing is not also important. The main point is to be comprehensive in the data collected so that all types of input are considered in the assessment, before any conclusions are reached.
10. Predicting that a person will be dangerous in the future without conducting a comprehensive evaluation, reviewing all relevant data and qualifying the statements with respect to limitations in our ability to predict dangerousness.
Predicting dangerousness for individuals in general is the least reliable of psychologists' abilities or skills, based on a variety of research and ethical principles. Thus, in order to increase the likelihood of making more accurate predictions for individuals, all possible data should be collected and reviewed, and comprehensive evaluations should be conducted, including an individual clinical interview. If these cannot be accomplished, psychologists must qualify their predictions and indicate that the reliability may be inadequate (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section II, Assessing Abuse, Harm or Potential Lethality). Since these issues and predictions may influence the well-being of individuals (in some cases, they are used in trying to determine life or death decisions), it is incumbent upon psychologists to be very cautious in these types of assessments and predictions, even with substantial data and thorough comprehensive evaluations. Without such data and information, psychologists should think carefully about whether they can make reliable predictions that would be ethical, based upon the current state of knowledge.
11. Conducting couples therapy without assessing risk of interpersonal violence.
In the absence of adequate assessment of the existence or the potential escalation of interpersonal violence, clinicians risk inadvertently putting a client in harm's way using even the most basic techniques of couples therapy. For example, by encouraging expression of feelings, the clinician may expose a battered partner to retaliation after the sessions has ended. Likewise, helping couples communicate their needs and concerns to one another may also lead the violent partner to become angry and hostile outside the session, leading to an escalation of violence. A clinician's attempt to align equally with both partners may result in the batterer gaining more power and control, because power is already unequally distributed through the use of violence to resolve conflict. While there may be differences of opinion regarding the appropriateness of individual sessions in the context of couples therapy, the overriding concern must be the principle of "first do no harm" (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section II, Assessing Abuse, Harm or Potential Lethality).
12. Encouraging the expression of conflict in a familial situation without assessing the potential for escalation to violence or abuse behavior.
Clinicians may believe that an important goal for couples or families is the expression and working through of conflictual situations. However, without a thorough assessment of the potential for conflict to escalate into abuse or violence, encouraging a couple or family to express their anger to each other can be extremely dangerous. For example, encouraging a woman to freely express her anger to her partner may lead to a violent reaction from the partner. Likewise, an adolescent expressing anger may become either a victim or perpetrator of violence with parents. Assessment of substance use is also a critical factor (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section II, Assessing Abuse, Harm or Potential II, Assessing Abuse, Harm or Potential Lethality).
13. Treating or evaluating victims without understanding one's tendency to blame the victim or one's tendency to exert inappropriate power or control.
Working with interpersonal violence stirs up greater emotional reactions and triggers more countertransference issues than perhaps any other clinical issue. Those working with interpersonal violence often experience secondary or vicarious traumatization, simply from hearing client's stories of victimization. Clinicians who have not examined and worked through their own victim/perpetrator, power or control issues risk such pitfalls as projecting blame onto victims, inadvertently aligning with perpetrators, or taking too much responsibility for the client's behavior. Clinical teams dealing with cases of abuse and violence may find team members engaging in splitting, angry reactions and blame directed at each other, as a response to the case dynamics. Awareness of these dynamics is crucial for effective intervention (see Professional, Ethical and Legal Issues Concerning Interpersonal Violence, Maltreatment and Related Trauma, 1996, Section III, Treatment).
14. Making custody recommendations without assessing for and taking into consideration violence or abuse.
The APA Guidelines for Child Custody Evaluations in Divorce Proceedings (1994) indicates that the psychologists should make recommendations concerning custody and visitation based upon the best interests of the child, and they should focus on parenting capacity, psychological and developmental needs of the child. In order to accomplish the above, any occurrence of violence or abuse directed by one parent at the other parent or at others (including the children) must be assessed. The APA Presidential Task Force on Violence and the Family Final Report (1996) agreed with other organizations in recommending that custodial preferences should be given to the nonviolent parent whenever possible, and that abuse or violence in the family may be presumptions or poor parenting and lack of consideration of a child's developmental and psychological needs. Spousal abuse, threats, other verbal abuse, intimidation and exposure to violence generally meet the criteria for psychological maltreatment of a child, and therefore must be considered in any custody or visitation recommendations. In order to determine this, an assessment of these possible behaviors or attitudes must be conducted by the psychologist so that recommendations would be consistent with the guidelines.
15. Assuming that allegations of spousal or child abuse during divorce, custody or visitation proceedings are a common occurrence and necessarily false.
In a 1990 study commissioned by the Association of Family and Conciliation Courts, child sexual abuse allegations were made in less then 2 percent of contested divorce cases which involve child custody. This study included 9,000 divorces in 12 separate states. The percentage of substantiated allegations in this study was about the same as in other contexts. In other words, allegations of child sexual abuse in divorce/custody cases do not have a greater degree of falsity than those in other types of cases. The incidents of intentionally false reports appear to be approximately 5-8% of all cases. It is important to remember that there are aspects of divorce which may increase the likelihood of sexual abuse disclosures and/or incidents when such abuse has indeed occurred (i.e., heightened stress on parents during a divorce may predispose someone to act out who normally would not, and when parents separate a child may be more willing to disclose when the perpetrator is no longer in the home). It is also important to remember that each case must be evaluated on its own merit. Assuming that an allegation of abuse is false may be dangerous and inappropriate until a comprehensive investigation has been conducted.
16. Making a child custody recommendation for clients without evaluating all parties.
In conducting forensic assessments, the Ethical Principles of Psychologists and Code of Conduct (7.02) required that recommendations be made only when sufficient information and examination have been acquired to support statements or conclusions. When making child custody recommendations, no statement regarding which parent should receive custody can be made without having examined and evaluated all parties, including personal interviews. Only in rare circumstances (as when a parent is not accessible or when abuse by a parent has been documented) can a recommendation be made from other available information. In those cases, psychologists must clarify the impact of their limited information. If a psychologist is asked to testify on behalf of one's client (in the role of a therapist, rather than as a forensic expert), the psychologist should limit the nature and extent of their conclusions by making statements only pertaining to the client or the child(ren) being evaluated (APA Guidelines for Child Custody Evaluations in Divorce Proceedings, 1994).
17. Failing to recognize appropriate boundaries, a special problem in the field of interpersonal violence, given the vulnerability of clients and the volatility of clients and the volatility of the issues addressed.
Because victims of interpersonal violence have often had their boundaries violated, it is very important for psychologists to provide structure and clarity regarding the therapeutic relationship. Providing clarity about the nature and anticipated course of therapy, fees and confidentiality, answering clients' questions, and avoiding misunderstandings about therapy are important in providing such structure (Ethical Standard 4.01). In addition, psychologists do not enter or promise any other relationship with a person if that relationship might impair the psychologist's objectivity or potentially harm or exploit the client (Ethical Standards 1.17, 4.05, 4.07).
18. Failing to recognize the limitations of one's role.
At times, psychologists may experience the pull to "rescue" or "save" a victim of interpersonal violence by stepping beyond the boundaries of a psychotherapist. Psychologists have a responsibility to fully understand the impact of the behaviors, the limitations of their roles, and to takes steps to avoid harming their clients (Ethical Standard 1.14). Promising more than one can provide, for example, is a potential pitfall for the psychologist. In interventions, psychologists should always be clear about theoretical orientation, goals and intervention objectives with regard to their choices, and be able and willing to document their choices in a timely and accurate manner.
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The following documents, cited above, are available from the American Psychological Association, 750 First Street NE, Washington, DC 20002:
- ad hoc Committee on Legal and Ethical Issues in the Treatment of Interpersonal Violence -
Melba J. T. Vasquez, PhD (Chair), Evvie Becker-Lausen, PhD, Bruce E. Bennett, PhD, Sionag M. Black, PhD, Ronald E. Fox, PhD, Robert A. Geffner, PhD, Asher R. Pacht, PhD
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