Journal of Marital and Family Therapy October 2002,Vol. 28, No. 4,455-466

THE DIFFERENT FACES OF INTIMATE VIOLENCE: IMPLICATIONS FOR ASSESSMENT AND TREATMENT

Kelly Greene Peel Children’s Centre, Mississauga, Ontario, Canada

Marion Bog0 University of Toronto, Toronto, Ontario, Canada

Current research about violence in intimate relationships suggests that at least two qualitatively distinct types of violence exist. This new knowledge challenges the dominant conceptualization of intimate violence as solely a manifestation of patriarchal male dominance. Following a review of the research and analysis of illustrative clinical examples, a conceptual framework is presented that assists couple therapists in answering three salient questions: What type of violence am I most likely to be working with? How can I assess the diferences between types of violence? And how might Iproceed with treatment for diferent types of violence?

The conceptualization of violence in intimate relationships and of appropriate interventions in the field of family therapy has reflected dominant paradigms at a particular stage in the history of the field. Earlier, influenced by systems theory, the field failed to detect that abuse was present, or “blamed the victim” by holding the woman equally responsible for male perpetrated violence. Since adopting a feminist critique and a gender analysis, the dominant conceptualization has emphasized male power and domination over women, rooted in patriarchy and gender-role socialization. Interventions have focused on ensuring the safety of the woman, treating male batterers separately, and avoiding couples therapy as inappropriate and unsafe (Avis, 1992; Bograd, 1992; Kaufman, 1992). Only recently have there been published reports that provide alternative perspectives and interventions and suggest the need for careful and thoughtful consideration of the utility and safety of conjoint treatment (Almeida & Durkin, 1999; Bograd & Mederos, 1999; Goldner, 1999; Greenspun, 2000; Holtzworth-Munroe, Beatty, & Anglin, 1995; Jory & Anderson, 2000).

The first author, committed to feminist approaches to woman abuse and with extensive experience working in shelters for abused women, became increasingly aware of the limits of the dominant conceptu- alization of intimate violence when she moved on to work with a community-based population of couples where there was violence in the relationship. There appeared to be a striking difference between the type of violence seen in this community-based population as compared to the shelter population. Intervention approaches, however, were based on a generic, universal conceptualization of intimate violence as primarily a manifestation of male domination. Recent research on batterer typology (Holtzworth-Munroe, Meehan, Herron, Rehman, & Stuart, 2000; Waltz, Babcock, Jacobson, & Gottman, 2000) and studies comparing the differences between clinical and community samples (Archer, 2000; Johnson, 1995) renders this nondiffer- entiated view problematic. This research suggests that at least two qualitatively distinct types of intimate violence exist, one type involving male power and control, and the other involving mutual conflict between partners (Johnson & Ferraro, 2000). Unfortunately, even the newer couple intervention models do not

Kelly Greene, Peel Children’s Centre, Mibsissauga, Ontario, Canada; Marion Bogo, Faculty of Social Work, University of

Correspondence concerning this article should be addressed to Kelly Greene, Peel Children’s Centre, 85A Aventura Court, Toronto, Toronto, Ontario, Canada.

Mississauga, Ontario L5T 2Y6, Canada. E-mail: kelly.greene@utoronto.ca

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distinguish between types of violence. Current assessment and intervention practices that focus almost exclusively on patriarchal male violence against women may not reflect an understanding of the lived experiences of many couples and ultimately may deny them the type of help they seek. The current and compelling research about violence in intimate relationships enables therapists to develop a more complex and individualized understanding of violent couples. This article provides concepts and accompanying assessment guidelines to discriminate between these different types of violent couples.

AN ALTERNATIVE CONCEPTUALIZATION OF INTIMATE VIOLENCE

The domestic violence literature includes disparate and controversial findings. On the one hand, studies of community samples find generally low levels of violence perpetrated by both males and females. On the other hand, studies of clinical samples drawn from courts, hospitals, and shelters find severe violence mainly perpetrated by men (Archer, 2000; Johnson, 1995). Feminist researchers have studied primarily clinical samples and conclude that intimate violence is the result of patriarchy and, thus, is primarily perpetrated by men as a means to maintain power and control (Dobash & Dobash, 1979; Pagelow, 1984). Family conflict researchers have studied mainly representative community samples and conclude that intimate violence between partners results from individual, relational, and societal variables that tend to be more gender neutral (Berkowitz, 1993; Straus & Smith, 1990). These two different perspectives have led to a long- standing debate about the veracity of each position. Until recently we have had no other way of conceptualizing violence that is inclusive, rather than exclusive, of different ideological positions, empirical findings, and clinical experiences.

Johnson’s ( 1 995) ground-breaking analysis, in which he compared and contrasted representative community samples with clinical samples selected for the presence of male violence, suggested that the dramatic differences in gender patterns of violence arise from the fact that researchers are actually studying different phenomena. He proposed that domestic violence is not a singular phenomenon; rather there are qualitatively distinct patterns of intimate violence that he named “patriarchal terrorism” (Johnson, 1995, p. 284) and “common couple violence” (p. 285). Patriarchal terrorism represents a pattern in which there is systematic use of both violent and nonviolent actions to achieve general control over one’s partner. Violence is merely one tactic of many used to gain absolute control in the relationship. Compared to common couple violence, patriarchal terrorism is more likely to escalate over time, have a higher frequency of violent incidents, cause serious injury, and involve the unilateral use of violence by one perpetrator (predominately men in heterosexual relationships). Common couple violence, unlike patriarchal terrorism, is not charac- terized by a pervasive pattern of control. Rather, violence is an intermittent response to a specific argument or conflict. Control is thus limited to a specific situation. Common couple violence is more likely to be mutual, is not as likely to escalate over time, does not occur as frequently, and is less likely to involve severe violence (Johnson, 1995; Johnson & Ferraro, 2000).

Although the term common couple violence has now become more widely used since Johnson coined the phrase in 1995, “common” should not imply that this type of violence is more benign or acceptable. Any conflict that escalates to the point where physical aggression is used can put couples in danger. Fortunately, because of the influence of feminism, the tendency for family therapists to disregard violence as a principal target of treatment has decreased (O’Leary & Murphy, 1999). The field of family therapy has recognized that ignoring violence is both unethical and unhelpful when working with violent couples. Treatment requires special skills and knowledge about this issue. Thus, the term common couple violence is meant strictly to denote a type of violence that is distinct and qualitatively different from patriarchal terrorism. Clinicians should be aware of and assess the risks throughout treatment, regardless of their initial assessment of the type of violence.

The majority of studies on couple violence have largely used samples involving only severely violent men. Conclusions and conceptualizations about violence and appropriate clinical interventions have been generalized from these samples to all couples in which there is aggression (Johnson & Ferraro, 2000). Comparably little research has involved couples voluntarily seeking conjoint treatment for intimate violence

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(Brown & O’Leary, 1997). Despite growing evidence of differences between these populations, distinctions have yet to be included in assessment. To select differential interventions that are responsive to the couples’ needs and experiences, couple therapists need to answer three questions: What type of violence am I most likely to be working with? How can I assess the differences between types of violence? How might I proceed with treatment for different types of violence?

WHAT TYPE OF VIOLENCE ARE COUPLE THERAPISTS MOST LIKELY TO SEE?

Studies suggest that couple therapists in the community are most likely to see common couple violence in couples presenting with some form of physical aggression in their relationship. The majority of couples (50%-65%) who seek couples therapy report some level of physical aggression, yet 90% of these couples do not perceive physical aggression as a major relationship problem (Ehrensaft & Vivian, 1996; O’Leary, Vivian, & Malone, 1992). The most common forms of violence are grabbing, slapping, pushing, and throwing things at one another (O’Leary & Murphy, 1999). Comparing self-referred men in intact relationships with men court mandated into treatment, the former engage in less physical aggression, are less likely to deny their physical aggression, and may be more motivated to change their behavior (Brown & 0’ Leary, 1997). Studies of couples treated conjointly in domestic-violence-focused treatment programs with clear exclusion and inclusion criteria found that very few women reported being fearful of remaining with their husbands or of participating in conjoint treatment. These women were placed at no further risk of abuse than women receiving treatment separately from their spouses (Brannen & Rubin, 1996; Dunford, 2000; O’Leary, Heyman, & Neidig, 1999).

Archer (2000) in a meta-analysis compared samples selected for male violence (from battered women’s shelters) with community samples to assess whether couple violence looked different across these populations. Very high levels of male aggression were reported in shelter samples, whereas in community samples women were slightly more physically aggressive. Archer (2000) also examined studies of couples undergoing treatment for marital problems and found that men were slightly more likely than women to be physically aggressive. However, in contrast to shelter samples, the level of male aggression was much lower. This suggests that couples receiving counseling, even for problems specifically related to male violence, do not have nearly the same kind of imbalance in physical aggression as might be found in couples in which the woman has sought shelter from abuse.

Although other typologies for differentiating male batterers have been proposed, research on female perpetrators is much less extensive. Holtzworth-Munroe and Stuart (1994) proposed three types of male batterers: Family-only, dysphorichorderline, and generally violent/antisocial. Batterers can be identified along three descriptive dimensions: Severity/frequency of violence, generality of violence, and psychopathology or personality disorders, as well as risk factors correlated with the development of violent behavior (such as witnessing violence in the family of origin). Dysphorichorderline and generally violenthtisocial batterers engage in moderate to severe levels of violence and the later are most likely to be involved in criminal behavior and use violence both within and outside the home. The dysphorichorderline tend to confine their violence to the intimate relationship. Family-only batterers engage in the least amount of violence, show little or no psychopathology, and have very low levels of risk factors. Empirical testing of the model has supported this batterer typology (Hamberger, Lohr, Bonge, & Tolin, 1996; Holtzworth-Munroe, et al., 2000; Tweed & Dutton, 1998; Waltz, et al., 2000).

Two recent studies compared couples from the community (Holtworth-Munroe, et al., 2000; Waltz, et al., 2000) with maritally distressed but nonviolent couples and found a striking resemblance between the family-only batterers and the nonviolent men. In these studies, the two did not differ significantly on a wide variety of measures hypothesized to be correlated with violent behavior (e.g., psychopathology, violence in the family of origin, attachment style, dependency, jealousy, impulsivity, social skills, attitudes toward violence, and attitudes toward women). In contrast, both the generally violent/antisocial batterer and the dysphorichorderline batterer differed significantly from nonviolent men on most of these measures. During a conflict discussion with spouses in a laboratory no differences in behavior between family-only batterers and nonviolent men were found. However, the other types of batterers displayed higher levels of contempt

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and negative behavior toward their spouse during problem discussions. Jacobson and Gottman (1998) identified two types of batterers, whom they labeled, pitbulls and cobras.

These two batterers resemble the dysphorichorderline and generally violent/antisocial batterers, respec- tively (Holtzworth-Munroe et al., 2000). Although Jacoboson and Gottman focused their study on severely violent men, they also discovered what they called a “low-level violent” group of couples, which they followed with the expectation of tracking the development of violence from minor to more severe forms. Unexpectedly, however, this group almost never escalated their use of violence, and are described by Jacobson and Gottman as a “stable group of couples who periodically have arguments that escalate into pushing and shoving, but never reach the point where we would call the men batterers” (p.25). This description coincides with Johnson’s (1995 j description of common couple violence.

Utilizing the same data set as Jacobson and Gottman (1998), Waltz, et al. (2000) tested the proposed typology set forth by Holtzworth-Munroe and Stuart (1994), with the inclusion of this low-level violent group. They found that 83% of the men from Jacobson and Gottman’s (1998) “low-level violent” group of couples were classified as family-only type batterers, whereas 89% of batterers classified as generally violent/antisocial came from Jacobson and Gottman’s sample of couples where there was severe husband- to-wife violence. This research appears to support Johnson and Ferraro’s (2000) observation that types of violence among couples appears to be associated with types of perpetrators.

In summary, the studies reviewed suggest that couple therapists working with voluntary couples in the community are most likely to see common couple violence and family-only type perpetrators. The family- only type differs from other types of perpetrators, yet closely resembles nonviolent men in distressed relationships. Although studies indicate that a certain type of violence may predominate in a specific population, these distinctions are not absolute (Archer, 2000). Thus, it is imperative that couple therapists have the knowledge and skill to identify the differences between patriarchal terrorism and common couple violence in order to provide individualized and effective interventions.

ASSESSMENT FOR DIFFERENT TYPES OF VIOLENCE

When working with couples, therapists need to first screen for violence and complete a safety assessment, Bograd and Mederos (1999) offer a comprehensive assessment procedure that is helpful in detecting violence and examining risk factors. Many advocates in the domestic violence field have stressed the importance of safety planning and ongoing evaluation of the potential for lethal violence as fundamental components of assessment and treatment (Aldarondo & Straus, 1994; Bograd & Mederos 1999; Cervantes, 1993).

Feminist scholars have helped illuminate the obvious and subtle ways that gender-based power differ- entials are evidenced in intimate relationships between women and men, and especially where there is violence. This perspective is likely to be the most useful lens to bring to the initial assessment of couples where aggression is present. All couples, however, whether violent or nonviolent, have conflicts involving power and control issues (Jacobson & Gottman, 1998). The extent to which this power and control is attrib- utable to gender inequalities, however, can vary greatly from couple to couple. The research summarized earlier in this article on common couple violence and the many couples we have seen in clinical practice obliges us to broaden our lenses when trying to understand aggression where gender inequities may not be the primary motivation. That is, the desire to control as an expression of male domination does not appear to be universally present in cases of common couple violence.

An assessment of violent couples needs to include an analysis of whether the violence represents patriarchal terrorism or common couple violence. This assessment is complex as it involves more than identifying who is using physical aggression. For example, Jacobson and Gottman (1998) found that wives of severely violent men often fought back both verbally and physically against their spouses. However these researchers did not consider the wives’ use of physical aggression as battering since they found that only the men successfully used violence as a method to control their partners and only the women were afraid. Fear and control differentiated the men’s and women’s use of violence. Jacobson and Gottman (1998) particularly stressed the element of fear as a defining characteristic of these relationships: “Without fear, there is no

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control. For us, fear became a barometer of control” (p. 82). Similarly, Johnson’s (1995) distinction between common couple violence and patriarchal terrorism is largely based on motivation to control.

Therefore, we propose that in order to distinguish types of violence an assessment needs to consider four factors: Range of control tactics (e.g., does the perpetrator use emotional abuse, isolation, threats, degradation, and withdrawal of access to resources?); motivation for the use of violence (e.g,, is the perpetrator’s intent to instill fear and thereby establish control over their partner, to essentially “put her in her place” or is it an intermittent response to a specific argument or conflict without the intent to exert general control over the other?); impact from the physical aggression (e.g,, is employment, social networks, physical or mental health being affected?); partner’s subjective experience (e.g., is one partner afraid of the other?). The following two case studies (we are satisfied that the information is presented in a way that will not compromise confidentiality) from our clinical practice illustrate how assessing these four key factors can help distinguish a pattern of patriarchal terrorism from common couple violence.

CASE STUDIES

Patriarchal Terrorism Mary and Bob are a White, Catholic couple in their early 30s with one 7-year-old son. Bob is a software

computer programmer and Mary previously worked as an executive secretary. During an initial therapy session Bob and Mary disclosed that some physical aggression was occumng in their relationship. The therapist decided to see each partner individually to assess safety issues more fully and to determine the type of intimate violence.

In the individual interview Mary explained that when she married Bob she thought they were “meant for each other.” She was attracted to the fact that Bob had a good job, wanted to support her, and was intensely loyal and committed to her. However, over time, Bob became more and more jealous and controlling, often refusing to let her visit family and friends. At work he would call her at least 20 times a day, and if she were not at her desk, he would accuse her of having affairs with her male coworkers. Bob also started becoming physically aggressive about 2 years ago, occasionally shoving, pushing and slapping her. He would often pick a fight with her just before she left for work. One day Bob told her that she looked like a “whore” in the skirt she was wearing and when she refused to change, he blocked the door and would not let her leave the house. When she tried to push him out of the way, he struck her across the face. This caused her to miss an important meeting, and she was fired. Since then, her relationship with Bob has deteri- orated. He sold her car, started putting his checks in a separate bank account, and refused to give her any money. He insisted on doing all the shopping, because “she spent too much money.” Mary has thought about getting another job, but Bob wants her at home, and besides she feels so anxious and depressed that she does not think she could hold down a job.

When asked to describe the most recent incident of violence, Mary said that last week she was ill and unable to prepare dinner before Bob arrived home. Bob started accusing her of spending her day screwing other men. Mary then yelled at him that if he wanted dinner sooner, he could make it himself. The next thing Mary remembers is being thrown up against the wall while Bob shouted in her face, “You had better make my dinner right now you lazy fucking bitch!” He then spit in her face. Mary said that she is frightened when Bob flies into these “rages” and never quite knows what will set him off next. She is afraid that if they do not get help for their marriage he may “really lose it on me one day.” Mary is also concerned about her son witnessing some of these arguments and that he is becoming more withdrawn.

In an individual session Bob expressed concern that he and Mary fight too much. He said that he loved her, did not want her to leave him, and was willing to do almost anything for her. He then proceeded to talk about all the things that he does for her, in particular, financially supporting her so that she can “stay home and do nothing all day.” He reported being baffled that given everything he does for her, she is not more grateful. Bob felt that he did not ask for much in return-just a clean house and dinner ready for him when he comes home. When asked about a recent fight, Bob talked about a day last week when Mary was “doing who knows what” and had not even bothered to get dinner ready. On top of this, she snapped at him and told him to make it for himself. Bob said that he grabbed her by the arms to “get her attention.” He believes

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that sometimes Mary needs “reminders” like this to treat him with more respect. When asked if Mary is ever afraid of him during these times, he laughed and said, “I wish she were, then maybe she would listen to me more often.”

Common Couple Violence Tracey and Steve are a second generation East Indian couple in their late 30s. They live in a midsized

city and both are teachers. Tracey and Steve reported having “heated arguments,” which have escalated to the point where they have pushed and shoved each other. Following standard safety protocol, the couple was then interviewed separately. Both Tracey and Steve identified that their marriage was under a great deal of stress because of their inability to conceive a child. Steve felt that Tracey was “stuck” on the idea of continuing to try to have children, whereas he wanted to move on to explore different options, such as adoption. Tracey felt that Steve had “given up” on them and was no longer emotionally supportive. They reported that in the last year they had been arguing more than ever. Several times these arguments had involved physical aggression-slamming doors, throwing things, and occasionally pushing or slapping each other. Tracey said that it can be either one of them who starts an argument and both of them seem to be unable to stop it from getting out of hand.

When asked to describe their most recent incident of violence, Tracey and Steve gave similar accounts of the same incident. Two weeks ago, Tracey learned that the fertility treatment was not successful. Tracey described the devastation she felt when she found out that their last attempt to conceive a child had failed. She recalls at the time feeling that she just did not have the words to talk to Steve about this, and remembers feeling really angry. She said that she went into the kitchen to make coffee in the morning, and out of frustration, started slamming cupboard doors when she could not find the filters. When Steve came downstairs, Tracey said all she could think was “What do you care anyway?’; when he insisted they talk, she told him to “fuck off.” Steve said that he was outraged, as this loss affected him just as much as it did her. He then told Tracey to stop being such a selfish bitch, at which point she pushed him and stormed out of the room. Steve tried to stop her from leaving by grabbing her arm. Tracey said that when he tried to stop her from leaving, she slapped him across the face. It was at that point that both of them realized things had gone too far.

Both Tracey and Steve feel that they were equally responsible for the conflicts and were ashamed of their behavior. They want to learn how to control their temper and resolve conflicts more constructively. When Tracey was asked if there were ever times she was afraid of Steve, she said “No, I know that Steve would never intend to hurt me.” She was afraid, however, that if their fighting continued this way, their marriage might be at risk. Steve did not indicate any fear of Tracey harming him, but, like Tracey, emphasized that the fighting was undermining the positive aspects of their marriage. Tracey and Steve were hoping that couples therapy would help them move on in a direction that was mutually agreeable and satisfying to both of them. They were keenly aware that the decision regarding whether to stop or pursue more fertility treatments involved heavy financial and emotional commitments. After several years of trying to conceive, the couple was now faced with severe financial difficulties after spending most of their savings on fertility treatments. As both of them have similar incomes, Tracey and Steve have a good understanding of their financial needs and participated together in financial planning. They reported having always made important decisions together and valuing each other’s opinion. They wanted to find a way that each of them could feel good about their future choices, but were feeling helpless over how to make this happen.

Analysis of Cases To uncover the patterns distinct to patriarchal terrorism and common couple violence four key

variables-range of control tactics, motivation, impact, and partner’s subjective experiences-need to be assessed. In Mary and Bob’s relationship, there is a wide range of control tactics being used by Bob beyond physical aggression. Mary discloses that Bob calls her degrading names, has denied her access to money and transportation, isolates her by cutting her off from friends, family, and work, uses intimidating and degrading gestures such as spitting in her face, and exhibits highly jealous and possessive behaviors. For Bob, physical aggression is but one part of his arsenal of weapons aimed at humiliating and subjugating his

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wife, Mary. Bob’s motivation for the use of violence can be understood as his attempt to assert general control over his partner’s thoughts, feelings, and behavior. Acts of physical aggression are used to keep Mary in line; they are “reminders” from Bob that she must follow his rules. There is also an unpredictable nature to his violence, which keeps Mary off guard and overly focused on trying to modify her behavior to avoid further abuse.

Tracey and Steve in contrast, have marital issues that lead to conflict involving physical aggression, but there is no attempt to exert control outside of this specific context. Tracey and Steve’s use of physical aggression arises in the context of a specific argument about an emotionally charged issue, in which they react by physically lashing out at each other. Unlike Bob, Tracey and Steve do not engage in a wide range of both violent and nonviolent behaviors that would indicate a general pattern of control. Tracey and Steve report the experience of violence as being about anger and frustration, but not about fear or the intent to instill fear in the other partner. Both acknowledge the aggression, admit that it is shameful, and want to change their behavior. There is no motivation to use aggressive acts as a means to establish widespread control over their partner’s life.

Although Tracey and Steve both feel at a loss when it comes to stopping these arguments from getting out of hand, these feelings of powerlessness do not profoundly affect other areas of their lives. Tracey and Steve continue to work full time, pursue hobbies, visit friends and family, and do not show signs of any mental health issues. Mary, in contrast, reports being depressed and anxious and does not feel capable of sustaining employment. These effects are consistent with the trauma literature, which has found that female victims of intimate violence suffer from negative psychological effects, such as posttraumatic stress disorder, depression, lowered self-esteem, in addition to social and economic disadvantages (Holtzworth- Munroe, Smutzler, & Sandin, 1997; Walker, 2000). Consequences beyond physical injury must be considered when assessing impact. For example, in terms of actual physical injury, both Tracey and Mary have sustained only minor injuries. However, when the psychological, social, and economic consequences are considered, a different picture emerges for these two couples.

Tracey and Mary also describe the experience surrounding the physical aggression very differently. Mary experiences Bob’s physical aggression as frightening, and she is afraid that he may cause her serious harm in the future. Tracey and Steve, in contrast, do not experience the aggression as frightening or intimi- dating. It is important to stress the need to understand the subjective experience of violence for each partner, as the presence of fear and intimidation appears to be a key distinguishing feature between patriarchal terrorism and common couple violence. The literature on domestic violence has emphasized that some women and men may minimize or deny both violence and their fear in the relationship (Bograd & Mederos, 1999; Holtzworth-Munroe et al., 1995). As mentioned previously, it is imperative for therapists to screen for violence continually and assess risk factors to understand fully the context and safety issues involved. At the same time, dismissing couples’ views of the main problems in their relationship and denying their experiences could ultimately alienate couples and may be one possible reason for their terminating treatment. Acknowledging and incorporating each partner’s understanding and view of the relationship problems may yield valuable information in distinguishing types of violence and strengthen the therapeutic bond necessary for effective treatment.

When the above four factors are considered together-range of control tactics, motivation, impact, and subjective experience-the differences in these two cases become apparent. In each case, a distinct type of violence is occurring; Bob and Mary’s case represents patriarchal terrorism, whereas Tracey and Steve’s case corresponds with a pattern of common couple violence. Couple therapists are often faced with helping couples experiencing different types of violence, such as in the two cases presented. A thorough assessment of these four factors can help therapists distinguish types of violence so that effective treatment planning can take place for each case.

DTFFERENTIATED TREATMENT STRATEGIES

There has been much discussion and controversy about how family therapists intervene in domestic violence cases. The debate in the field concerns whether or not couples therapy is an appropriate and

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effective treatment modality. The consensus has generally been to avoid couples therapy in domestic violence cases and to provide gender-specific treatment primarily through separate men’s and women’s groups (O’Leary, et al., 1999; Wileman, 2000). The wisdom of this approach, however, has been challenged by empirical research. Reviews of batterer treatment outcome studies have not been favorable, calling into question whether men’s treatment groups are truly effective or not (Dunford, 2000; Hamberger & Hastings, 1993; Rosenfeld, 1992). Furthermore, several recent studies directly comparing conjoint treatment with gender specific treatment have found no significant differences in treatment effectiveness, including the risk of further violence (Brannen & Rubin, 1996; Dunford 2000; O’Leary, et al., 1999).

Dunford’s (2000) comparative study is particularly compelling in that it avoided many of the method- ological flaws characteristic of previous studies. Dunford employed a randomized no-treatment control group design involving a large sample of 861 U.S. Navy couples in which husbands were reported as having physically assaulted their wives. Each case was randomly assigned to one of four different treatment conditions: A men’s group, a conjoint group, a rigorous monitoring group, and a no-treatment control group. Interventions for the men’s and conjoint groups consisted of weekly sessions for 6 months, followed by six monthly meetings. A number of standardized assessment tools were used to measure continued abuse, and both wives’ and husbands’ reports were used. At a 1-year follow-up, Dunford found that there were no statistical differences between any of the four treatment groups-including the control group-on measures of continued abuse. In other words, treatment had no effect on reducing continued abuse.

Dunford (2000), along with other researchers (Holtzworth-Munroe, et al., 2000; Saunders, 1996; Waltz et al., 2000) have suggested that treating physically aggressive men as one homogenous group, rather than tailoring interventions according to the different motivations and needs of physically aggressive men, could be responsible for the ineffectiveness of treatment. Dunford urges us to give “full and preferential attention” to the possibility that one-size-fits-all approaches to treatment may not meet the needs of these couples (p. 475). Examining the effectiveness of distinguishing between couples in different types of violent relationships and tailoring treatment interventions accordingly is a promising area for future clinical exploration and empirical research.

As empirical research has failed to show that any one of the current treatment approaches are superior to another, the debate about how to intervene in domestic violence cases has largely centered on ideological differences. These differences originate from two overarching dominant perspectives-feminist and systemic. These two perspectives conceptualize intimate violence very differently. Almost every step in the assessment and treatment approach is, in turn, affected by this conceptualization.

Comparison of Feminist and Systemic Approaches to Treatment From a feminist perspective, domestic violence is a problem of male domination and control of women.

rooted in patriarchy. Interventions have targeted structural change and coordinated community responses, particularly the implementation of criminal sanctions. Regarding treatment, male batterer groups are seen as an opportunity to challenge men’s sexist beliefs regarding their entitlement to exert power and control over women (Pence & Paymar, 1993). As mentioned above, this view has been the most influential in informing treatment approaches, as evidenced by the fact that batterer’s groups are the most common form of treatment (O’Leary, et al., 1999; Wileman, 2000). The systemic perspective, in contrast, assumes circular causality for problems and thus views intimate violence as a relationship issue, with both partners contributing to the escalation of conflicts. Spouse-abuse treatment programs based on this approach are rare, as systems theories have been extensively criticized for revictimizing women and putting them at greater risk (Holtzworth-Munroe, et al., 1995).

However, given the research reviewed above, there may be more than one type of violence, and each theoretical perspective and intervention approach may be more appropriate for a specific kind of violence. The debate regarding appropriate and inappropriate approaches has polarized the field casting some methods as “wrong” and diverted us from addressing which type of treatment is most effective with which type of violence.

For example, Heyman and Niedig’s (1997) Physical Aggression Couples Treatment model (PACT)

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appears to be well-suited to address common couple violence as illustrated in the case of Tracey and Steve. This is not standard marital therapy; it specifically aims to eliminate violent behaviors by focusing on both identifying and managing anger, and increasing competence in relationship skills. The program consists of 14 sessions, with the first half devoted to helping spouses identify and manage their anger. It is believed that this is a necessary prerequisite to focusing on couple issues. Based on systemic principles, both partners are encouraged to examine and take responsibility for their own role in escalating the conflict. Relationship issues, such as communication, jealousy, negotiation, and recognizing underlying feelings are also dealt with in order to decrease conflicts that may lead to violence. The concept that abusive behavior is a desperate, self-defeating attempt to effect relationship change is used to help couples develop more constructive, healthy ways of improving their relationship and ending the violence.

Although this model may be very useful for common couple violence, one can see its limitations and hence that it is inappropriate to use it to address a pattern of patriarchal terrorism, as in the case of Mary and Bob. For example, the idea that both partners are responsible for escalating the violence is clearly not the case for Mary and Bob. In fact, Mary feels she has no control over the situation and lives in fear that Bob may “really lose it one day.” Essentially, Bob’s use of both physical and nonphysical methods has established general control in the relationship. To encourage Mary to accept personal responsibility for the violence by asking questions such as “What do you think you did that made the situation worse?’ (Heyman & Niedig, 1997, p. 594, italics in original) would be “blaming the victim’’ by not acknowledging the severe power imbalance in the relationship. Similarly, primarily focusing on issues of “anger management” would shift the focus away from Bob’s systematic use of violence. In this case, a model with an explicit focus on male power and control would be more appropriate.

In contrast, using the dominant feminist approach that focuses on violence as predominately an issue of male power and control would be inappropriate for cases of common couple violence such as Tracey and Steve. It is unlikely that Tracey and Steve would experience such a definition of their issues as accurate. In a study of voluntary participants assigned to either a conjoint or gender-specific spouse-abuse treatment, Brown, O’Leary, and Feldbau (1997) found that the reason cited most frequently by couples for dropping out of treatment was that treatment did not fit with their needs. More specifically, the majority of these couples said that they dropped out of treatment because a program focusing on aggression did not address enough of their own individual marital issues. It is interesting to note that the majority of participants in the conjoint group (based on the PACT model) had dropped out before the sessions that focused on relationship issues, such as communication. The excessively high drop-out rate in spouse-abuse treatment programs, as compared to standard marital therapy, warrants consideration of whether these programs are meeting the needs of these couples (Brown, et al., 1997). This research suggests that perhaps, in cases of common couple violence, intervention should maintain a dual and simultaneous focus on both anger management and relationship building. Gottman’s (1999) research has also highlighted the importance of addressing issues beyond conflict, such as strengthening the marital bond.

Integrative Models Although some models derived from certain perspectives (systemic or feminist) seem to “fit” better

with certain types of violence, there is a growing recognition in the family therapy field of the need to integrate different theoretical perspectives and practice models for effective practice. Johnson and Lebow (2000) see the trend toward integration as a “sign of a maturing field that general principles and interventions become delineated and applied in varying formats and contexts” (p. 32). Lebow (1997) believes that integrative approaches have the potential to offer greater flexibility, an increased repertoire of interventions, higher treatment efficacy, and greater acceptability among clients. The latter is particularly important in domestic violence cases, given that many clinicians have noted that women and men often want to be seen together (Goldner, 1999; Lipchik & Kubicki, 1996; Shamai, 1996). Shamai (1996) has noted how the categorical dismissal of systemic principles in the treatment of domestic violence, may be akin to “throwing the baby out with the bath water,” (p.202) and serves to detract from efforts to develop a more effective, broader range of interventions.

Goldner and her colleagues at the Ackerman Institute (Goldner 1998, 1999; Goldner, Penn, Sheinberg,

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&Walker, 1990) have spent the last 10 years developing an integrative treatment model for intimate violence where systemic and feminist perspectives inform and enrich one another. They have articulated how each of these perspectives in isolation from the other serves as an insufficient explanatory framework, and highlight the need to move from an either/or orientation to a both/and position. Over the years, a complex and sophis- ticated “multisystemic” approach to treatment consisting of several different approaches-feminist, systemic, psychodynamic, narrative, neurobiological and behavioral approaches-have been integrated under the guiding principle that one level of description or explanation does not have to exclude another (Greenspun, 2000).

Equipped with a sound theoretical basis for addressing intimate violence in a couple format, feminist family therapists have continued to develop couple approaches that are sensitive to issues of power and gender (Almeida & Durkin, 1999; Bograd & Mederos, 1999; Greenspun, 2000; Jory & Anderson, 2000; Lipchik & Kubicki, 1996; Shamai, 1996). Utilizing these treatment models with couples such as Mary and Bob could prove very effective, as they target the power and control issues involved in Bob’s use of violence and seek to hold him accountable for the violence, while exploring the relational dynamics, which may contribute to the escalation of violence and leave Mary vulnerable to further abuse. Moreover, by working within a relational context, the couple’s wish to be seen as a couple is respected.

The advent of integrated couple approaches to address intimate violence for couples such as Mary and Bob represents progress in the family therapy field. These models, however, do not distinguish between different types of violence. An exception is Jory, Anderson, and Greer (1997) who clearly state that their approach addresses male domination while recognizing that other types of violence may exist which need different approaches. Because most integrated models conceptualize intimate violence as patriarchal terrorism, they may be less useful for cases of common couple violence, such as Tracey and Steve. The tendency to define all violence as a form of patriarchal terrorism, combined with the relative paucity of research on common couple violence, appears to have resulted in comparably fewer integrated treatment models to draw on to address common couple violence. A better understanding of the dynamics of common couple violence is needed to enable the development of more sophisticated, integrative approaches.

For example, it has been well documented by feminist researchers that gender is a central organizing principle for both individuals and couple relationships and therefore must be an integral feature in family therapy (Goldner, 1985; Hare-Mustin, 1986). The fact that a model such as PACT is “gender free” is a limitation requiring the introduction of a feminist analysis. Vatcher and Bog0 (2001) point out that many couples presenting for therapy today are struggling precisely with issues of shifting, contradictory gender roles. Tracey and Steve are no exception. In Tracey’s view, stopping fertility treatments would forever mark her as a “failure” because she would not truly have fulfilled the role of “mother” in the way she had envisioned. To Tracey, this felt like a death sentence. Tracey reported that Steve’s insistence to stop the fertility treatments and look at other options such as adoption felt at times like he was the one delivering that final death blow. Tracey said that it often felt like Steve was the enemy that she had to fight against. Steve, in contrast, talked about feeling “defective” because he had not been “man” enough to impregnate his wife. Many of their friends were having children and he found that the men would often compare how long it took for them to get their wives pregnant. In Steve’s mind, Tracey’s desire to continue trying to conceive only served to prolong his feelings of shame and inadequacy and during conflict, he often found himself telling her to just shut up and let the issue go. Clearly a feminist analysis of how gender-based societal expectations produce strong emotions in each partner would be critical to addressing these issues. More research, analysis, and understanding of how intersecting factors, such as gender, class, race, and ethnicity operate in cases of common couple violence is urgently needed.

CONCLUSION

The history of family therapy is tarnished by our inability to detect and adequately respond to women who were being brutalized by their male partners. On this issue, there can be no debate. However, the field’s attempt to rectify earlier mistakes may have neglected recognizing the presence of other forms of intimate

464 JOURNAL OF MARITAL AND FAMILY THERAPY October 2002

violence. This article has used current empirical research and illustrative clinical examples to support a conceptual framework for guiding assessment and treatment intervention. Couple therapists who work with intimate violence are searching for opportunities and approaches that offer more flexibility in meeting the individualized needs of couples. A broader lens that takes into account the different faces of intimate violence may expand the alternatives for assessing and treating these couples.

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