I have a client (18yr female) who I have seen twice a week for 8 months who is currently in a relationship plagued with intimate partner violence. This has been dubbed “mutual combat” by several of my co-workers, but in exploration with her, it appears as though the severity of his violence, his physical strength, and his emotional control create a dynamic where she sometimes reacts with violence (i.e., pushing him so she can escape, scratching his arms when they are around her neck). She has asked to begin couples therapy with her partner, and he has agreed. I am familiar with some of the literature on couples therapy and intimate partner violence and have had some training in this area, but no one else at my location (a community mental health center) is trained in couples therapy and/or intimate partner violence. My agency is now discussing the possibility of me seeing them as a couple while continuing to see her. Are there guidelines or best practice recommendations about
whether it would be appropriate for me to see them as a couple?

Response by Jeffrey Barnett

Thanks for this great question. I’m really glad you are asking it. Clearly you are sensitive to the issue of competence with regard to the knowledge and skills needed to provide couples therapy. As your question implies, being competent in individual psychotherapy doesn’t necessarily translate over to clinical work with couples. Once must have the necessary education and training from course work, readings, CE activities, and supervised clinical experience before expanding our practice into a new area. I agree with you that you need to be aware of relevant practice standards and guidelines as well.

The situation you describe is also challenging because of the highly volatile nature of the relationship and the risks present for all involved (including yourself!). It will be important to be sure you have in place safeguards to protect yourself should anyone become aggressive or violent during a session. Having a colleague present or nearby during sessions, having a ‘panic button’ at your desk to quickly summon security if needed, positioning yourself near the door and not having clients seated between you and the door each may be important. Additionally, having a treatment contract/informed consent agreement that clearly specifies rules of conduct for the psychotherapy relationship is important as well. It should specify acceptable and unacceptable behaviors, appropriate alternatives to use if one is angry, and responses or consequences that will occur should certain specified behaviors happen.
With regard to the competence issue and relevant standards I suggest you consult with colleagues who are experts in couples therapy and in clinical work with intimate/partner violence. APA’s Division of Family Psychology and the Family Psychology section of the American Board of Professional Psychology may be good resources. While you may not have a competent supervisor on site, consultation and supervision may be done across distances by use of televideo communications such as Skype or by telephone and by sending the supervisor tapes of sessions with appropriate consent of the clients.

You are wise to be concerned about practicing in a new area without first knowing relevant practice standards, obtaining needed education and training, and receiving ongoing consultation or supervision. Then, should you proceed with this case, be sure your expert colleagues provide suggestions on how to structure the treatment sessions and relationships to ensure the safety of all involved. I hope this is of help. Should you have additional questions or comments please let me know. I also hope others will share their thoughts on this important area of practice as well. Perhaps some colleagues who work with these types of couples can share their perspectives.

Thanks and best wishes – Jeff

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Supervision is a fact of life for most of us.  We experience years of supervision in our professional training sequence and possibly afterward, and many of us move on to becoming supervisors of other professionals.  In their classic text, Coping with Conflict, Mueller and Kell (1972), some of the earliest writers in the field of supervision, suggested that because of the “oversight” provided by the supervisor, there is a natural power differential in the supervisory relationship that can be a crucible for discord.  Influenced by a psychodynamic perspective, they suggest that supervision is a clinical relationship within which supervisees can learn healthy management of power differences, as well as of conflict.  They suggest that conflict in supervision, if not handled skillfully, can be passed on to the therapeutic relationship through parallel process, or tacit learning.  Likewise, however, if handled skillfully, supervisory conflict can be a source of positive learning and development for supervisees, and this learning about being in healthy clinical relationships can be passed on to clients/patients.

Supervision scholars have noted that supervisees frequently do not reveal to their supervisors when they feel uncomfortable (Ladany, Hill, Corbett, & Nutt, 1996).  They fear reprisal, breaches in the relationship, and poor evaluations.  It is estimated that up to a third of mental health professionals have experienced some form of bad or harmful supervision at least once.  In fact, when asked, many of us can vividly recall at least one difficult, if not detrimental, experience with a supervisor.  The experience of harm in supervision has been well documented (Gray, Ladany, Walker, & Ancis, 2001; Kozlowska, Nunn, & Cousins, 1997; Nelson & Friedlander, 2001), and most of the harmful experiences described in the literature have occurred as a result of mishandled conflicts.

I and some colleagues recently conducted a study of “wise supervisors,” or supervisors considered by professional therapists to be the best in the field (Nelson, Barnes, Evans, & Triggiano, 2008).  They were asked how they thought about conflict in supervision and what strategies they used to work with conflict.  Findings indicated that “wise” supervisors understood that conflict is a normal (albeit discomfiting) occurrence in clinical relationships and saw it as an opportunity for growth for their supervisees and themselves.  They were unusually humble and willing to acknowledge and accept their shortcomings.  They valued and enjoyed supervision and communicated this enjoyment to their supervisees.  They saw a positive supervisory relationship as key to negotiating eventual differences with their supervisees and worked to foster trust in the supervisory relationship.  Many indicated that they discussed race, gender, and other differences with supervisees early on, as well as the power differential inherent to supervision, and processed related tensions.  They were willing to set clear boundaries and expectations and to communicate these to supervisees from the outset.  Though they set high expectations, they also valued and worked to facilitate developmentally appropriate learning in their supervisees.

All supervisors endorsed the use of interpersonal process as a key strategy for managing conflicts.  They seemed able to reflect on the process of conflict in supervision and what they had learned from past conflicts.  They were open to observing markers of supervisee discomfort, as well as their own, and addressing their observations openly in session with supervisees.  They actively considered the developmental needs of a supervisee in determining a course of action to address conflict.  Many indicated that they regularly undertook self-examination to understand the role they played in a conflict situation, and in cases of highly challenging conflicts, many sought outside counsel from trusted colleagues. A key strategy mentioned by all participants in the study was revisiting and clarifying role expectations with supervisees, renegotiating if necessary.

Most of the strategies mentioned by the supervisors in this study seem like common sense, and indeed they do represent the best of common sense.  They also represent the strategies of the courageous.  Rather than assuming a defensive or superior stance, these supervisors were open to owning their role in interpersonal conflicts.  They were willing to address conflicts openly with their supervisees in spite of the added discomfort such conversations create.  Thus these wise supervisors were courageous and open, and this openness is what earned them nominations from their peers for being outstanding supervisors.  We all know that the basic humanness of the therapist should be at the core of any psychotherapy relationship.  It is this same humanness in supervisors that creates the most optimal setting for supervisees to learn to negotiate conflicts.  Such in vivo learning in supervision can provide outstanding training in the nuances of negotiating difficulties in clinical relationships and serve as a model that supervisees can incorporate into psychotherapy.

Gray, L. A., Ladany, N., Walker, J. A., & Ancis, J. R. (2001). Psychotherapy trainees’ experience of counterproductive events in supervision.  Journal of Counseling Psychology, 48, 371-383.

Kozlowska, K., Nunn, K. & Cousins, P. (1997). Adverse experiences in psychiatric training. Part 2. Australian and New Zealand Journal of Psychiatry, 31, 641-652.

Ladany, N., Hill, C. E., Corbett, M. M., & Nutt, E. A. (1996). Nature, extent, and importance of what psychotherapy trainees do not disclose

Nelson, M.L., & Friedlander, M.L. (2001).  A close look at conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology, 48, 384-395.

Nelson, M.L., Barnes, K.L., Evans, A.L., & Triggiano, P.J. (2008).  Working with conflict in clinical supervision: Wise supervisors’ perspectives.  Journal of Counseling Psychology, 55, 172-184.